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Case write up 1

Demographics:
Name: KodezaSultan
MRN#: 0000
Age: 34 Years Old
Gender: Female
Nationality: Bangladesh
Occupation: Housewife
Marital status: married for 6 years
Gravidity and parity: G2 P0
LMP:22/7/2016
EDD:29/4/2017
Gestational age: 14+1 wks
Blood group: ordered

Subjective:
CC: patient came for her booking visit to antenatal clinic.
HPI:
34 years old female presented to PHC for first time during her pregnancy
(booking visit) to follow her pregnancy. She also complaining of fever and dry
cough for the past 4 days.
Her condition is improving and she didnt take any medicine to relieve her
symptoms and just take rest. Nothing makes it worse.
There are no headaches, dizziness, chest pain, flank or back pain, no change
in bowel motion or change in the urination pattern and no burning sensation
while urination was note.
No hx of recent travel, contact with sick people or STDs.

ICE
Parents Ideas: Patient knows that she is pregnant.
Patients Concerns: She wants to know if there is risk of miscarriage in
her pregnancy.
Patients Expectation: She wants to get the proper management and
care during her pregnancy.

History of current pregnancy:

This was a planned pregnancy and she knew about it by a positive urine
pregnancy test at home.

LMP was on 22/7/2016 GA: 14+1 weeks EDD: 29/4/2017

1st trimester: she is complaining of morning sickness which is decreased


compare to start of pregnancy and she is not taking anything to relieve it.
Early scan was done that confirmed pregnancy and gestational age. No
significant complaints. The estimated date of delivery was confirmed.
2nd trimester: fetal movements are not felt yet .Anomaly scan was ordered.

Obstetric history:

She had one previous pregnancy which is ended by abortion during 3rd month
of her pregnancy at home and she didnt do D &C since it was complete
abortion and confirmed in hospital.

Menstrual history:

Menarche: at 11 years old

Menses are regular occurring every 28 days for 7 days of average flow without
signs of menorrhagia and dysmenorrheal.

Gynecological history:

She didnt do Pap smear or mammogram before.

Contraceptive history: she denied use of any contraception method but she
said she avoided pregnancy naturally by her own (natural contraception).

Medical history: There are no previous hospital admissions or surgeries. The


patient has no history of hypertension, anemia, DM, thyroid disorders or any
chronic diseases.

Past Surgical History: not significant.

Drugs History:
Drugs: none
Allergies: Penicillin allergy.

Family History: there is No family history of hypertension, diabetics, asthma,


blood disorder, twins or abnormal baby in the family.

Social History: she is a housewife, married and lives with spouse and spouse
family.
She eats home cooked food mainly, doesnt smoke, drink alcohol, or consume
recreational drugs and exercise occasionally.

Objective:

Examination:
General: she looks well, alert, oriented, not in acute distress, sitting on bed
comfortably.

Vitals:

T: 37.6oC BP: 120/75 mmHg Pulse: 82 bpm

HEENT:
Nose: normal, no obstruction.
Throat: Normal
LN: not enlarged

Chest Examination:
Chest is symmetrical, clear to auscultation. Normal breathing sounds and air
entry.

Heart: RRR, normal S1/S2, no murmurs/rubs/gallops

Abdomen: distended symmetric gravid uterus with pregnancy signs (increase


pigmentation of linea nigra, striea gravidarum) and there was no obvious
scare on the abdomen.

Breast examination: no scare, good elasticity, increase pigmentation of


areola, no tenderness or nipple discharge was note.

Back: no muscle tenderness, normal ROM, no warmth/erythema

Extremities: no edema/clubbing/cyanosis, symmetric pulses, no varicose


veins, no skin breakdown, joints: normal, not tender, normal ROM bilaterally,
no scars/deformities

Skin: no jaundice, no excoriations, no spiders/telangiectasia/palmar


erythema/rash, palms moist

Investigations: following investigation was ordered.

Blood type and group


CBC
Random blood sugar
HIV
HBs Ag
VDRL/RPR
Rubella antibodies
Urine analysis
Assessment:
- Pregnant female for follow up in PHC
- Upper respiratory tract infection

Plan:
Management Plan and counseling:

o Investigation was ordered for her


o Need to do anomaly scan in the provided date
o Come back for follow up after 4 weeks

Patient education was done and advised to take folic acid, vitamin D,
calcium supplements during her pregnancy and safety netting regarding
danger signs of pregnancy ( like vaginal bleeding, decrease fetal
movement, leakage of water, dizziness, eye problem and edema was
given).

Moreover , she was advised to come back to PHC if her upper


respiratory tract infection didnt improve within 2 days for the antibiotic
prescription.

Medications:

Vitamin D 500 IU,1tab,oral,daily

Calcium 600 mg,1 tab, oral, daily

Folic acid 400mcg,1 tab, oral, daily

Ethics:
No Ethical issues or conflicts were involved in this cas