Case of Preeclampsia Severe Final3
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Transcript of Case of Preeclampsia Severe Final3
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CASE OF GESTATIONAL
HYPERTENSIONJunior Intern Fairoz Macud Adap
200870003
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General Data
J. B.
40 years old
Married, Filipino, Catholic
Housewife
Cembo, Makati
G4P3 (3003)
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ChiefComplaint
BP Elevation
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Historyof Present Illness
1st
TrimesterAmenorrhea
Pregnancy Test not done
No bloody show
No nausea and vomiting
With increase in appetite
No medication taken
No maternal illnesses noted
No UTZ
No consult done
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Historyof Present Illness
2nd Trimester
Patient had nausea
With quickening noted on the 6th month
No mucoid/watery/bloody vaginal discharge
Experienced irregular contractions
First consult done at St. Andrew Lying-In Center
and was prescribed with multivitamins OD,
ferrous sulfate OD and calcium tablet OD Isoxsuprine tablet given at 32 weeks for 1 week
No laboratory work up done
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Historyof Present Illness
3rd
Trimester Presence of good fetal movement
With irregular contractions
No mucoid/watery/bloody discharge
With intake of multivitamins and ferrous sulfate
UTZ, CBC with PC, UA, BT, VDRL/RPR, HbSAg
were done
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Laboratory Results
Patient
VDRL Nonreactive
RPR Nonreactive
HBsAg Nonreactive
Blood Type B positive
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CBC withPC September20,2011
WBC
10Neutrophils 78.6
Lymphocytes 14.3
Monocytes 7.1
Eosinophils
Basophils
RBC 3.85
HGB 10.9
HCT 32
MCV
79MCH 24.2
MCHC 30.6
RDW 16.3
Platelet 340
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URINALYSIS September20,2011
Color Yellow
Transparency Hazy
Epithelial Cell Few
MucusThread Rare
AmorphousUrates Rare
Pus Cells 4-8
Erythrocytes 0-2
Albumin Negative
Sugar Negative
S
pecificG
ravity 1.010pH 6.0
Bacteria
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BPS withBiometry
(November 11, 2011)Single, alive, intrauterine pregnancy, cephalic presentation,
33 4/7 weeks AOG by BPD and 344/7 weeks AOG by FL.
Placenta posterior, high-lying, grade 2-3.
Adequate amniotic fluid.
Sonographic estimated fetal weight is appropriate for
gestational age.
Biophysical profile score is 8/8.
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Historyof Present Illness
FewHours
PT
A
4th PNCU at OMMC OB-OPD
With good fetal movement
No bloody show
No watery discharge
No headache
No dizziness
BP was 160/90 and patient was brought to ER for
further management
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Past MedicalHistory
(-) previous hospitalization
(-) BA
(-) HPN
(-) DM
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Family MedicalHistory
Hypertension father
(-) BA
(-) DM
(-) allergy to food and medications
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Personal and SocialHistory
Nonsmoker
Non-alcoholic beverage drinker
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Reviewof Systems General: No fever, weight loss and loss of appetite
Skin: No jaundice, no pallor, no cyanosis
HEENT: No headache, no blurring of vision, no pain and
redness of the eyes, no tinnitus, no lymphadenopathies
Respiratory: No colds, cough and dyspnea
CardiovascularCardiovascular:: NoNo palpitations,palpitations, nono paroxysmalparoxysmal
nocturnalnocturnal dyspneadyspnea andand nono chestchest painpain
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Reviewof Systems GastrointestinalGastrointestinal:: NoNo abdominalabdominal pain,pain, nono changechange inin
bowelbowel movement,movement, nono nausea,nausea, nono vomiting,vomiting, nono
melenamelena..
RenalRenal:: NoNo dysuriadysuria,, nono hematuriahematuria,, nono frequency,frequency, nonoincontinenceincontinence
MusculoskeletalMusculoskeletal:: NoNo paralysis,paralysis, NoNo numbnessnumbness
NeurologicNeurologic:: NoNo lossloss of of consciousness,consciousness, NoNo
convulsionsconvulsions
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SexualHistory
Age of 1st coitus: 21
Sexual partner/s: 2
(+) OCP used for 6 years - Ergestrol
(-) IUD (-) Dyspareunia
(-) PCB
(-) STI
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PhysicalExamination
General Awake, conscious, not in respiratory
distressVital Signs 150/90 82 23 37.5
HEENT AS, PPC, (-) NAD, (-) TPC, (-) CLAD
Chest and Lungs SCE, (-) retractions, clear breath sounds
Heart AP NRRR (-) murmurs
Abdomen Globular, nontender
FH: 30 cm EFW (2.8-3.0kg)
FHT: 140s
Extremities Grossly normal, (-)edema,
(-) cyanosis
IE 1 cm, BE, cephalic, (+) BOW, floating
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URINE ALBUMIN: TRACE
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Admitting Diagnosis
G4P3 (3003) Pregnancy Uterine 36 - 37
weeks AOG by LMP, Cephalic in Beginning
Labor
Gestational Hypertension
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Course in the ER
NPO
IVF: D5LR x 8 hours
For Assisted Vaginal DeliveryDiagnostics:
CBC with PC
Urinalysis Blood Typing
SGOT, SGPT, BUN, Crea, BUA, LDH
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Course in the ER
Medication:
Hydralazine 5 mg TIV for BPu160/100
W
OF: persistent BP elevation, signs ofeclampsia, difficulty of breathing
Monitor progress of labor
Monitor VS q1 and FHT q1
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CBC withPC
WBC 12.1
Neutrophils 76.9
Lymphocytes 15.3
Monocytes 7.8
Eosinophils
Basophils
RBC 3.91
HGB 10.7
HCT 30.4
MCV 77.9
MCH 24.9MCHC 32
RDW 16.3
Platelet 325
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Urinalysis
Color Yellow
Transparency Slightly turbid
Epithelial Cell Moderate
MucusThread Few
AmorphousUrates Many
PusCells 0-2
Erythrocytes 0-1
Albumin Trace
Sugar
Specific Gravity
pH
Bacteria
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LaboratoryResults
Patient Normal Values
BUN 14.05 7-18
Creatinine 0.8 0.6-1.1
Uric Acid - -
AST 9.3 0-38
ALT 23.56 0-40
LDH 165.2 103-227
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Course in the DR
BP = 140/70, HR = 86, RR = 20, FHT = 156
Maintained on NPO
IVF: D5LR 1 L x 8 hours
Meds: HNBB TIV q4
Hydralazine 5 mg TIV prn BP > 160/100
1 cerviprime gel given
WOF: fetomaternal distress, BP elevation
Monitor Progress of labor Monitor Vital signs q1 and FHT q 15mins
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10th HourofLabor
Patient delivered via normal spontaneous delivery with
perineal support to live baby boy, AS 9,9
Placenta out completed
IVF: D5LR + 30 u oxytocin x 8 hours IVF to follow: D5LR 20 u oxytocin x 8 hours, then to
consume
To start on low salt and low fat diet
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Final Diagnosis
G4P4(4004) Pregnancy Uterine Delivered
Spontaneously to a Term Cephalic Livebirth
Baby Boy with AS 9,9, BW 2.9 kg, BL 50
cm, PA 37 weeks
Gestational Hypertension
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Course in theWards
1st Postpartum Day Vital Signs: BP 130/90 (BP range 120-130/80-90)
HR 89 RR 21 Temp 36.8
Low salt low fat diet
Medications:
Co-Amoxiclav 625 mg/cap TID x 7 days
Multivitamins 1 tab OD
Ferrous sulfate 1 tab OD
Metoprolol 50 mg/tab 1 tab BID Clonidine 75 mcg/tab 1 tab SL prn BPu160/100
Mefenamic Acid 500 mg/tab 1 tab q6 prn pain on full stomach
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SGPT, SGOT, BUN, Crea and LDH done normal results
WOF: BP elevation, signs of eclampsia
May go home once with control BP range
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Course in theWards
On 3rd postpartum day, patient was sent home with
controlled BP range of 120-130/80-90
No subjective complaints
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