Download Gathered: May 18, 2010 at 2:00pm Source: Patient Reliability: 90% I

Gathered: May 18, 2010 at 2:00pm
Source: Patient
Reliability: 90%
I. PATIENT’S PROFILE
A. General Data
G.G, 33 y.o., G2P0(0100), 35 wks and 4/7 days AOG , Filipino, Roman Catholic,an office clerk,
born on February 4, 1977 in Mati, Davao oriental, presently residing in B. Rodriguez, Cebu City, was
admitted for the first time on May 14, 2010 at Cebu Doctors’ University Hospital.
B. Menstrual History
Menarche was at 17 y.o. with flow lasting for 5 days consuming 2-3 fully soaked pads per day.
Subsequent menses occurred at in irregular interval of mostly two months with flow lasting for 5 days
consuming 2-3 pads/day. Associated sign and symptom is breast tenderness. No dysmenorrheal, no
intermenstrual bleeding noted. LMP was on September 9, 2009 and PMP was on July 10, 2009.
C. Obstetric History
OB score of G2P0(0100)
Previous Pregnancies: G1 – April 20090, 32 weeks AOG, IUFD, D/C done in Maternity Hospital
Present Pregnancy:
LMP = September 9, 2009
EDC = June 16, 2010
AOG = 35 weeks and 4/7 days
D. Prenatal History
Patient’s first prenatal check up was done on December 23, 2009 at 15 weeks AOG at CDUH
OPD. Vital signs were normal. The following laboratory tests were requested: CBC and FBS = normal,
Urinalysis = (+) protein. She also has papsmear on her first prenatal which showed positive for N.
gonorrheae. Patient took cefuroxime 500mg, 3x/day for 1 week at 24 weeks AOG and was resolved as
claimed by the patient. Subsequent prenatal check up was done regularly, every 4 weeks until 32 weeks
AOG and every 2 weeks until 35 weeks AOG. TT3 was given on March 2010. Patient took vitamins,
Beniforte OD and Caltrate plus for calcium supplement. Quickening was observed on 16 weeks AOG.
Present weight of 119 lbs with a weight gain of 20 lbs. Usual BP ranges 100/70 mmHg – 120/70 mmHg.
Last prenatal check up was done on May 7, 2010.
E. Contraceptive History
Patient has no history contraceptive use.
F. Sexual History
Patient’s first coitus at the age of 31 years old with her husband as her only sexual partner. Coitus
done regularly, satisfied, no dyspareunia noted.
G. Past Medical History
Childhood illnesses: (+) chickenpox and measles
Immunizations: BCG, DPT, OPV, Hep B with booster with unrecalled dates
-was given TT1 and TT2 during her first pregnancy.
Hospitalization: in Maternity Hospital for her first pregnancy, IUFD, D/C was done on April 2009
Serious Illnesses : Preeclampsia on her first pregnancy and was resolved after taking Dopamet OD
for 1 week.
- Gonorrhea but was resoled as claimed by the patient after taking medication.
H. Personal and Social History
Patient is a college graduate and work as an office clerk. She had no allergies on food, drugs and
dusts. No history of using prohibited drugs, non smoker and do not drink alcoholic beverages. She’s
married for 3 years. Husband is 34 y.o and a driver and is apparently well as claimed by the patient.
I. Family History
Father: 66 years old, hypertensive
Mother: 55 years old, apparently healthy
Birthrank: 3rd / 5 children, all siblings are alive and healthy
Heredofamilial diseases: Hypertension, no History of twinning, difficulty of delivery and congenital
anomaly
II. CHIEF COMPLAINT
EDEMA
III. HISTORY OF PRESENT ILLNESS
Patient’s condition started 10 days PTA when patient noticed a non pitting edema on her feet. No
pain felt. No fever, no dizziness but decrease urine output inspite increase fluid intake. No consultation
done.
8 days PTA, during her prenatal check up, edema persisted and extended to her lower legs. Vital
signs were normal. Patient was told by her OB that it was normal and was advised to elevate legs at home
and while sleeping. Edema reduces upon waking up but recurs every afternoon and during activities. No
medications taken.
Few hours PTA, patient claimed that edema went up to her thighs thus decided to sought
consultation in the ER. During PE, BP was noted to be elevated, fluctuating from 160/90 mmHg to
160/100 mmHg to 170/90 mmHg. Patient was advised for admission for close monitoring on her edema
and BP.
IV. REVIEW of SYSTEMS
Weight gain of 20 lbs.
Bilateral non-pitting edema on lower extremities
oliguria
Slight breast tenderness
Striae gravidarum on abdomen and linea nigra
V. PHYSICAL EXAMINATION
General Survey: Patient is alert, coherent, oriented to time, date, place and person, not in distress,
maintained eye contact, well-groomed.
Vital Signs:
BP: 120/70 mmHg, right arm, high fowlers
TEMP: 38.8, left axilla
PR: 90 bpm, regular rhythm, right radial pulse
RR: 19 breaths/min, regular rhythm, high fowlers
HT: 4’9”
WT: 119 lbs
BMI:
Skin: warm, smooth, good mobility and turgor
HEENT:
Head: no lumps, symmetrical, no pain or tenderness
Face: (+)facial edema, (+) periorbital edema, no lesion
Eyes: visual acuity of 150/20 both eyes, anicteric sclera, (+) direct and consensual light reflex, (+) ROR,
no blurring of vision, intact visual fields and EOM
Ears: no pain on external ear, no hearing loss, no discharges, no tinnitus
Nose: no tenderness of sinuses, no septal deviation
Mouth and Throat: pinkish oral mucosa, no soreness, no ulcers, no sore throat, no tonsillitis, no gum
bleeding, no pigmentation
Neck: no enlarged lymph nodes, trachea midline, no goiter
Breast and Axilla: no lumps, no nipple discharges, slight tenderness
Chest and Lungs: equal chest expansions, no adventitious breath sounds, not tachypneic, equal tactile
fremitus
Heart: no murmur, no splitting of heart sounds
Abdomen: protuberant, no mass, (+) striae gravidarum, (+) linea nigra, normoactive bowel sounds
Palpation: Fundal height = not done
Leopold’s Maneuver = not done
Uterine contraction = not done
Ausculation: normoactive bowel sounds
Featal Heart Tone = not done
Female Genitalia: positive pain
Back and Extremities: (+) non-pitting edema on lower extremities, no muscle and joint pain
Neurologic: intact cranial nerves, no loss of sensation, no muscle weakness, +4 muscle strength, good
rapid alternating movements
Rectal Examination: not assessed
VI. DIAGNOSIS
1. Mild Preeclampsia
Rule in = BP fluctuating from 160/90 to 160/100 to 170/90 mmHg at 35 wks 4/7 days
AOG.
(DBP : <100mmHg.)
= Proteinuria = (+)
= Oliguria
= Edema
2. Pregnancy Uterine, 35 wks 4/7 days AOG, cephalic presentation, not in labor, delivered a
premature baby girl by NVSD (induced).
VII. DIFFERENTIAL DIAGNOSIS:
1. Severe Preeclampsia
Rule in = oliguria
Rule out = DBP not > 110 mmHG
= proteinuria = not (++)
2. Gestational Hypertension
Rule in = mild hypertension
Rule out = no proteinuria
3. Chronic Hypertension
Rule in = mild to severe hypertension
Rule out = Chronic HPN occur <20 wks AOG or before pregnancy
= no proteinuria
4. Eclampsia
Rule in = Hypertension, Proteinuria, Edema
Rule out = No seizure