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CASE PRESENTATION

CASE PRESENTATION. Cada , Joanne Irish DC. SBCM Med clerk QMMC OB ROTATION JUNE 21, 2011. IDENTIFYING DATA. A.A. 32 y/o Single Catholic, Filipino Antipolo, Rizal SOURCE OF REALIBILITY OF INFORMATION: Patient. CHIEF COMPLAINT. vaginal bleeding. HPI. 1 ST TRI

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CASE PRESENTATION

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  1. CASE PRESENTATION Cada, Joanne Irish DC. SBCM Med clerk QMMC OB ROTATION JUNE 21, 2011

  2. IDENTIFYING DATA • A.A. • 32 y/o • Single • Catholic, Filipino • Antipolo, Rizal • SOURCE OF REALIBILITY OF INFORMATION: Patient

  3. CHIEF COMPLAINT • vaginal bleeding

  4. HPI • 1ST TRI • 2ND TRI – cold intolerance, fatigue with enlarging mass on her anterior neck. Initial TSH was normal, FT4 elevated. Diagnosed with goiter Jan 2011 at FCLI, given eltroxin 50 mg OD, took it for 11 days only. • 3rd TRI

  5. ROS • (+) dysuria • (+) muscle weakness

  6. IMMUNIZATIONS • (+) completed childhood immunizations. (-) completed ttd. (-) mmr, hepa b.

  7. PAST MEDICAL HISTORY • (+) goiter Jan 2011- eltroxin 50mg OD poor compliance

  8. FAMILY HISTORY • (+) DM – mother • (+) HPN – father • (+) Goiter – mother; sister

  9. OBSTETRIC HISTORY • OB SCORE: G1P0 • LMP: September 24, 2010 • EDD: June 29, 2011 • AOG: 38 weeks via LMP.

  10. SEXUAL HISTORY • Coitarche at 25 y/o, husband is only sexual partner, sexually active, no dyspareunia, (-) decrease in libido. No previous STDs.

  11. General: patient conscious and coherent not in distress, cooperative pleasant. Medium built. HT: 5’2ft, WT: 145 lbs. • VS: afebrile. RR=22 bpm, BP120/80, HR=92bpm. Regular normal pulse. • HEENT: (+) thyroidal enlargement 2 by 2 cm. Moves with deglutition. No tenderness, non inflamed, no discharges.

  12. CHEST AND LUNGS: symmetrical chest. No use of accessory muscles. No tenderness. Equal chest expansion. Equal and normal tactile fremitus. Resonant on percussion. Clear breath sounds. No adventitious breath sounds. • HEART: no pericardial bulge. No thrills , heaves and friction rub. Good s1 and s2. No s3 and s4. No murmurs.

  13. ABDOMINAL EXAMINATION • round, large abdomen. (+) linea nigra, straie gravidarum, and striae albicans. (+) fetal movements. FH: 29 cm. longitudinal lie. Cephalic presentation. FHT at RLQ at 140 bpm. L1-nonballotable, L2- fetal parts at left, fetal back at right. L3-fetal head cephalic. L4-not engaged.

  14. FEMALE GENITALIA: sparse coarse pubic hair. Equal distribution. No lesions. • EXTREMITIES: no deformities, no joint swellings, no limitation in ROM • SKIN/NAILS: dark in complexion, no petechiae, no ecchymoses.

  15. INTERNAL EXAM • 8 cm dilated, 70% effaced, station -2, (-) BOW clear, (+) pool of fluid in cervix.

  16. LABS • UTZ – May 2011 Single live intrauterine pregnancy, presently cephalic. BPS 10/10 • Cogulation Panel – June 2011 Nomalresults • CBC - June 2011 Increased WBC 15.6 Decreased RBC 4.08 Increased neutrophils .803 Decreased lymphocytes .138

  17. TSH/FT4 - March 2011 Normal TSH Low FT4 .10 • May 2011 Normal TSH Normal FT4

  18. REGULAR NORMAL FHT. RANGES 140-160bpm. • NO ELEVATIONS ON BLOOD PRESSURE. • PATIENT WAS NOTED TO BE WARM TO TOUCH BUT AFEBRILE. • NOTING MILD CONTRACTIONS EVERY 10 -15 MINUTES WITHOUT PROGRESSION.

  19. CALL FOR AD AROM HNBB Q 4HOURS D5LR + 10 UNITS OXYTOCIN

  20. ADMITTING DIAGNOSIS • G1P0 Pregnancy uterine 38 weeks AOG, Cephalic In labor, hypothyroidism biochemically euthyroid.

  21. FINAL DIAGNOSIS • G1P1 (1001) s/p LTCS I secondary to arrest in cervical dilatation secondary to inlet contraction to a live term baby girl. • T/C UTI

  22. DISCUSSION

  23. DYSTOCIA A. Abnormalities of the expulsive forces • Uterine dysfunction • Abnormal labor patterns • Rupture of membranes w/o labor • Precipitous labor and delivery B. Abnormalities of presentation, position, or development of the fetus; • Abnormalities of the maternal bony pelvis—that is, PELVIC CONTRACTION.; D. Abnormalities of soft tissues of the reproductive tract that form an obstacle to fetal descent.

  24. PROTRACTE ACTIVE-PHASE DILATATION • ARREST IN DILATATION • Fetal descent largely follows complete dilatation – no failure of descent

  25. HNBB IV Q1 D5LR + 10 UNITS OXYTOCIN

  26. CAUSES OF ARREST DISORDERS

  27. definition • considered to be contracted if its shortest anteroposterior diameter is less than 10 cm • or if the greatest transverse diameter is less than 12 cm. • anteroposterior diameter of the pelvic inletis commonly approximated by manually measuring the diagonal conjugate, which is about 1.5 cm greater. • Therefore, inlet contraction usually is defined as a diagonal conjugate of less than 11.5 cm.

  28. PLANS

  29. Identification of pregnancy risk factors. • Comprehensive antenatal history taking is essential • Asses adequate pelvimetry • Intrapartum the RCOG Guidelines “The Use of Electronic Fetal Monitoring” identifies the intrapartum risk factors for FHR monitoring. Doppler auscultation, VS every hour • ContinousIE and labor watch.

  30. Induction of labor. • Order for follow-up labs. • REFER to pediatrics and endocrinologist. • Re-evaluate and asses need for CS DELIVERY. • Prepare for CS. • MANAGE UTI. MANAGE GOITER.

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