Mark Arthur M.

Martinez

OB-GYN Rotation

General Information
Patient is B.M. a 34 y/o, G3P2(2002), Roman Catholic, born on Dec 9, 1980, from Pasig City.
Patient was the informant; with good reliability.
LMP August 30, 2015
AOG 9 weeks by LMP
EDD June 5, 2016
Chief Complaint
Shortness of breath
History of present illness
Patient was apparently well until seven days prior to admission, wherein the patient noted
productive cough with whitish phlegm associated with nasal congestion and some shortness of breath. No
fever, no fast breathing, no chest pain, no palpitations, no medicines taken and no consult done
On the interim, patients condition persisted with daily morning symptoms of cough and
shortness of breath, still with nasal congestion, with no episodes of late night awakenings due to cough or
shortness of breath.
Two days prior to admission, the persistence of cough and shortness of breath lead to patients first
consult with her attending physician. She was referred to a pulmonologist for evaluation where she was
diagnosed with asthma. She was nebulized with salbutamol, which gave the patient temporary relief of
symptoms. She was sent home with instructions of salbutamol nebulization every 8 hours and oral
prednisolone once a day. She reports incompliance to the given treatment.
On day of consult, worsening of the shortness of breath, presenting even on minimal exertion,
leading to interference of normal activity, prompted consult and admission.
Review of systems
Pertinent positives:
Unremarkable and un-contributory to the case
Pertinent negatives:
No fever, weight loss or fatigue; No chest pains, palpitations or orthopnea ; No back pain,
pelvic pain; No constipation or diarrhea; No dysuria, vaginal bleeding or discharge; No rashes,
joint and muscle pains; No tremors or seizures; No heat or cold intolerance, polyuria and
polydipsia.
Past Medical history
With known allergy to seafood and Sinutab
No previous hospitalizations
No previous surgery
Medications
No maintenance medications
No vitamins or supplements
No herbal medicines
Ancillary procedures
CBC Hg 116/ Hct 0.36/ WBC 11.5/ RBC 4.23/Platelet 334/ Neutrophils 0.64/ Lymphocytes
0.28/ Monophils 0.06/ Eosinophils 0.2/ Bands 0/ Basophil 0
RPR = Non-reactive

OGTT FBS: 4.19, 1 hour: 6.79, HbA1c: 5.30

Urinalysis Yellow/ clear/ pH 5/ Sp. Gravity 1.015/ Glucose (-)/ protein (-)/ RBC 2/ WBC 2/
Urobilinogen (normal), Bilirubin (-), Nitrites (-), Ketone (-), Blood (-), Leukocytes (-), Lactase
(-). Epithelial cells 1, Bacteria 6

Family history
Allergy, asthma and cancer
Personal and social history
Patient denies smoking, drinking and drug use. Lifestyle is mostly sedentary with no special diet.
She is a college graduate that currently works as an employee. Living in a cemented house with his
husband and three children. Drinking water is store bought and electricity is from Meralco. Patient claims
to have no exposure to tobacco/toxins/biohazards and with daily trash disposal. Currently has no pertinent
history of travel.
Immunization history
No vaccinations
Menstrual history:
Patients menarche is at 13 y/o and has been regularly menstruating; monthly, occurring every 2830 day, since then. Menses usually last for 4-5 days, consuming 4 pads per day moderately soaked. No
associated symptoms such as dysmenorrhea during menses.
Reproductive history
Age at first coitus is at 22 y/o and claims to have only 1 sexual partner. Reports not using any
form of contraception and denies any previous sexual disease or disorders.
Obstetric history: Gravida__3__ Para__2__
G1= In 2004, patient gave birth to a live term baby boy, appropriate for gestational age at 3356 kg, via
NSD at well family
G2= In 2009, patient gave birth to a live term baby girl, appropriate for gestational age at 3447 kg, via CS
at The Medical City due to failure of descent.
G3= Current pregnancy
Physical exam
General: Conscious, coherent, in respiratory distress
Vital signs: BP 110/70, RR 20, PR 90, T 37.4
Anthropometrics: Ht - 163, Wt - 88, BMI 33.1kg/m2
HEENT: normocephalic; anicteric sclera with pink palpebral conjunctiva; with white-mucoid nasal
congestion; no tonsilopharyngeal congestion, no hyperemia or exudates; Use of SCM for breathing, no
cervical lymphadenopathies with flat neck veins.
Cardiovascular: Adynamic precordium; apex beat in the 5 th ICS, no heaves or thrills; normal rate and
regular rhythm, distinct S1 and S2, no murmurs.
Respiratory: Symmetrical chest expansion; Wheezing on both lung fields, no crackles.
Abdomen: Flat, midline cesarean scar appreciated. Normoactive bowel sounds, FHT not appreciated;
tympanic in most quadrants, soft, non-tender on deep and light palpation, uterus enlarged above the
symphisis pubis.
Leopolds maneuver: Not done
Speculum exam: Not done

Internal exam: Not done

Pelvimetry: Not done
Initial Impression:
G3P2 (2002) pregnancy uterine, 9 weeks age of gestation by LMP, Bronchial asthma in acute
exacerbation, moderate persistent.
Plan:

To treat bronchial asthma medically and to prevent future exacerbations.

To educate patient on the effect of uncontrolled asthma in pregnancy and the importance
of compliance.

Discussion:
Asthma is a chronic inflammatory airway syndrome that is characterized by having increased
airway responsiveness. It has a hereditary component and an environmental component. There is a higher
risk of acquiring asthma if one parent has the disease and a greater risk if both has the disease. Asthma
also has an inevitable environmental component, with allergic triggers such as infection, cigarette smoke,
animal dander or strong odors that could trigger an attack. As seen in our patient, allergy and asthma is
seen in their family. Although the patient had no previous asthma attack, she has been known to have food
allergy to seafoods, and food allergy is actually a part of what is known as the atopic march. Based on the
definition of the American Academy of Allergy Asthma & Immunology the atopic march or allergic
march, is defined as the natural history or typical progression of allergic diseases that often begin
early in life. These include atopic dermatitis, food allergy, allergic rhinitis and asthma. The patient
started with food allergies and has now developed new onset asthma. Also, it is important to identify
potential triggers to asthma, in our case it couldve been triggered by the initial upper respiratory tract
infection that started with nasal congestion and cough.
Asthma usually presents with wheezing, this is due to bronchoconstriction, leading to obstructed
airways, decrease airflow and thus shortness of breath. Objectively and quantitatively the patient would
present with reduced forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio and
peak expiratory flow (PEF). Asthma severity can be classified depending on the symptoms and timing. It
is important to classify asthma severity since it affects the management. Seen below is the table of
Classification of Asthma Severity from Willams Obstetrics 24th edition.

Based on the patients HPI, she has symptoms (cough and shortness of breath) and interference of
normal activity. Looking at the table, the patient has daily symptoms of cough and some limitation of
activity due to shortness of breath. Based on the table, we can classify our patient as moderate persistent.
Although the patient has only presented with these symptoms for a week. In Asthma, the state of hypoxia

is augmented by hyperventilation which maintains PO2 levels and subsequently causing PCO2 to
decrease with resultant respiratory alkalosis due to the PCO2 losses. If asthma continuously worsens due
to severe obstruction, ventilation becomes impaired due to fatigue causing early CO2 retention and worst
of all respiratory failure.
Asthma is dangerous for the pregnant woman and her fetus. There is a slight increase in incidence
of spontaneous abortion in women with asthma as well as preeclampsia, preterm labor, placental
abruption, preterm rupture of membranes, growth-restricted infants, and perinatal mortality. The risk of
having complications is now increased in our patient who has developed new onset asthma. In pregnancy,
asthma can be improved, remain unchanged or worsen. But our patient has new onset asthma, thus
pregnancy effect on her asthma is still unknown. Although it is unknown if there is direct correlation with
the patients pregnancy and onset of asthma, some studies have shown occurrence of asthma due to
pregnancy, although it is more likely that our patients asthma is due to the progress of the atopic march.
It is important to educate the patient on the effect of asthma in pregnancy including a possible
asthma exacerbation during labor and delivery. In one study, there was a reported 18-fold increase in
exacerbation risk after a cesarean delivery versus a vaginal delivery. But complications in pregnancy
usually rise depending on the patients control and severity. There is a significant increase in morbidity
and mortality in severe disease, poor control or the presence both. If the patient is severely uncontrolled,
she may develop status asthmaticus that includes muscle fatigue with respiratory arrest, pneumothorax,
pneumomediastinum, acute cor pulmonale and cardiac arrhythmia. If patients control is poor, respiratory
alkalosis may develop, explained in the latter, and fetal hypoxemia develops. The hypothesis is that the
fetus is affected due to decreased umbilical blood flow, increased systemic and pulmonary vascular
resistance, and decreased cardiac output. Also, there has been reports of fetal-growth restriction that
increases with the severity of asthma. Thus, due to the effects of asthma to the fetus, aggressive
management and constant monitoring is advised for the patient.
Diagnostics
ABG analysis for objective assessment of maternal oxygenation, ventilation and acid-base
status. Results must be interpreted in relation to normal values for pregnancy.
Pulmonary function test (Spirometry) should be routine for management of chronic and acute
asthma. FEV1 is measured, which best indicates asthma severity. IF FEV1 is less than 1L or
<20% of the predicted value, it indicates severe disease (hypoxia, poor response to therapy and
high relapse reate).
Pulmonary function test (Peak flow meter) Peak expiratory flow (PEFR) is measures which
determines a womans own baseline when asymptomatic compared to when symptomatic. PEFR
usualy does not change during the course of normal pregnancy
Management
Patient education on asthma prevention, importance of control and compliance and the effect of
poor control to the fetus.
Identification of potential triggers such as infections, smoke, cold air, animal dander and etc.
Instruct patient on monitoring of PEFR to evaluate daily pulmonary function as well as
spirometry during pre-natal check ups
Pharmacological management of asthma based on the stepwise approach of asthma treatment.
Based on the figure below, moderate persistent asthma is treated with long acting B-agonist
(LABA) and a low-dose ICS for maintenance medication, and a short-acting B-agonist (SABA)
as a reliever medication. Ex. 1.) Budesonide-formoterol fumarate (Symbicort) 160/4.5 or 80/4.5
mcg per dose, 1-2 inhalations twice a day, if PEFR is below baseline may add inhalation, max of
4 ihnalations twice a day. 2.) Salbutamol (Salbuair) 100mcg per dose, 2 puffs three times a day as
needed.

SOAP Notes:
Subjective
November 2, 2015
No fever, nasal
congestion, with cough,
no chest pains,
improved breathing, no
hypogastric pain, no
vaginal bleeding or
passage of meaty tissue

November 3, 2015
No fever, no nasal
congestion, decrease
cough, no chest pains,
ino dyspnea or
shortness of breath, no
hypogastric pain, no
vaginal bleeding or
passage of meaty tissue

Objective

Assessment

Plan

BP 125/67, HR 88, RR
24, T 36
Peak flow meter
230-210-250
No naso-aural
discharge.
Normal cardiac rate and
regular rhythm.
Equal chest expansion,
tight air entry with
wheezing on bilateral
lung fields.
Flat, soft, non-tender
abdomen, FHT not
appreciated.

G3P2 (2002) pregnancy

uterine, 9 weeks 1 day
age of gestation by
LMP, Bronchial asthma
in acute exacerbation,
moderate persistent.

Hydrocortisone 200mg
IV every 8 hours.
Ipatropium+salbutamol
nebulization every 6
hours.
NaCl nasal spray, 2
sprays per nostril three
times a day.

BP 110/80, HR 79, RR
21, T 35.9
Peak flow meter
290-300-290
No naso-aural
discharge.
Normal cardiac rate and
regular rhythm.
Equal chest expansion,
wheezing on bilateral
lung fields.
Flat, soft, non-tender
abdomen, FHT not

G3P2 (2002) pregnancy

uterine, 9 weeks 2 days
age of gestation by
LMP, Bronchial asthma
in acute exacerbation,
moderate persistent.

Oral Prednilosone
Salbutamol
nebulization at
midnight, then every 8
hours thereafter, and as
needed.
NaCl nasal spray, 2
sprays per nostril three
times a day as needed.

appreciated.
November 4, 2015
No fever, no nasal
congestion, with dry
cough, no chest pains,
no dyspnea and
shortness of breath, no
hypogastric pain, no
vaginal bleeding or
passage of meaty
tissue.

BP 100/70, HR 85, RR
23, T 36.9
Peak flow meter
280-300-350
No naso-aural
discharge.
Normal cardiac rate and
regular rhythm.
Equal chest expansion,
clear breath sounds on
bilateral lung fields.
Flat, soft, non-tender
abdomen, FHT not
appreciated.

G3P2 (2002) pregnancy

uterine, 9 weeks age 3
days of gestation by
LMP, Bronchial asthma
in acute exacerbation,
resolving.

Steroids to be
continued for 7 days.
NaCl nasal spray, 2
sprays per nostril three
times a day.
Give home
medications.
May go home pulmo
wise.
OB asymptomatic.

Reference:
Cunningham, Leveno, Bloom, Spong, Dashe, Hoffman, Casey, Sheffield. Williams Obstetrics, 24th
edition. New York : McGraw-Hill Education, 2014.
Atopic March by American Academy of Allergy, Asthma & immunology. 2015. Retrieved from:
http://www.aaaai.org/conditions-and-treatments/conditions-dictionary/atopic-march.aspx..On
Nov 8, 2015.