A.P.T., 36 y/o G1P0 (0000) 40-41 weeks AOG

1. A.P.T.,36 y/o G1P0 (0000)40-41 weeks AOG CC: Watery Vaginal Discharge

2. History of Present Illness

3. History of Present Illness

4. LMP: January 18 – 21, 2010 • PMP: December 18 – 21, 2010 • AOG by LMP: 41-42 weeks • AOG by ultrasound: 40-41 weeks

5. Review of systems • No weight loss • No fever, cough, colds, headache • No pruritus, jaundice, cyanosis, pallor • No nausea or vomiting • No diarrhea, constipation • No dysuria, hematuria, edema • No easy bruisability, epistaxis • No polyuria, polydypsia, polyphagia

6. Past Medical History • 2008- Stage 1 Invasive ductal CA, s/p right MRM at Perpertual Help Hospital • no chemotherapy done • negative recurrence during check-ups done every 6 months • No hypertension, diabetes mellitus, asthma, allergies, goiter • No previous blood transfusion

7. Family History • (+) Hypertension – Mother and Father • (+) Bronchial asthma – Maternal Grandfather • (-) cancer, diabetes mellitus, tuberculosis, epilepsy, heart disease

8. Personal and Social History • Non-smoker • Non-alcoholic beverage drinker • Denies illicit drug use or abuse • No exposure to radiation or viral exanthem

9. Menstrual History • Menarche: 13 y/o • Interval: 28 -30 days • Duration: 3 – 4 days • Amount: 4 pads per day, moderately soaked • Symptoms: No dysmenorrhea • LMP: January 18 – 21, 2010 • PMP: December 18-21, 2010

10. Marital/Sexual History • First sexual contact at 27 years old • 1 sexual partner • No post-coital bleeding or dyspareunia • Family planning method: none

11. Obstetrical History

13. CBC (5/29/10)

14. Single live intrauterine pregnancy of about 18 weeks 0 days AOG, Breech presentation, Normal placental implantation and Amniotic fluid volume Male SEFW 212 grams Amniotic fluid: adequate Placenta: posterior, high lying, grade 0 in maturity EDC: October 30, 2010 Ultrasound Report (5/29/10)

17. 08/05/2010 • 50 grams OGCT: 138 mg/dL

19. Single live intrauterine pregnancy of about 29-30 weeks AOG, cephalic presentation Male BPS 8/8 SEFW 1342 grams AFI: 22.92 cm Placenta: posterior, grade 1 in maturity Fetal Biometry: BPD: 7.29 cm AC: 24.86 cm FL: 5.49 cm FAC: 24.86 cm Fetal Biometry (8/10/10)

20. 8/23/10 • 100 grams OGTT: • Fasting: 64.8 mg/dL • 1st hour: 104.4 mg/dL • 2nd hour: 90 mg/dL • 3rd hour: 86.4 mg/dL

24. Single live intrauterine pregnancy of about 35-36 weeks AOG, cephalic presentation, BPS 8/8, SEFW 3005 grams; Polyhydramnios Male AFI: 28.55 cm Placenta: posterior, grade III Fetal Biometry: BPD: 8.75 cm HC: 31.93 cm FL: 6.69 cm FAC: 34 cm Fetal Biometry (10/06/10)

27. Single live intrauterine pregnancy of about 31-32 weeks in cephalic presentation BPS 8/8 SEFW 1639 grams AFI: 15.02 cm Placenta anterior, grade 1 BPS (10/11/10)

28. Urinalysis (9/1/10) Pap Smear (6/22/10) Non specific inflammation

29. BPS result noted • Continue Multivitamins, FeSO4 and 1 glass of milk OD • Still for MRI • Follow up with Neuro with MRI results • Mother’s class every Saturday • Follow up after 2 weeks

30. MRI REPORT (10/13/10) Impression: • Consider Mesial Temporal Sclerosis, on the right, clinical correlation and follow up suggested

31. Physical Examination on Admission • Conscious, coherent, not in cardiorespiratory distress • BP 120/80 PR 84 RR 16 T 36.5 °C • Weight: 146 lbs Height: 157.5 cm • Warm moist skin, no active dermatosis • Pink palpebral conjunctivae, anicteric sclerae • Neck not rigid, no palpable cervical lymphadenopathy, no anterior neck mass • Symmetrical chest expansion, no retractions, clear breath sounds, no retractions • Adynamic precordium, AB 5th LICS MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs

32. Globular abdomen, FH 30 cm • LM1 - breech LM2 - FBR LM3 – cephalic • FHT 150 bpm • Uterine contractions every 7 minutes 40-50 seconds, mild to moderate • IE: cervix 2-3 cm dilated, 50% effaced, (+) BOW, cephalic, floating • Extremities: (-) edema, (-) cyanosis; pulses full and equal

33. Neurologic Exam • Alert, awake, oriented to 3 spheres GCS 15 (E4V5M6) • Intact cranial nerves • MMT: 5/5 on all extremities • Can do APST, FTNT with ease • DTRs ++ on all extremities • No sensory deficit • No Babinski • No nuchal rigidity, Brudzinski, Kernigs

34. Pregnancy 33-34 weeks cephalic, in preterm labor Seizure disorder Assessment

35. Plans • CBC with platelet • Urinalysis • LAT • Refer to Neurology for further evaluation and management • Watch out for recurrence of seizures

36. LAT (10/18/10)

38. A> Pregnancy 33-34 weeks, cephalic, in preterm labor Mesial temporal sclerosis P> Start Isoxsuprine drip (4 ampules in 500 cc D5W) Betamethasone 12 mg/IM q 24 x 2 doses

39. Neurology Referral • A> Generalized Tonic-clonic Seizure secondary to right Mesial Temporal Sclerosis • P> No contraindication for use of Tocolytic Drugs or any form of delivery • Refer if with seizure recurrence • May give Diazepam 5mg/IV every 8 hours for active Seizures

40. NST (4th hour)

41. CBC (10/18/10)

42. Urinalysis (10/18/10)

43. 2nd HD • Isoxsuprine 10mg/tab 1 tab every 8 hours

44. 3rd HD Discharge Medications: • Isoxsuprine 10mg/tab, 1 tab every 8 hours x 2 weeks • Multivitamins 1 cap OD • Ferrous Sulfate, 1 cap OD • Milk 1 glass OD Special Instructions: • Bed Rest • Avoid Sexual Contact and strenuous activities Follow-up or Transfer Instructions: • To come back for follow-up on Oct 29, 2010, 8AM at OB-OPD • To come back for follow up at Neurology after 1 week

45. Neurology • Lamotrigine 50 mg/tab ½ tab ODHS

46. Thank You!