DETAILED HISTORY OF PRESENT ILLNESS (HOPI)

All India Institute of Medical Sciences (AIIMS), Gorakhpur

PATIENT DETAILS

CHIEF COMPLAINTS

• Bleeding PV - 1 day
• Abdominal pain - 1 day
• Decreased fetal movement - 1 day

HISTORY OF PRESENT ILLNESS

1. Bleeding Per Vaginum (1 day)

• Patient was apparently well until 1 day prior to admission when she developed bleeding per vaginum.
• The bleeding was of sudden onset.
• The character, amount (soakage of pads), and presence of clots are noted but partially illegible - described as associated with passage of products/tissue per vaginum.

2. Abdominal Pain (1 day)

• Pain in the lower abdomen, onset 1 day back.
• Colicky in nature (lower limb / lower abdomen).
• She also received pain relief (analgesics) prior to arrival.

3. Decreased/Absent Fetal Movement

• Patient noted decreased/absent fetal movements.
• She was apparently unconscious / altered sensorium and was brought to the hospital by a family member (Gentleman companion).

Associated Features

• Patient also complains of cellulitis (right lower limb cellulitis mentioned).
• Patient was found to have altered sensorium on arrival - she was not fully conscious and oriented.

OBSTETRIC HISTORY

PAST HISTORY

• O/E: GCs 1/1/1/A2 (GCS noted)
• S/A at 3.5 months - Fetal movement / anomalies noted (Nuchal translucency / anomaly scan at 3.5 months, fetal medicine consultation done)
• Previous medications: Folic acid, Iron-sucrose, Betahistine, Wysolone (steroids) - noted as ongoing medications

• Tab. Wysolone (prednisolone) - dose noted
• Tab. BBQ (possibly Metronidazole/co-amoxiclav) - illegible
• Tab. Dipyrone / analgesic - noted
• Antibiotics for lower limb infection/cellulitis

PERSONAL HISTORY

• Diet: Veg / Non-veg / Mixed
• Addiction: No alcohol; Tobacco chewing present
• Occupation: Housewife (implied)

FAMILY HISTORY

• Not contributory (details not clearly visible)

IMMUNIZATION HISTORY

• Routine Immunization: Adequate / Inadequate - noted
• Covid Immunization: Vaccine - Covaxin/Covishield - Dose I / Dose II noted

EXAMINATION FINDINGS

Vitals

General Examination

SYSTEMIC EXAMINATION

CVS

• B/L Air entry - equal and adequate bilaterally
• S1 S2 heard, no murmur

CNS

• Patient is conscious and oriented to time, place and person (or partially oriented)
• GCS noted as above

Respiratory System

• B/L air entry equal and adequate
• No added sounds

P/A (Per Abdomen)

• Uterus - at 34 weeks size (or the POG is being described based on fundal height)
• FHS @ 141-144 bpm (fetal heart sounds heard)
• OS - 2 cm soft, effaced/central - Blood-stained liquor noted (BSL present)
• Membranes: Present / intact (? mem +)

Gyn/Obs

• O/A: Acute fetal distress at POG ~34 weeks (if admitted later in gestation OR previous Anomaly scan showed ~34 week equivalent)
• Blood-stained liquor noted

PROVISIONAL DIAGNOSIS

• Blood-stained amniotic liquor
• Possible Antepartum Hemorrhage (APH) - placental abruption vs. placenta previa
• Right lower limb cellulitis

INVESTIGATIONS ADVISED

Routine:

• CBC (Complete Blood Count) / RBS
• Coagulation Profile (PT/INR, APTT)
• KFT (Kidney Function Tests)
• LFT (Liver Function Tests)
• CBS (?)
• HbA1c
• ECG
• CXR
• Urine R/M
• Viral Markers

Special:

• S. Procalcitonin
• LDH
• CRP (Quantitative)
• Ferritin
• D-Dimer
• IL-6
• Urine Culture
• Blood Culture (Aerobic & Anaerobic)
• Sputum Culture / Sputum for MTB Gene Xpert / TrueNaat
• Covid-19 Rapid Antigen
• Covid-19 RT-PCR

SUMMARY

Note: Some handwritten entries were partially illegible. Values interpreted to the best of clinical contextual reading. Please verify against the original document for prescribing or clinical decisions.