CLINICAL CASE

DISCUSSIONNAME:S REKHA
3RD YEAR MBBS

BGS GIMS
BANGALORE
PATIENT PARTICULARS
Name: Mrs.abc
Age: 23 years
Address: bangalore
Occupation: home maker
Education status: 10 std

Husband’s name: Mr. abc Age:27 years

Occupation : autodriver
LMP:4/06/2019 EDD:11/3/2020
Gestational Age: 33 weeks 5 days
Socio economic state: Lower middle class( modified kuppuswamy scale )
Date of admission : 24/01/2020
Date of examination : 27.01.2020
Obstretic history
Married life – 2 years
Non consaguinous marriage
Obstretic score – Gravida 1
Patient came for regular ante natal check up and was found
to have high blood pressure levels on evaluation
History of present pregnancy
1st TRIMESTER:
History of spontaneous conception
Pregnancy was detected at home with urine pregnancy test after one and half
month of her last missed period
dating scan was done – which confirmed pregnancy and was said to be normal

h/o of folic acid intake

No history of nausea , vomiting
No history of increased frequency of micturition
No history of easy fatigability
No history of pain abdomen
No history of bleeding pv
No history of fever with rashes
No history of exposure to radiation and drug intake
Routine ANC was done and was said to be normal
2ND TRIMESTER:
quickening was felt in 5 th month and continued to perceive fetal movements well
2 doses of Td vaccine was administered
Iron and calcium tablets were taken
Anomaly Scan done at 5th month – and was found to be normal
No history of pedal edema , epigastric pain , blurring of vision and headache
No history of pain abdomen, leaking or bleeding per vagina
No history of easy fatigability , palpitations
No history of burning micturition
Routine antenatal investigations were done and was found to be normal
3rd trimester
She continued to perceive fetal movements
Iron and calcium tablets were taken
She came for a regular antenatal checkup and was found to have high blood pressure levels
No history of headache ,vomiting, blurring of vision, epigastric pain, pedal edema
No history of decreased urine output
No history of bleeding pv
No history of pain abdomen
No history of leaking pv
Menstrual history
Menarche: 13 years
Menstrual cycle: regular cycles of 28 days, flow for 3-4 days
Regular and used 2 pads / day
No history of dysmenorrhea
No history of passage of clots
LMP: 4/06/2019
EDD: 11/03/2020
Past history
Not a known case of hypertension , diabetes mellitus , asthma , epilepsy, thyroid disorders
No history of bleeding or clotting disorders
No history of blood transfusions in the past
No history of any surgeries in the past
FAMILY HISTORY
No history of hypertension , diabetes in the family
No history of pregnancy induced hypertension in mother or sister
No history of twins in the family
PERSONAL HISTORY:
Diet : mixed diet
Appetite is normal
Sleep: adequate
Bowel and bladder: normal and regular
No history of smoking and alcohol consumption
No history of any drug allergy
No history of use of contraception
Summary of history
A 23 YEAR old primi gravida with history of 8 months of
amenorrhea , came for regular checkup and was found to have high
blood pressure levels on evaluation
Suggestive of hypertensive disorder of pregnancy
General physical examination
Patient is conscious, cooperative and well oriented to time, place and person.
Patient is moderately built and nourished

VITALS:
Pulse: 90/min ; regular rhythm, good volume. No radio-radial or radio-femoral delay.
All peripheral pulses are felt.
Respiration: 17 breaths/min
BP:144/94 mmHg
Patient is afebrile: temp – 98.4 degree Fahrenheit
No pallor ,icterus, clubbing, cyanosis, lymphadenopathy, edema
Height : 158 cm pre pregnancy weight :55kg present weight : 65 kg
BMI : pre pregnancy : 21.6kg/m2
at present : 25.3kg/m2

Thyroid : normal
Spine appears to be normal
Breast: normal
Obstetric Examination
PER ABDOMEN EXAMINATION:
Inspection:
Shape of abdomen is globular, longitudinally distended
Umbilicus is central and everted
Linea nigra and stria gravidum present
Hernia orifices are intact
Palpation:

fundal height : 32 weeks

Symphysio-fundal height is 34 cm, corresponds to gestational age
Abdominal girth is 96 cm ( at the level of the umbilicus)
Leopold maneuvers:
1.Fundal grip: soft, broad and irregular mass suggestive of breech
2.Lateral grip:
right side : smooth and convex suggestive of spine
left side : irregular , knob like structures suggestive of limbs
3.first s pelvic grip : smooth, hard , globular mass suggestive of fetal head
4.second Pelvic grip: approximation of finger tips, suggestive that head is not
engaged
Auscultation:
Fetal heart sound: 142 beats/ mins
CVS: S1 and s2 heard, no murmurs heard
RS: Normal vesicular breath sounds heard
CNS: no focal neurologic deficit
Investigation
Hemogram : hb: 12g/dl
RBC count normal
wbc count normal
platelet count normal
Peripheral smear : normocytic normochromic cells
Reticulocyte count : normal
Urine analysis : urine ouput – normal
no significant proteinuria
Liver function tests : bilirubin levels are normal
liver enzymes levels are normal
renal function tests : normal
Fundoscopy : normal
Diagnosis
A 23 year old primigravida with history of 8 months of amenorrhea
who came for a regular antenatal checkup and was found to have
high blood pressure levels with no signs and symtoms of impending
eclampsia was diagnosed as gestational hypertension