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Obs

Case -3Name: Raghad Reyati is a 29 years old female patient, married for
3 years, not employed lives in Rafah blood group O+.
She is Gravida 4, para 0, +3, living 0. She is a housewife, pregnant
at 36 week and lives in Rafah.
Her LMP is 15/1/2015 and EDD is 22/10/2015.
She was admitted through the ER. At Monday 6st April 2015
This history was taken by me Abdelrahman M sheikh Ahmad, from
the patient herself who looks informative and cooperative.

Chief Complaint: Vaginal bleeding 1 hour prior to admission.


History of presenting complaint:
The patient was doing well till 1 hr before admission when she
started to suffer from painless vaginal bleeding 1 hour prior to
admission, bleeding was about cup of tea in amount and red in
color without clots, and has no odor.
Also 5 days prior to admission She was complaining of little
amount of watery vaginally discharge without odor and was
painless.
She also suffered from colicky lower abdominal pain radiated to
the back 4 days prior to admission with gradual onset and
intermittent course, no clear aggravating or relieving factors ,
pain takes 5/10 in severity scale.
No history of trauma, no urinary symptoms, no headache There is
no history of fever, weight loss, anorexia or night sweat.

There was no history of constipation, diarrhea, and distension.

Systemic review:
All other systems are normal.

#Current pregnancy:
The LMP was at 15th of January 2015 and expected date of
delivery is 22th of October 2015, therefore she is pregnant at 36
weeks gestational age.
This pregnancy was planned, the patient noticed that she is
pregnant by complaining from amenorrhea for 4weeks, associated
with nausea, vomiting and tender breasts.
Pregnancy was confirmed by serum pregnancy test in private clinic in
15/2/2015 which was positive.
At the beginning of pregnancy she diagnosed as a case of thrombophilia
according to genetic study and takes heparin and aspirin

The pregnancy was followed up by doing US scan in private


clinic during routine follow up and it showed normal male fetus
with cephalic presentation and her development is appropriate for
gestational age.
The patient had no problems early this pregnancy and had normal
fetal movement.

Past obstetric history:


Gravida 4, para 0, +3, living 0
She married 3 years ago and has 3 abortions

First pregnancy in first year of marriage and she aborted after 4


weeks of gestation in private clinic without clear cause of
abortion.
Second pregnancy in second year of marriage and she aborted
after 4 weeks of gestation in private clinic without clear cause of
abortion.
Third pregnancy in third year of pregnancy and she aborted after
13 weeks of gestation in Emirati Hospital by curettage without
clear cause of abortion

#gynecological history
Menarche was on 12 years old with regular period. Cycle is
regular every 28 days and lasts for 4-5 days, she uses 2-3 tampons
per 5 days and blood without clots
No mid-cyclic pain, inter-menstrual bleeding neither post coital
bleeding
No use of any contraceptive methods and no gynecologcal
problems as fibroid, endmoetriosis or breast diseases.
The patient wasn't aware of cervical smear.

#Past medical and surgical history:


No chronic medical illnesses.
No surgical history.

#drug history or allergy:


She takes heparin 1 cm subcutaneous injection twice daily during
last pregnancy until now with good compliance.
And takes aspirin 81 mg once daily during last pregnancy with
good compliance.
She starts iron + folic acid tablets once daily during pregnancy.
She takes OTC medications such as needed, No herbal uses.
No history of drug or food allergy.

#family history:
No significant Medical history
No inherited disease (hemophilia, bleeding tendency)
No Pre-eclampsia, chromosomal or congenital anomalies
no Fetal born error of metabolism

#social history:
1. Occupation: not employed
2. Income and medical insurance: good income, they have medical
insurance
No travel history
College education
Well ventilated and exposed to sun house