CASE PRESENTAT

ION
GROUP NO 2
SUBGROUP 2
SEC C
GARGE SHRIKANT HARISH 33
GUNASEKARAN JANANI 37
KURPAT MUSTHABEEN 49
GENERAL DATA
Patient's name : A.A
Age : 22yrs old
Sex : female
Civil status : single
Religion :RC
Address : Davao City
Blood group: O+
Informant: patient
Reliability :70%
Date and time of admission in SPMC: feb 9, 2019 , 4.00pm
Date of delivery: feb 9, 2019 ,9.35pm
Date of interview : feb 11, 2019
CHIEF COMPLAINT

Lower Abdominal pain with watery discharge

from vagina
History of present illn
ess
1 day prior to admission, patient felt hypoga
stric pain and low back pain, so she went to her
regular maternity clinic. She was told to take rest
and sent home because her bag of water was int
act and no cervical dilatation. That night she noti
ced blood spots in her innerwear, for which she t
ook rest.
On the day of admission, patient noticed w
atery discharge from her vagina early in the mor
ning and was admitted to maternity clinic.
I.E At 6A.M-3cm dilation
AT 10 A.M - 4cm dilation
AT 5P.M -4cm dilation

She was then reffered to SPMC because there was slow progress in
dilation from morning.
AT 6 P.M TO 9 P.M – 8cm dilation
She was then delivered via C-Section because of arrest in dilation .
OB HISTORY
Ob score: G1P1(1 0 0 1)
LMP- May 6,2018
EDD- Feb 13,2019
AOG- 39 weeks 6/7 days
No contraceptives used
PREGNANCY PREGNANCY YEAR GESTATION SEX BIRTH PRESENT COMPLICATIONS
ORDER OUTCOME COMPLETE WEIGHT STATUS

G1 CS 2019 39 Weeks M - living Unrecalled by

6/7days mother.
GYNE HISTORY
Menarche - 13 years
Menstruation –Regular monthly periods lasts 5 to 7
days, 1to 2 pads (moderately soaked)
Dysmennorhea during menses
Coitarche - 20yrs
No of sexual partners – 1
Had Sexual intercourse during pregnancy( month unr
ecalled)
PAST MEDICAL HISTORY
No history of childhood illness
No history of previous surgeries
No history of allergy to food and medicines

ANTENATAL HISTORY
Prenatal visits :10 visits in Mercy Maternity clinic ,2 visits in SPMC
Immunization: tetanus toxoid -2doses(month unrecalled)
Medications: multivitamins, ferrous sulfate, calcium
FAMILY HISTORY

Maternal side : (-)hypertension (-)diabetes

(-)asthma (-)heart problems (-) TB
Paternal side : (-)hypertension (-)diabetes
(-)asthma (-)heart problems (-) TB
PERSONAL AND SOCIAL HISTORY
Patient is a housewife and her partner is a driver. sh
e has good relationship with her partner. Both patie
nt and her partner are non smokers. Patient does no
t drink but her partner drinks alcohol occasionally.
ENVIRONMENTAL HISTORY
The patient and her family live in a clean area. There
are 11 members in their house. source of water is fr
om faucet. No recent outbreak of diseases in their s
urrounding.
 REVIEW OF SYSTEM
GENERAL : (-) Fever and chills,(+) weight changes.
SKIN: (-) pallor, (-)rash, (-)itching, (-)lesion (-) ulcer.
EYES: (-)visual disturbances (-) discharge (-) irritation
EARS: (-)deafness (-)discharge (-)pain
NOSE:(-)discharge (-) bleeding
RESPIRATORY : (-) dyspnea , (-)cough, (-) sputum
CARDIOVASCULAR: (-)chest pain , (-) palpitations (-)edema.
GASTROINTESTINAL: (-)nausea, (-)vomiting, (-) dysphagia
(-)anorexia (-)diarrhea (-)hemoptysis (-)hematoschezia
URINARY SYSTEM : (-) Dysuria, (-) Hematuria. (-) nocturia,
MUSCULOSKELETAL : (-) muscle pain (-) joint pain (-) stiffness.
PSYCHIATRIC: No history of depression or anxiety.
NEUROLOGIC : (-) seizures ,(-) Fainting, (-) dizziness,
(-)syncope, (-)paralysis, (-)ataxia
HEMATOLOGIC: (-) anemia, (-)bleeding (-)bruising.
ENDOCRINE : (-) Heat and cold intolerance, (-) sweating,
(-)diabetes (-)thyroid problems
PHYSICAL EXAMINATION
VITAL SIGNS
Temperature- 37.5°c
Blood pressure-115/64 mm of hg
Heart rate-89bpm
Respiratory rate- 28 breaths per min.
Weight during pregnancy :66.7kg
weight before pregnancy : 55kgs
Weight gain during pregnancy:11.7 kgs
GENERAL STATUS : patient is awake, alert,and cooperative. she
is afebrile and not in respiratory distress.
SKIN : the skin was fair smooth to touch, no rashes, no discolor
ations , no pigmentation
HEAD : no trauma, no lesions, no scars
EYES : anicteric sclera, pink palpebral conjuctiva,no redness,
No discharge
EARS: symmetric, no deformities, no discharge
NOSE: nasal septum midline , no polyps, no discharge and no e
pistaxis.
EARS: symmetric, no deformities, no discharge
NOSE: nasal septum midline , no polyps, no dischar
ge and no epistaxis.
MOUTH AND THROAT : moist lip and pink oral muc
osa, no deviation of tongue and uvula, non erthyem
atous non exudative tonsils
NECK : trachea in midline, no masses, no deformitie
s, no palpable lymph nodes
RESPIRATORY SYSTEM

INSPECTION : symmetric chest expansion with a RR of counts per minute, a

nd no chest wall deformity noted.
PALPATION : equal vocal fremitus
PERCUSSION : resonant note
AUSCULTATION : Clear breath sounds on both lung field.
CARDIOVASCULAR SYSTEM
INSPECTION : adynamic precordium,
PALPATION : no heaves and no thrills.
PERCUSSION : not assessed.
AUSCULTATION : distinct heart sounds ,no murmur
ABDOMEN
INSPECTION: the skin was fair, linea nigra seen in the midline, low v
ertical incision made from below the umbilicus till symphysis no
rashes, no scars, no prominent veins, no pigmentations.
Auscultation: clicks and gurgles heard

MUSCULOSKELETAL : no joint deformities, no swelling of joints, no t

enderness
EXTREMITIES: no cyanosis, no edema in the extremities, no scars.
BREAST: skin is smooth ,no discharge ,nipples everted and no masse
s , feels some pain during breastfeeding and no pain on palpation
GENITALS and RECTAL: Not assessed
SALIENT FEATURES
WATERY DISCHARGE FROM VAGINA AT AOG 39WEEKS
6/7 DAYS
LOW BACK PAIN
LOWER ABDOMINAL PAIN
SLOW CHANGES IN CERVICAL DILATION
PROTRACTED ACTIVE PHASE
 IMPRESSION
G1P1 (1-0-0-1) pregnancy uterine
AOG(39 WEEKS 6/7 DAYS)
Hypogastric pain with watery discharg
e before the onset of labor
Premature rupture of membranes.
 Differential diagnosis
DISEASE RULE IN RULE OUT

Preterm premature Steady leakage of fluid from No Fever

rupture of membrane vagina No ROM before 37weeks of
gestation

Bacterial vaginosis Hypogastric pain no foul smelling discharge

Vaginal discharge No burning sensation
during urination
No vaginal itching
DISEASE RULE IN RULE OUT

URINARY INCONTINENCE WATERY VAGINAL NO YELLOW COLOUR

DISCHARGE DISCHARGE
NO FREQUENCY IN
DISCHARGE

PLACENTAL ABRUPTION BLOOD SPOTS IN NO UTERINE TENDERNESS

UNDERWEAR NO FREQUENT
ABDOMINAL PAIN CONTRACTIONS
NO CONTINUOUS
BLEEDING
DIAGNOSIS
G1P1(1 0 0 1) PREGNANCY UTERINE 39WEEKS 5/7
DAYS AOG DELIVERED TERM CEPHALIC, LIVING VIA
PRIMARY C-SECTION DUE TO ARREST OF
DILATATION AND FAILURE OF DESCENT.
PROM
Premature rupture of membranes occurs bef
ore the onset of labor. The mechanism behind the
membrane is due to apoptosis of membrane cellula
r components , increased specific proteases in the
membrane & amniotic fluid and degradation of coll
agen in the membrane, beyond 37 weeks of gestati
on.
PROM can be confirmed with nitrazine test.
MECHANISM OF PROM SECOND
ARY TO INFLAMMATION