Case presentation

1. Altiveros, Ann Jacqueline San beda College – Medicine level IV Case presentation

2. C.B. is a 24 year old Filipino Born Again Christian Married Housewife Admitted for the second time at QMMC on April 25, 2011. General data

3. Severe abdominal pain Chief complaint:

4. 8 days PTA - admitted and gave birth to a live baby girl via normal spontaneous delivery with no complications noted. HPI

5. 6 days PTA • discharged from the institution • take home medications • Mefenamicacid 500 mg q6 for pain, • cefalexin500mg TID for 7 days, • Ferrous sulfate 1 tab once daily, • vitamin C 1 tab once • daily with instruction of full body bath and perinealhygiene

6. 3 days PTA • abdominal pain of 6/10 scale • watery diarrhea • No consult was done.

7. 2 days PTA • (+)abdominal pain • (+) diarrhea • (+) undocumented fever

8. Few hours PTA • persistence of the above symptoms with increasing severity in abdominal pain of 9/10 pain scale • high grade fever (undocumented) • visual and auditory hallucinations consult at the institution

9. G1P1 (1001) G1- 2011 via NSD with no complications noted. Obstetric history

10. Menarche at 13 y/o moderate flow 3 to 4 days 2-3 napkins a days no associated signs and symptoms. Menstrual history

11. Coitarche at 19 only one sexual partner 2-3 sexual intercourse/week. Sexual History:

12. denies using oral contraceptives use barrier or withdrawal method during coitus Contraceptive History:

13. (+) paternal hypertension Past medical history and Family history

14. Review of System: (upon admission)

15. BP: 90/60 mmhg HR: 81 beats per minute RR: 20 cpm Temp: 40 C PE upon admission

16. General Survey • on a wheel chair • Conscious • Coherent • cooperative, • not in cardiorespiratory distress.

17. Skin Palms and soles are dry and pale in color. No clubbing of fingers. No redness or rashes. No jaundice and cyanosis. No ulceration and eruption. Head Has fine dry black straight hair. No palpable mass or tenderness. Head is symmetric and round. Eyes Orbits are symmetrical in position. No tenderness. Both eyes has pale palpebral conjunctiva. Scleras are anicteric. Eyeballs are not sunken. No scleral or conjunctivaldischarge. No exopthalmos. Pupils are equally reactive to light (3mm) Ears Both ears have minimal cerumen. Intact tympanic membranes of both ears. No lumps, discharge, redness and tenderness. Nose Nasal septum is midline. Mucosa is pink. No discharge, swelling, obstruction. No tenderness.

18. Mouth & Throat Moist buccal mucosa. Gums are pink in color. Uvula is midline. Tongue is midline with no atrophy. No swelling or redness of pharynx. No redness or swelling of tonsils. No tenderness. NeckNeckis supple, No palpable lymph node Trachea midline and thyroid not enlarged Chest and Lungs Inspection: Thorax was symmetrical in shape at rest (AP<transverse diameter) with symmetrical expansion during breathing. No retraction of costal muscles on inspiration. Does not use accessory muscles during respiration. Spine is in midline position. Palpation: No palpable mass. No tenderness. Equal tactile fremitus on both lungs. Auscultation: Lungs are equally resonant on all lung fields. Equal vocal fremituson both lungs. Breath sounds are vesicular on both lungs (I>E on both lungs). No egophony or whispered pectoriloquy. No crackles, wheezing or friction rub. Heart No precordial bulge or heave. PMI is tapping, adynamic in the 5th ICS at the left midclavicular line with a diameter of 2.5 cm. S1 is best heard at the apex while S2 is best heard at the base with premature contractions. No expiratory splitting of S2. There are no S3 and S4 sounds. No murmur or clicks were heard. No thrills or friction rub.

19. Abdomen flabby abdomen, soft and tender on light and deep palpation Pelvic exam:(+) wound dehiscence 2nd degree 4 cm long Internal exam: warm vault, cervix is open, uterus is enlarged

20. Extremities • Upper Extremities: No clubbing of fingers or hyperpigmentation. Finger nails are pink in color. Capillary refill is 2-3 seconds. No palpable mass. No atrophy or tenderness. No pitting or non-pitting edema. • Lower Extremities: No clubbing of toes or hyperpigmentation. Toe nails are pink in color. No palpable mass all over. No atrophy or ternderness. No pitting or non-pitting edema.

21. . G1P1 (1001) s/p NSD day 8 institutional delivery wound dehiscence, to R/O puerperal sepsis, t/c retained secundines Admitting Diagnosis:

22. G1P1 (1001) s/p NSD with right mediolateral episiotomy repair, institutional delivery, Acute gastroenteritis, wound dehiscence, puerperal sepsis secondary to retained secundines with concomitant hypokalemia corrected and anemia s/p blood transfusion 4 units PRBC and 4 unit FFP, corrected Proposed diagnosis

23. Course in the ward

29. Discussion

30. Peurperal infection • term used to describe any bacterial infection of the genital tract after delivery • lethal triad • preeclampsia • obstetrical hemorrhage • puerperal infection

31. temperature of 38.0 C or higher, which occur on any 2 of the first 10 days postpartum, exclusive of the first 24 hours taken by a standard technique at least four times daily Peurperal fever

32. Route of delivery • prolonged membrane rupture and labor • multiple cervical examinations • internal fetal monitoring • adverse perinataloutcomes • stillbirths • low birth weights • preterm delivery Risk factors

33. Anemia • Nutritional state of the patient • Bacterial colonization of the lower genital tract • Multifetal gestation • Young maternal age and nulliparity • Prolonged labor induction • Meconium stained amniotic fluid Other risk factors:

35. Pathogenesis

36. Clinical course

37. oral antimicrobial agent is usually sufficient • For moderate to severe infections, intravenous therapy with broad spectrum antimicrobial regimen is indicated. Improvement follows after 48 to 72 hours in nearly 90% • Typically the patient is discharged after she has been afebrile for at least 24 hours. Further antimicrobial therapy is not needed. treatment

38. End…