Jane Doe

HUH
JD555@drexel.edu
Page 1 of 3

CC: “fluid leakage”

HPI: Patient is a 21 year old African American Gravida 3 Para 1011 at 37 weeks gestations by
LMP of 10/25/10 giving her an EDD of 8/1/11. Patient complains of leakage of fluid, which
occurred earlier this morning. She described it as a loss of maybe a half cup full, and only
occurred on this single occasion. She has not lost any additional fluid since. She stated the fluid
was clear, denied the presence of blood. She has not experienced any contractions, and states
that fetal movements have been as active as usual. She reports no other symptoms. Denies
nausea, vomiting, fever, chills, or any urinary symptoms. She was very distressed by this loss of
fluid and is concerned that she has broken her water.

Prenatal Care:
Patient receives PNC currently at Temple University Hospital
Patient is noncompliant, has missed multiple PNC visits
States U/S received at 20 weeks, no complications
No current pregnancy complications detected

Obstetric History:
G3P1011
2007- Full Term live male infant 8lbs4oz, NSVD, no complications
2009- Elective Abortion, D and E, no complications, Temple University Hospital

Gynecologic History:
Menarche at 12 years old
Menses: regular cycles, last 30 days, bleed for 5
Contraception: patient has never used any hormonal contraception methods, occasional
condom use
STDs: patient has a history of Chlamydia one month prior, was treated with oral ABX
No history of abnormal PAP smears reported
Sexual History:
o 1st coitus at age 14
o 6 total sexual partners, male
o currently one male sexual partner
o currently satisfied with sexual life, denies dyspareunia

Past Medical History:

No pertinent medical history
Up to date on vaccinations

Past Surgical History:

Dilation and Evacuation for elective abortion, 2009

Medications:
Zofran as needed for morning sickness
Jane Doe
HUH
JD555@drexel.edu
Page 2 of 3

Allergies:
NKDA, denies food, seasonal

Family History:
No known history of HTN, DM, VTE, or genetic disorders

Social History: Patient lives with her parents and son. She has finished high school and does not
currently work. She occasionally smokes marijuana, but has not since becoming pregnant. She
denies cigarette use, alcohol, or other illicit drugs. She does not exercise. She eats small
frequent meals currently as it has helped to lessen her GI upset. She drinks plenty of water and
juices daily. She denies any current or history of abuse and feels safe where she lives. She
always wears a seat belt and has smoke detectors in her home. Patient is not currently speaking
with the father of the baby, who was her boyfriend until she was diagnosed with Chlamydia a
month ago, at which point he admitted to having sexual relations with another woman.

Review of Systems:
General: denies fevers, headaches; experiences appropriate fatigue and weight gain
HEENT: denies changes in vision, smell, hearing or taste
Cardiac: denies palpitations, chest pain
Pulmonary: denies SOB, sputum production
GI: occasional nausea and vomiting earlier in pregnancy, none currently
GU: denies dysuria, frequency or urgency
Gynecologic: see HPI
Musculoskeletal: denies joint or muscle pain
Neurologic: denies changes in memory or concentration
Psychologic: denies feelings of depressed mood, denies desire to harm self

Physical Exam:
General: well nourished pregnant female, in no acute distress, alert and oriented
Vitals: BP=115/75 Pulse =76, regular Respirations =18
Height= 5’5” weight= 145 lbs BMI=24.1
HEENT: normocephalic, pupils round, equal and reactive, moist mucus membranes, no
lymphadenopahy, no sinus tenderness, no thyromegaly
Cardiac: regular rate and rhythm, S1 S2, A2>P2, no rubs, gallops, or murmurs
Respiratory: lungs clear to auscultation, no wheezes, rales, rhonchi. No CVA tenderness
Abdomen: gravid, fundal height measured at 37 cm from pubic symphysis, non-tender.
Cervix: Speculum exam- cervix without lesions, slight discharge present, no pooling, and
no blood visualized. Nitrazine test negative, no ferning present on slide, cultures taken.
Normal epithelial cells seen on wet mount, no trichimonas or yeast present. Digital
exam- 1/thick/high
Fetal Evaluation: Fetus is longitudinal cephalic. Baseline FHR of 145, moderate
variability, accelerations present. No decelerations noted. Reassuring, Category I
Breast exam: no masses palpated, no nipple discharge
Jane Doe
HUH
JD555@drexel.edu
Page 3 of 3

Labs:
GCCT cultures negative
GBS negative
Ultrasound performed, AFI measured at 9.

Assessment and Plan:

Patient is a 21 year old female, G3P1011, who presents to the L and D triage for one
episode of vaginal fluid leakage.

1. Vaginal fluid leakage: Rule out ROM. Differential diagnosis includes SROM,
urinary leakage/incontinence, normal vaginal/cervical discharge of pregnancy,
exogenous fluids such as semen, and fistulas. We can most likely rule out SROM due
to absence of vaginal pooling, negative Nitrazine test, an AFI within normal range,
negative ferning and no further experiences of fluid loss. This is most likely a urinary
incontinence episode as the fluid was clear without blood or mucus. A fistula is
unlikely in a patient of this age with only a prior surgical history of a D and C.
Patient was counseled on normal discharge and how exogenous fluids can be
confused for ROM.

2. Education: Patient was provided with information on SROM, true and false labor,
what to expect when she is in labor and when to come in to the hospital. As she has
gone through a NSVD prior, she was familiar with the information provided and
seemed to understand.

4. Contraceptive options: Patient should be counseled after delivery on contraceptive

options and started on some form of birth control prior to leaving the hospital.

5. Drug use: Patient was counseled on adverse effects of drugs in utero. Consider
toxicology screen while hospitalized for delivery and possibly a social work consult.

6. Patient is Rh+, no RhoGAM considerations necessary.

7. Patient is currently GBS negative, no ABX prophylaxis needed as this time.

8. Screenings: encourage patient to seek routine ob/gyn and general health care, as well
as following up with her current PNC appointments. She is a 21 year old female with
a prior STD history so she should continue to receive her yearly gynecologic exams
including PAP smears and cervical cultures.