Identifying Data: 

Full Name: XX

Address: Jamaica, NY

Date of Birth: XX/XX/1999

Date & Time: 10/09/24 10AM

Location: Jamaica, NY

Religion: Muslim 

Source of Information: Self via interpreter 

Reliability: Reliable 

Source of Referral: Self 

 

Chief Complaint: “my baby is not moving” x 24 hours

History of Present Illness: 

XX is a 25 year old G2P1001 female at 39 weeks and 5 days, complaining of decreased fetal movement for the last 24 hours. Patient denies headache, visual symptoms, epigastric pain, abdominal pain, abnormal vaginal discharge/bleeding, loss of fluid, urinary symptoms, contractions. 

Patient had prenatal care with a doctor in Bangladesh and did not bring any records for review. She states the provider switch was initiated by her spouse and she is unaware of the reason for transfer at this time. Patient’s last pregnancy in 2021 resulted in a c-section due to oligohydramnios in Bangladesh. Reports that her current pregnancy is uncomplicated to present. Patient was a late registrant >22 weeks. Patient had declined Panorama and Horizon was negative. 

OB/GYN History:

G2P1001

LMP: 01/05/2024

Menarche Age: 12

No abortions.

Denies postcoital bleeding, history of uterine fibroids and STIs.

 

Past Medical History: 

None

Immunizations: Fully up to date

Childhood illnesses: non-contributory

 

Past Hospitalizations: 

None

 

Past Surgical History:  

Cesarean section, 2021

 

Medications: 

None

Allergies: 

No known drug/food allergies

 

Family History: 

Did not specify 

 

Social History: 

Ms. FJ is a female living at home with her husband and her daughter. She is unemployed and is supported by her husband. 

Habits: Denies smoking. Denies smoking marijuana recreationally. Denies alcohol intake. Denies illicit drug use. 

Travel: Denies recent travel.  

Diet: States she has a well balanced diet.

Exercise: Does not have a robust exercise program. 

Sexual history: Admits to being currently sexually active with one partner. Denies history of STIs. 

 

Review of Systems:

General – Denies weight loss, fever, malaise, weight change, or night sweats.

Skin, hair, nails – Denies pain, pruritus, discoloration, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting.

Eyes – Denies discharge, eye pain, visual changes, and photophobia. 

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. 

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema

Gastrointestinal System – Denies heartburn/regurgitation. Denies abdominal pain, diarrhea, vomiting, loss of appetite, hemorrhoids, constipation, rectal bleeding. 

Genitourinary System – Denies nocturia, increased frequency, urinary hesitancy, flank pain, oliguria, urgency, incontinence. 

Sexual History – Admits to being currently sexually active. Denies history of STIs. 

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies stiffness, erythema, joint pain. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies lymph node enlargement, blood transfusions, clotting.

Endocrine system – Denies heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed female, appearing as her stated age of 25 years, with small build. She appears awake, alert, oriented to person and place. She appears in emotional distress secondary to lack of fetal movement for 24 hours.

Vital Signs: 

BP: Seated – (R) 112/73

R: 18 breaths/min, unlabored 

P: 111 beats/min, regular rhythm

T: 97.8 (Tympanic)

O2 Sat: 100%, room air 

Height: 4’11 inches     Weight: 152 lbs     BMI: 30.70 kg/m2

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. No tenderness to palpation.

 

Heart

+Tachycardia, regular rhythm. S1/S2 with no murmurs, splitting, friction rubs.

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is firm, symmetrical, nontender to palpation. No ecchymosis, rebound, or guarding. No suprapubic tenderness or CVA tenderness. 

 

Female Pelvic Exam

Normal external female genitalia without erythema or lesions.

Sterile Speculum Exam: no evidence of vaginal bleeding. Normal vaginal mucosa pink. Cervix visualized with no visible lesions or discharge.

Bimanual Exam: C/L/P

 

Differential Diagnosis

• IUFD

• Oligohydramnios 

• Fetal hypoxia 

 

Assessment

25-year old G2P1001 female with suspected IUFD. PE unremarkable for cervical dilation, active vaginal bleeding, fluid pooling. Patient is vitally stable with mild tachycardia, likely related to emotional distress. 

 

Lab Results:

• • UA – negative proteins, trace leukocytosis 
  • T&S –  O+, Rh Factor Positive, Antibody Screen negative 
  • NST – non-reactive 

• OB Ultrasound – no FH or fetal movements appreciated 

• APL workup – +Lupus anticoagulant (S/C 1.41, LA pos) 

 

Plan

• Emotional support, seen by social work  
  • Patient declines autopsy and plans for city burial 
• Plan for admission for induction of labor, TOLAC 
• IV fluids D5LR @125 mL 
• GBS & GC collected 
• SCD to both legs for DVT prophylaxis 
• APL work-up done – notable for positive Lupus anticoagulant. 
• Delivery: complicated by chorioamnionitis (PP temp 100.7). Was given Ampicillin 2g IVPB Q6 hrs and Gentamicin 100 mg Q8 hrs. Male fetus delivered with nuchal cord x 1 loose loop. Umbilical vein dark red discoloration with thrombosis. Based on APL workup and umbilical cord abnormality – suspect APL syndrome. Recheck in 12 weeks for confirmatory diagnosis.