ADMITTING HISTORY

Admission Date: May 2, 2017

Chief Complaint: Elevated Blood Pressure

Brief Clinical History:

Patient is a G2P1 (1000), B.S. Nursing graduate, a ward nurse, Roman Catholic, from Bulacan,
with a blood type of O+, married to a B.S. Nursing graduate, a ward nurse with an unknown
blood type. Prenatal Check-up started at 4 weeks, with a total of around 10 visits. She was
prescribed Methyldopa 250 mg TID for elevated blood pressure. Antenatal ultrasound done 5x,
first 4 were normal, and 5th showed oligohydramnios. OGTT done was normal. There was no
exposure to viral exanthem, radiation and denies smoking, alcohol, and illicit drug use.
Few hours PTA, patient went for a pre-natal check-up in Bulacan where she was found to have
an elevated BP of 160/100, she was given 1 dose of Methyldopa 250 mg/tab subsequent
systolic blood pressures were 170, 180. She was then referred to our institution for
management.

Past History
2014
(+) GDM
(+) IUFD (37 weeks)
(+) Preeclampsia
(+) Allergic Rhinitis

Family History
(+) HTN- Father
(+) DM- Father
(+) Papillary Thyroid CA- Mother

Pertinent Physical Examination Findings

BP: 170/100
PR: 110
RR: 20
SPO2: 99
Temp: 36.6 degrees centigrade
-Conscious, coherent, ambulatory, not in respiratory distress
-Pink palpebral conjunctiva, anicteric sclera, pupils 2-3 cm
-Nasoaural discharge, dry lips, moist buccal mucosa
-Symmetrical chest expansion, clear breath sounds
-Apex beat 5th LECS, MIL, no murmurs heard

List of Current Medications

Methyldopa 250 mg TID
ASA 80 mg/tab

Alert-Allergic to
Celecoxib

Admitting Diagnosis
G2P1 Pregnancy Uterine 31-32 weeks, cephalic, consider Preeclampsia with severe features

OB-GYN ULTRA SOUND

Date: May 2, 2017
G: 2 P: 1
LMP: September 23, 2016
Menstrual Age: 31 W 4 D

Second and Third Trimester

Number of Fetus
Singleton
Presentation: Cephalic
Heart Activity: 159 BPM

Biometry
BPD: 7.88 cm
SEFW: 1430 grams
FL: 5.71 cm
FAC: 24.53 cm

Age of Gestation based on today's scan: 30 weeks 1 day

Amniotic Fluid
AFI: 8.80 cm

Placenta
Location: Posterior
Grade: II-III

Biophysical Score:
NST: 0
Amniotic Fluid: 2
Body Movement: 2
Fetal Tone: 2
Fetal Breathing: 2
Total: 8/8

Doppler Velocimetry:

S/D: 2.55
PI: 0.89
RI: 0.61

Remarks:
Single Live Intrauterine Pregnancy of about 30-31 Weeks, in Cephalic Presentation
BPS 8/8, SEFW 1430 Grams
Normal Umbilical Artery Doppler Indices

OB-GYN ULTRA SOUND

Date: May 3, 2017
G: 2 P: 1
LMP: September 23, 2016
EDC: June 26, 2017
Menstrual Age: 31 W 5 D

Second and Third Trimester

Number of Fetus
Singleton
Presentation: Cephalic
Heart Activity: 147 BPM

Amniotic Fluid
AFI: 8.831 cm

Placenta
Location: Posterior
Grade: II-III

Biophysical Score:
NST: 0
Amniotic Fluid: 2
Body Movement: 2
Fetal Tone: 2
Fetal Breathing: 2
Total: 8/8

Doppler Velomicetry:

S/D: 2.64
PI: 0.92
RI: 0.62

Remarks:
BPS 8/8 Normal Umbilical Artery Doppler Indices