Apollo Institute of Medical Sciences & Research
(Jubilee hills, Hyderabad, Telangana)
Department of Obstetrics and Gynaecology
Consultant Dr.RANI REDDY
NAME: Mrs K DIVYA. AGE: 25 years
HUSBAND : INPATIENT NO: 361402
ADDRESS: FILM NAGAR, Hyderabad -Telangana-India
WARD LOCATION: 1
UNIT: I ADMISSION DATE: 10/05/25
DISCHARGE DATE : /5/25
DISCHARGE TYPE: PLANNED DISCHARGE
PROVISIONAL DIAGNOSIS: G3A2 with 39weeks 5days POG with PROM
FINAL DIAGNOSIS: G3A2 with 39weeks 5days POG with PROM
CHIEF COMPLAINTS:
G3A2 with 39weeks 5days POG came with ℅ clear leaking pv since 1.5hrs(5:30pm)
No h/o bleeding pv
No ℅ pain abdomen and abdominal tightness
Perceiving fetal movements well
Medical history:
N/ K/C/O HTN ,Thyroid, DM, TB, asthma, epilepsy disorders.
Surgical history:
No H/o previous surgeries.
Menstrual history:
Regular cycles, 4days flow /30d,3pads/day,Normal flow, no pain , No clots.
LMP- 5/08/24 ,EDD : 12/05/25 -SEDD-16/05/25(7weeks), ML: 8months(NCM)
OBSTETRICS HISTORY:
A1 : SC/ induced abortion @ 1 month of POG( medically managed)
A2 : SC/ induced abortion @ 1 month of POG( medically managed)
G3 : SC/PP/ NT missed/ TIFFA normal
Examination Findings on Admission:
Patient is c/c/c
GC: Fair
Temp:afebrile
No Pallor
No Pedal edema
Pulse:80 bpm,regular
Blood pressure:110/70mmHg
RR-16 cpm
Systemic examination:
Cardiovascular :S1, S2 +, no murmurs
Respiratory: BLAE+ , no added sounds
CNS : NFND
P/A : uterus ~ term
cephalic, relaxed
FHS + ,145 bpm
LOT
P/S : clear leak noted
P/V : os admits 1 finger
Cervix soft, mid position
Early effaced 20-30%
PPVX @ -2 station
Pelvis: adequate, gynecoid
INVESTIGATIONS:
BLOOD GROUP: O positive(10/03/25)
10/5/25
CBC:
Hb: 13.5gm/dl
TLC: 12.39 x 10^3/mm3
Platelets: 293 x10^3/mm3
CUE: normal
APTT:39.5sec
PT:12.9sec
INR:0.95
07/05/25
CBC:
Hb: 14.3gm/dl
TLC: 12.91 x 10^3/mm3
Platelets: 287 x10^3/mm3
CUE: normal
10/03/25
S.TSH: 1.9uIU/ml
RBS: 117mg/dl
Viral markers
HIV- 1+2 - Non reactive
VCRL- Non reactive
HBsAg- Negative
ANTI HCV ELISA- Non reactive
CBC:
Hb: 12.5gm/dl
TLC: 13.17 x 10^3/mm3
Platelets: 251 x10^3/mm3
CUE: NORMAL
7/5/25
Obstetric Ultrasound
Gestational age of the fetus by sonography: 38 weeks 2 days
EDD by sonography: 19 / 5 /2025
Approximate present fetal weight :3233 gms ( +/ - 472 gms)
Active fetal movements are present.
Fetal heart rate: 144 bpm and regular.
Amniotic fluid index - 12-13, adequate.
Placenta is posterior upper mid segment in location with grade III maturity.
IMPRESSION:
Single live intra uterine gestation of 38 weeks 2 days maturity.
obstetric parameters - suggested follow up scan.
Abdominal circumference is lagging behind by 1 week when compared to other obstetric
parameters
COURSE IN HOSPITAL STAY:
G3A2 with 39weeks 5days POG came with ℅ clear leaking pv since 1.5hrs(5:30pm)
No h/o bleeding pv
No ℅ pain abdomen and abdominal tightness
Perceiving fetal movements well
All baseline investigations were done and evaluated.
NVD conducted on 11/05/25.
Patient vitals are stable hence being discharged with following advice
Condition At discharge:
Patient is c/c/c
GC: fair
Temperature: afebrile
PR- 80bpm,
BP – 110/70mmhg.
RR -16/min
No Pallor
No Pedal Edema
CVS-s1s2 heard ,no murmurs
RS-NVBS ,No added sounds
CNS- No focal neurological deficit noted
P/A- uterus well retracted
L/E- bleeding WNL
Episiotomy wound healthy
Discharge Medication:
S.NO: DRUG DOSE ROUTE FREQUENCY DURATION
FURTHER ADVICE:
1) Iron and protein rich diet.
FACULTY SIGNATURE
SUMMARY
VERIFIED BY
DR.
DR. KUBRA(PGY1)
