The Case of Ao

Harold Nathan Tan

090109

The Case of A.O.

Identifying Data: A.O. is a 28-year old, G1P0 (0000), married, Born Again Christian from Manila who had her first admission at The Medical City on June 7, 2012

Physician-in-charge: Dr. Rowena Rivera

Source and Reliability: Information was gathered from the patient herself; she seemed to have good reliability.

Chief Complaint: fever of one day duration

History of Present Illness:

Patient was apparently well until one day prior to admission when she noted of fever (max temperature = 38.9 degrees Celsius) with accompanying sharp, intermittentright flank pain (severity = 4/10) and easy fatigability. There was no dysuria,frequency, hematuria, cough and colds. Patient self-medicated with Paracetamol 500 mg every four hours which helped in relieving fever. However, fever recurred after four hours of Paracetamol intake.

A few hours prior to admission, fever was still persistent with maximum temperature recorded at 39.1 degrees Celsius with accompanying sharp, intermittent right flank pain (severity = 6/10). Patient also noted of one episode of non-projectile vomiting with vomitus resembling clear watery fluid and amounting to approximately 500 mL. Patient noted of good fetal movements. There was no note of regular uterine contractions, watery or bloody vaginal discharge or abdominal pain. Persistence of fever prompted admission at the OB Intensive Maternal Unit at The Medical City.

History of Present Pregnancy:

Patient was regularly menstruating until eight months prior to admission when she noted of missed menses. She had been sexually active, with frequency of coitus noted to be at two times per month with one partner. Patient undertook a pregnancy test, where she tested positive. There was no associated headaches, dizziness, breast tenderness, nausea, abdominal pain, easy fatigability and low back pain.

Due to the positive pregnancy test, patient had her first prenatal checkup at The Medical City on...