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A Journey of Medical Marvels: Unveiling the Diagnosis of Patient CD's Obstetric History

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Question: diagnostic procedure for In March 2024, 3 days prior to admission, Patient CD, a 19-year-old female residing in Parola, Tondo, was admitted to Bagong Ospital ng Maynila Medical Center due to abdominal pain. She underwent normal spontaneous vaginal delivery to a live baby boy. The patient was discharged after 48 hours confinement, and she also mentioned breastfeeding sustained for one month with her first baby. In 2022, 2 years prior to admission, she was admitted to JASGEN due to miscarriage second month into conception. Patient CD reported bleeding and is unable to recall or identify the cause of miscarriage. She did not undergo dilatation and curettage. Patient CD was not hospitalized for other reasons aside from pregnancy following this. An hour prior to admission, patient CD reported hypogastric pain, uterine contractions, and lumbosacral pain. After validation, the last menstrual period was on July 12, 2023, the EDC is March 19, 2024 and the AOG is 39 1/7 weeks. Upon internal examination, cervix is 7 cm dilated, 90% effaced with bag of water, with cephalic presentation and station of -2.

Asked by dale_hendric

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From the mentioned facts, the patient seems to be in labour. Here are the basic diagnostic procedures and assessments that should be done based on these symptoms: 1. **Obstetrical History** - This has already been established, but it is important to double-check the details again, especially about past deliveries, pregnancies, and any complications that occurred. 2. **Presenting Symptoms Assessment** - Evaluate the patient's pain, contractions, and backache. The frequency, duration, and intensity of contractions should be documented. 3. **Physical Examination** - This should include an examination of all systems, not just the reproductive system, but primary focus should be given on the reproductive system. It includes checking the dilation and effacement of the cervix, position and station of the baby. As per the provided details, the patient is already in active labour. 4. **Lab Tests** - Routine blood tests including CBC, blood type, Rh factor should be ordered to check for any abnormalities which could affect the delivery or indicate potential concerns for mother's health. 5. **Cardiotocographic Monitoring (CTG)** - CTG monitoring should be advised to monitor the baby's heart rate and the mother's contractions. This will help to detect any fetal distress early. 6. **Ultrasound** - An ultrasound can give a clear picture of the baby's position, the location of the placenta, amniotic fluid levels and other crucial details. 7. **Vital Signs Monitoring** - Regular monitoring of BP, pulse rate, temperature. If there are any complications or risks found, other diagnostic procedures may be needed. It is absolutely vital that the patient is closely monitored for progression of labour and to look for any signs of distress both in the mother and baby. As she has reported miscarriage in the previous pregnancy, special care should be taken to avoid any complication in the current pregnancy. Notify the gynecologist immediately if any abnormal signs or symptoms appear. As in any healthcare procedures, make sure the patient's consent is obtained before carrying out any tests or procedures.

Answered by gpt-4

April 26, 2024, 1:15 a.m.

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This article was generated in part by one of OpenAI’s large-scale language-generation model, answering user dale_hendric's question. Images were generated with OpenAI's AI model, DALL·E 2. The Internet takes ultimate responsibility for the content of this publication.
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Published: Friday, April 26, 2024

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