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1
Hospital: Southern Philippines Medical Center
Date & Time of Admission: February2, 2017 02:15 PM
Date & Time of Interview: February2, 2017 02:20 PM
Informant: Patient
Reliability: 90%
GENERAL DATA
RT
28 years’ old
G2P1 (1001)
Married | Davao City
CHIEF COMPLAINT
Patient went for her 2nd prenatal check-up at a local lying-in by a midwife and was noted to
have new onset of elevated BP of 160/100mmhg, pre-pregnancy BP was claimed to be 110/70-
120/80mmhg. She was prescribed with Methyldopa 250mg/tab BID as a maintenance medication
and was advised for hospital delivery upon approaching her expected day of confinement, no
other medications, no laboratory workup done. Patient took above medication for 1 week with
good compliance however no improvement of BP was noted. Patient sought consult at the same
lying-in and Methyldopa 250mg/tab was increased to TID, patient took said medication up to
present with good compliance however BP did not improve, highest BP was noted to be
160/100mmhg and lowest was 150/90mmhg.
Patient was apparently well at the interim except for the elevated BP, no other
manifestations. Weekly BP monitoring was done at the lying-in; patient was also advised for
consultation at a hospital however did not comply due to busy schedule.
Patient sought consult at the OPD as a referral case from a local lying-in by a midwife, with
an elevated BP of 160/120 mmHg, with associated labor pains every hour with duration of
approximately 20 seconds with pain scale of 4 out of 10. No other medications taken aside from
her maintenance, persistence of above manifestations prompted this admission.
2
PAST MEDICAL HISTORY
FAMILY HISTORY
Hypertension: Mother
Diabetes Mellitus: Father
Asthma (-)
Cancer (-)
PERSONAL/SOCIAL HISTORY
Patient was born and raised in Davao City. She finished high school and is currently
working as a service crew in Gaisano mall. She is married and currently lives with her husband
and 1 child.
The patient is not a smoker or an alcoholic beverage drinker. She has no history of illicit
drug use.
She eats three meals a day and she prefers vegetables, and meat. She usually wakes up
around 6am in the morning to take care of her family and prepare for her work.
OBSTETRIC HISTORY
G2P1 (1001)
Pregnancy Year Sex Birth Mode of AOG at Complications Present
Order Weight Delivery birth and Status
Abnormalities
1 2008 F 3.1 kg Home Term None Living
Delivery
attended
by a
midwife
2 PRESENT PREGNANCY
3
Antenatal Visits:
total number of checkups=2
1st checkup @ 13 weeks AOG (Ultrasound done on August 2, 2016, result: Single, live early
intrauterine pregnancy with an AOG of 13 wks. and 4 days by crown-rump length measurement.
EDD 2-3-17 +/- 1 week, no repeat ultrasound was done, Urinalysis - normal as claimed, CB -
normal as claimed, FeSO4 tab OD with good compliance).
GYNECOLOGIC HISTORY
Menarche: 13 y.o.
Thelarche: 12 y.o.
SMP: Regular (30-31 days’ cycle) x 5 days’ duration x moderately soaking 2 pads/day
Dysmenorrhea: (-)
(+) contraceptive use
2008 – 2015: Oral Contraceptive Pills (no side effects experienced as claimed, with good
compliance).
(-) gynecologic surgeries
(-) Pap smear
REVIEW OF SYSTEMS
4
(-) goiter • (-) Dysphagia
(-) lump • (-) Hemorrhoids
(-) pain Genitourinary
(-) stiffness of neck • (-) Urinary frequency
Breasts • (-) vaginal pruritus
(-) lumps • (-) Sores
(-) pain • (-) Passing of stones
Musculoskeletal
(-) discharge
• (-) Joint pain
• (-) Trauma
Respiratory
• (-) Stiffness
• (-) Dyspnea
• (-) Cramps
• (-) Cough
• (-) weakness
• (-) Hemoptysis
Neurologic
• (-) Sputum production
• (-) Numbness
• (-) Wheezing
• (-) Tingling sensation
Cardiovascular
Endocrine
• (-) Chest pain
• (-) Heat/cold
• (-) Palpitations
intolerance
Gastrointestinal
• (-) Breast/voice change
• Good appetite
• (-) Polydipsia
• (-) Constipation
• (-) Polyphagia
• (-) Nausea
• (-) Thyroid problem
• (-) Hematemesis
5
PHYSICAL EXAMINATION
General Survey
• Awake, alert, and responsive. Comfortable, afebrile, and not in
respiratory distress.
Vital Signs
BP 170 / 110 mmHg -> 200/130 mmHg
T 37.1 C
RR 20 cpm
CR 82 bpm
Height = 153 cm
Weight = 82 kg
Fundic Ht: 28 cm
Estimated Fetal Weight: 2635 kg
Preconception Weight: 60 kg
Preconception BMI = 25.3 (Overweight)
HEENT:
• Head – Normocephalic.
• Hair is long, black, and even in distribution.
• Face is symmetrical, without tics, edema, or masses.
• No Periorbital edema
• Eyes – Pupils are equally round and reactive to light and accommodation,
constricting at 2mm.
• (-) ptosis or nystagmus.
• (-) icterisia
Cardiovascular:
I– No visible pulsations.
A – Cardiac rhythm regular. Audible S1 and S2, PMI at left 5th intercostal space,
midclavicular line. No murmurs or adventitious heart sounds.
Abdomen:
Non-distended, no lesions or scars, linea nigra and striae gravidarum noted,
normoactive bowel sounds noted, 15 per minute, tympanitic, no involuntary guarding.
No rebound tenderness.
Fundic height of 28 cm
Mild intensity uterine contractions every 3-5 minutes lasting 15-30 seconds.
Leopold’s Maneuver:
L1 – large, nodular mass (breech)
L2 – hard, resistant structure at maternal right side, whereas in the
maternal left side there are numerous small, irregular, mobile parts
(fetal back @ right side)
L3 – round, ballotable structure (cephalic)
L4 - cephalic prominence at the same side of the fetal small parts
Interpretation - Cephalic in presentation, not engaged
Pelvic exam:
External genitalia: No gross lesions, no ulcerations, no discharge, no swelling
noted.
Speculum exam: Cervix is bluish in color, is positioned midline and smooth
consistency. No lesions noted.
Internal exam: Introitus admits two fingers with ease, cervix is 3 cm dilated, 50%
effaced, station -3, intact bag of water, cephalic presenting
part.
Extremities:
Bipedal edema, non-pitting, grade 1. Full pulses, CRT<2 seconds.
Cranial Nerves:
I: Identified scent of coffee and cologne on both nostrils
II: able to read small text on newspaper print.
II & III: Good direct and consensual pupillary constriction
III, IV, VI: Both eyes were able to follow examiners finger without adventitious
movements.
V: S: Localized area where wisp of cotton was applied; M: Clenched
jaw
VII: S: (-) changes in taste; M: able to puff her cheeks and raise her
eyebrows symmetrically.
VIII: Able to hear whispered voice.
IX: Able to swallow without difficulty. With good articulation. Intact gag reflex.
X: Able to speak fluently. Uvula is in midline.
XI: Able to shrug both shoulders and turn head from right to left against resistant.
XII: Tongue midline and able to move tongue from right and left, up and down.
Cerebellar Function: Able to do Rapid alternating movements
Motor: Good muscle bulk and tone. Muscle strength 5/5 throughout.
Sensory: Pinprick, light touch and position sense intact
Reflexes: 2+ throughout and symmetric.
SALIENT FEATURES:
Admitting Impression:
G2P1 (1001) Pregnancy Uterine 40weeks AOG, Cephalic in Latent phase of Labor,
Gestational Hypertension
Differential Diagnosis:
Rule In Rule Out
Preeclampsia Normotensive prepregnancy (-) headaches
Hypertension started at 8 (-) visual
It is characterized by new-onset months AOG
disturbances
elevation of blood pressure of BP of 170/110mmHg upon
admission (-)epigastric/RUQ
>140/90 after 20 weeks of gestation,
often near term with accompanying Highest BP:170/110mmHg pain
proteinuria exceeding 300mg/24 BMI of 25.3 prepregnancy (-)oliguria
hours or a urine;creatinine ratio >/= (overweight)
0.3 or persistent 30mg/dL (+1 Weight gain of 22.1kg
dipstick) protein in random urine Edema of the lower
sample. extremities extending up
to the distal 3rd of the
This is best described as a
pregnancy-specific syndrome that
lower legs. Grade 2
can affect virtually every organ edema (4mm).
system. Proteinuria, an objective We ruled this in because the
marker,reflects the system-wide patient was normotensive
endothelial leak which characterizes before the pregnancy. Upon
the preeclampsia syndrome. admission, her blood pressure
was documented at 170/110
mmHg with highest BP of We ruled this out since
170/110 mmHg as claimed. the patient did not
Hypertension started at 8 have proteinuria,an
months AOG. She also had objective marker,
prepregnancy BMI of 25.3 which reflects the
which is interpreted as system-wide
overweight, a risk factor endothelial leak which
implicated in the development characterizes the
of this syndrome. Weight gain preeclampsia
during the course of pregnancy syndrome. She did not
was 22.1kg which exceeds the also have
recommended weight gain for thrombocytopenia,
overweight individuals which headaches, visual
was supposed to be 15-25lbs. disturbances or right
In her physical assessment, she upper pain which are
had bipedal and distal 3rd lower very characteristic of
extremities nonpitting edema preeclampsia.
which is usually seen in
preeclamptic patients although
it is no longer required for
diagnosis.
Chronic Hypertension of BP of 170/110 mmHg Normotensive
Any Etiology upon admission prepregnancy
Hypertension
started at 8 months
This is diagnosed in a woman
AOG
with documented blood
pressure of >/= 140/90mmHg Usual BP 110/70-
known to exist before 120/80 mmHg
pregnancy or before 20 weeks
of gestation, or both.
We ruled this in since the patient We ruled this out since
had a blood pressure of the patient was
170/110mmHg upon admission. normotensive before the
pregnancy with usual
blood pressure of
110/70-120/80. Her
hypertension started at 8
months age of gestation.
HOSPITAL DAY 1
SOA PLAN
S: Patient was admitted with consent to care
(+) hypogastric pain with Patient was placed on NPO
pain scale of 4/10 Venoclysis started of D5LR @ KVO
(-) headache Vital signs were monitored every 4 hours
(-) abdominal pain The following laboratories were requested which
(-) blurring of vision revealed:
o CBC:
O: Hgb 129
BP = 170 / 110 mmHg HCT 0.41
PR = 82 bpm RBC 6.18
RR = 20 cpm WBC 12.87
Temp = 37.1
Neutrophil 77
Lymphocyte 17
Height = 153 cm
Weight = 82 kg Monocytes 4
Eosinophil 2
Linea nigra and striae PLT 460
gravidarum noted o Blood type: O positive
Fundic height of 28 cm o Urinalysis:
Appearance: cloudy
L1 – large, nodular mass Color: dark yellow
(breech) Protein: 1.0 2+ H
L2 – hard, resistant structure pH: 6.0
at maternal right side Specific gravity: 1.013
whereas maternal left side Glucose: negative
there is numerous small, RBC: 3123 H
irregular, mobile parts. WBC: 174 H
L3 – movable mass is present Epithelial cells: 39 H
(floating) Cast: 0
Bacteria: 6.
FHT = 153 bpm Mucus threads: 13
o HBsAg: Nonreactive
External genitalia: No gross o SGPT: 12.1 L
lesions, no ulcerations, no o LDH: 569.7 H
discharge, no swelling noted o Creatinine: 40
O:
BP = 200/130 mmHg
PR = 88 bpm
RR = 20 cpm
Temp = 36
FHT = 144
EFM Tracing:
Baseline fetal heart rate:
140-145
(+) Acceleration
(-) Deceleration
Moderate variability
Mild to moderate uterine
contractions every 3-4
minutes lasting for 30-45
seconds
O:
BP = 150/100 mmHg
PR = 92 bpm
RR = 20 cpm
Temp = 36.7
Moderate to strong
contractions every 2-3
minutes lasting for 45-60
seconds
Internal examination:
4 cm dilated, 40% effaced, -1
station, ruptured bag of water
S:
(-) headache
(-) abdominal pain
(-) blurring of vision
(+) pain at episiorrhapy site
O:
BP = 170/100 mmHg
PR = 86 bpm
RR = 20 cpm
Temp = 36.8
O:
BP = 190/100 mmHg
BP (rechecked) = 130/100
mmHg
S:
(-) headache
(-) abdominal pain
(-) blurring of vision
O:
BP = 170/90 mmHg
BP (rechecked) = 130/80
mmHg
PR = 84 bpm
RR = 20 cpm
Temp = 36.2
12:00 AM
S:
(-) headache
(-) abdominal pain
(-) blurring of vision
O:
5:10 AM
S:
(-) headache
(-) abdominal pain
(-) blurring of vision
O:
BP = 140/80 mmHg
PR = 85 bpm
RR = 20 cpm
Temp = 36.2
Final Diagnosis:
G2P2 (2002) Pregnancy uterine delivered a live term baby boy by normal
spontaneous vaginal delivery, with repair of 2nd degree median episiotomy,
Preeclampsia severe
CASE DISCUSSION
Introduction
Preeclampsia syndrome
Etiopathogenesis
Gestational hypertensive disorders are more likely to develop in women with the
following characteristics:
Etiology
Management
Consideration of delivery
With moderate or severe preeclampsia that does not improve after hospitalization,
delivery is usually advisable for the welfare of both mother and fetus. This is true
even when the cervix is
unfavorable. Labor induction is carried out, usually with preinduction cervical
ripening from a prostaglandin or osmotic dilator. Whenever it appears that induction
almost certainly will not succeed or attempts have failed, then cesarean delivery is
indicated.