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General Data R.O. Age: 21 years old Obstetric Score: G1P0 Civil Status: Single Address: Cavite Religion: Born-again Christian Date of Admission: August 9, 2012 Chief Complaint: Labor pains Past Medical History: • • No history of diabetes mellitus, hypertension, pulmonary tuberculosis, bronchial asthma • No allergies to food and drugs • No history of previous surgery Family History: • (+) Diabetes mellitus - Mother • No hypertension, bronchial asthma, thyroid disease, heart disease, cancer Personal and Social History • Vocational Course graduate • Previously worked as a production operator • No vices • First coitus at 20 years old • 1 nonpromiscuous sexual partner • (-) contraceptive use Menstrual History • Menarche at 11 • Regular monthly interval • lasts 3 days • Uses 4-5 pads per day, fully-soaked • (+) dysmenorrhea Obstetric History • G1P0 • LMP: December 13, 2011, unsure • AOG: 31 4/7 by LMP; 33 6/7 by early ultrasound • Quickening at ~20 weeks • 9 prenatal checkups care of private lying-in clinic History of Present Illness: One month prior to admission, patient had productive cough and colds but no associated fever. No consult was done, no medications were taken. Two weeks prior to admission, patient noted dyspnea, easy fatigability after walking ~3 meters described as “hinihingal ako”. There was noted progression of dyspnea which prompted patient to absent herself from work. She sought consult with her private Obstetrician who diagnosed her with pneumonia and was prescribed with a mucolytic with no relief of symptoms. Patient was then referred to a cardiologist and X-ray was done which revealed cardiac enlargement. A 2D-echocardiogram was also requested which showed markedly dilated left ventricle with normal wall thickness; global hypokinesia; only anterior left ventricle from base showed normal contractility; dilated left atrium; normal right atrium and right ventricle dimensions; depressed systolic function and stage II diastolic dysfunction and aortic regurgitation. Patient was then prescribed with Digoxin and Fenoterol + Ipratropium. One week prior to subsequent admission, there was increase in the severity of dyspnea and easy fatigability. Patient noted bounding chest wall which she described as “kumakabog ang puso”. Patient was no longer able to sleep lying down and was only able to do so while sitting. Patient also noted of edema in bilateral lower extremities reaching up to her knees. Interval history revealed persistence of symptoms. Six hours prior to consult, patient noted uterine contractions every 5-10 minutes, moderate. Patient had no watery vaginal discharge, no vaginal bleeding, but with good fetal movement. Persistence of above symptoms prompted consult at PGH and subsequent admission. Review of Symptoms: (+) anorexia (+) malaise (+) weight loss, 4kg (-) headache (-) blurring of vision (-) changes in smell/taste (-) abdominal pain (-) changes in bowel movement (-) diarrhea (-) constipation (-) hematuria (-) dysuria (-) myalgia (-) arthralgia Physical Examination at Admission: General Appearance: Ambulatory , coherent, speaks in full sentence Vital Signs: BP = 110/70 HR = 132 RR = 31
Block V Sunglao, Suratos, Symaco, Tababa, Tagal, Taganas, Talusan, Tan C., Tan K.
05 HEENT: Anicteric sclerae. no spasticity/flaccidity. A 2D Echo with doppler studies was requested and patient was prescribed with the following medications: Furosemide 40mg/IV prn for congestion. 2 stage of labor was rd approximately 25 minutes. She had LV heave. orthopnea and easy fatigability. Patient was started onMetoprolol tartrate 50mg/tab ½ tab BID and her Digoxin was decreased to 0. Her BP was 90/60 mmHg. Suratos.0 kg.9. At that time. Patient was maintained on O2 support and Foley Catheter and was advised complete bed rest with no bathroom privileges. CIPTL Gravidocardiac Functional Class III probably secondary to Rheumatic Heart Disease probably severe mitral regurgitation G1P0 Course in the Wards: The patient upon admission was seen by CVS and was reviewed with a 2-week history of progressive heart failure symptoms of exertionaldyspnea. and her 3 stage of labor was 1 minute in duration. no preferential movement of extremities. jaundice. 35 weeks by pediatric aging. CNs intact. HR of 116bpm regular. Patient had rupture of her bag of water at 10:40am.3 Ht = 150cm Wt = 56 kg BMI = 23. slightly pale palpebral conjunctivae. No slurring of speech. Tan C. At that time patient was given Furosemide 20mg/IV stat dose. and no fever. Full ROMs. FHT: 160s LLQ Internal Examination: Normal external genitalia. BP was 90/60 mmHg. and was afebrile. Tagal. distinct S1 and S2. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. AB displaced. Tan K. no chest pain. and was afebrile. She had equal chest expansion. (+) crackles over bilateral lower lung fields. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. PU delivered. (-) S3. nulliparous vagina. tachycardic. HR 88 regular. patient had no difficulty of breathing. JVP 5 cm Lungs: equal chest expansion. LV Block V Sunglao. appropriate for gestational age in cephalic presentation. soft.Trachea midline. no wheezes Cardiovascular: dynamic precordium. oriented. regular.(-) non-healing wound/lesions Neuro Exam: Well-kempt. She had equal chest expansion. able to speak in full sentences. 50% effaced. normoactive bowel sounds. She delivered a preterm.25 mg/tab OD. st nd Her 1 stage of labor was 5 hours. in sinus rhythm. HR of 98 regular.82.25mg/tab ½ tab OD. She had equal chest expansion. Patient was then assessed with CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. CIPTL. (+) grade 3/6 holosystolic murmur heard best at the left parasternal border Gastrointestinal: globular.. RR of 24. DTRs ++ in all four extremtities. (+) splitting of S1 heard best at aortic area. Patient was still for 2D Echo with doppler studies. Symaco. station -3 Extremities: Full equal pulses. EFW: 1. RR 20. but subsequently became normal ranging from 90-100/60-70. RR 20.SGD CASE PROTOCOL Temp = 36. in sinus rhythm. normal rate. patient had 1 episode of BP 80/60. Patient was maintained on O2 support and was run with IVF PNSS at KVO rate. PU 34 weeks AOG by EUTZ. and was afebrile. (+) 3/6 holosystolic murmur at left lower parasternal border with gr II bipedal edema. (-) crackles. no difficulty of breathing. no tenderness. No limitation of movement both on passive and active actions 5/5 muscle strength for B upper and lower extremities. no chest pain. CVS preferred Assisted Vaginal Delivery for the patient. intact bag of water. (+) 3/6 holosystolic murmur at apex. coherent. RR of 28. in sinus rhythm. (-) palpable CLAD. No facial asymmetry. patient had BP of 100/70 mmHg. AB displaced. cephalic. via vacuum-assisted delivery under epidural anesthesia (CLEA). LV heave. LV heave. clear breath sounds. AB displaced. clonus Admitting Impression: PU 34 weeks AOG by EUTZ. (-) Babinski. (-)tenderness. Immediately post-partum. Tababa. (-) S3. FH: 26 cm. with an APGAR score of 8. Patient was still advised complete bed rest with no bathroom privileges and was still for 2D Echo with doppler studies. regular rhythm. . (+) 3/6 holosystolic murmur at left lower parasternal border. and was afebrile. (-) carotid bruits. and no fever. a live baby girl. st On the 1 hospital day. Baby was delivered at 10:58 am and placenta was subsequently delivered at 10:59 am. HR 115 regular. Apex beat and PMI not appreciated due to heave. PU delivered. regular. Talusan. regular. edema. Taganas. (-) masses/organomegaly. nd On the 2 hospital day. rd On the 3 hospital day. (-) crackles. the patient had a BP of 85/55. 1800 grams. cervix 2 cm dilated. pink nail beds. (-) cyanosis. (+) crackles. and Digoxin 0. tachycardic. (-) S3. A mediolateral episiotomy with repair was done. (-) anterior neck mass. At that time she had a BP of > 110/70 mmHg. tachycardic. A foley catheter was placed and I & O were recorded accurately.
(+) 3/6 holosystolic murmur at apex.0 320-360g/L 319 337 11-16% 14. regular. Oral fluid intake was restricted to not >1.060 0.25mg/tab 1 tab OD.003 8/13 11.392 95.5L/day.SGD CASE PROTOCOL heave.30 12 4-6x10 /L 4.006 0. AB displaced. Furosemide was shifted to 20mg/tab OD. Tagal.5 32.540% 0. th On the 6 hospital day.25mg/tab ½ tab OD. Tan C. th On the 5 hospital day. AB displaced. AB displaced. She had equal chest expansion. (-) crackles at RLLF. patient had no difficulty of breathing..06 0. RR 20.163 0. Patient had equal chest expansion. (+) crackles at the RLLF. and her Metoprolol tartrate 50mg/tab ½ tab BID was put on HOLD.010 0.025 0.17 3. AB displaced. (-) S3. patient had no difficulty of breathing. Assessment was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. (-) S3.20 4. 7. LV heave.058 0. Patient was kept on O2 support.1 14. PU delivered. Taganas.399 0.766 0. Patient had equal chest expansion. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD.5 0. Furosemide was then shifted to Spironolactone 25mg/tab 1 tab OD. Captopril 25mg/tab 1/4 tab q8h.02 0.746 0.7 0. regular. in sinus rhythm.2 298 0. Her Digoxin was decreased to 0. RR 20s.770 0.50 12. Suratos. BP was 90/60 mmHg. LV heave. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. th On the 4 hospital day.02-0.86 120-180g/L 127 123 0. and was afebrile. and was afebrile. tachycardic.157 0.11 131 0. PU delivered. no chest pain.0 27-31pg 30. HR 100s regular. Complete bed rest with no bathroom privileges was advised and she was still for 2D Echo with doppler studies.367 80-100fL 95. LV heave. in sinus rhythm. regular.4 9 150-450x10 /L 278 263 DIFFERENTIAL COUNT 0. (-) crackles at RLLF. tachycardic. tachycardic. Laboratory Worksheet: Complete Blood Count Date WBC RBC Hgb Hct MCV MCH MCHC RDW-CV Platelets Neut% Lymph% Mono% Eo% Baso% Arterial Blood Gas Date FiO2 Temp Hb pH PCO2 PO2 HCO3 8/9 21 37 12 7.062 0. Tan K. and no fever. Talusan. no chest pain.169 0. and her BP trend was observed. HR 100s regular. (-) S3. no chest pain. (+) 3/6 holosystolic murmur at apex. patient had no difficulty of breathing.349 24. and was afebrile. regular.45 35-45mmHg 90-100mmHg 22-28mEq/L Block V Sunglao. (-) S3. in sinus rhythm.35-7. PU delivered. (+) 3/6 holosystolic murmur at apex.9 13. PU delivered.5 32.4 8/9 8/11 9 4-11x10 /L 9.0 335 14. Tababa. BP was80/60 mmHg.002 0. (+) 3/6 holosystolic murmur at apex.5-0. .0-0.5 62. She was hooked to O2 via FM at 6LPM and maintainedon mod-high back rest. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD. HR 100s regular.0-0.2-0. BP was 90/60 mmHg.09 0.7 95. Patient was started on the following medications: Furosemide 20mg/IV q12h. in sinus rhythm. RR 20s.370-0.002 hold for BP <90/60 and Digoxin 0. and no fever. tachycardic. and no fever. Symaco.
32 0.12-2.7 0.SGD CASE PROTOCOL TCO2 Be O2 Sat Blood Chemistry Date BUN Creatinine Sodium Potassium Chloride Calcium Magnesium Albumin 12-L ECG 3.76 0.75mmol/L 0. Tan C. Taganas. Tan K.7 3.40 57 141 4.0 mmol/L 53-133umol/L 135-145mmol/L 4. Suratos.2 -10 90. Talusan. Tababa. Tagal.5 60 140 8/14 14. Symaco. .0-4.05/1.0 105 2.74 • • Sinus Tachycardia Left Ventricular Hypertrophy 2D Echocardiography • Eccentric LVH with multi-segmental wall motion and severely depressed overall systolic function • Doppler evidence of diastolic relaxation abnormally • Dilated LA • Mitral sclerosis • Thickened pulmonic and tricuspid valves • Severe MR • Moderate TR • Moderate to severe pulmonary hypertension Block V Sunglao.2-8.4-2.75 29 8/12 4.1 38-51g/L 8/9 2.70-1.5mmol/L 99-110mmol/L 2..
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