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CASE MANAGEMENT
CONFERENCE
GATDULA A., GATDULA E., GAUTANI,
GONZALES, MUTIA
OBJECTIVES
General: To be able to diagnose and initially manage patients
presenting with hypertension during pregnancy.
Specific:
1. Extract a concise clinical history
2. Perform relevant physical examination
3. Assess and come up with differential diagnosis
4. Know the initial management and treatment options
for this case
GENERAL DATA
● M.D., 40 y/o G5P3 (3013)
● Married
● Filipino
● Born and currently living in Silang, Cavite
● Admitted for the first time on April 2, 2019
CHIEF COMPLAINT
Headache
PAST MEDICAL HISTORY
● Hypertensive – 5 years
○ maintained on AMLODIPINE 5mg OD taken regularly
FAMILY MEDICAL HISTORY
● Hypertension - maternal side
PERSONAL AND SOCIAL HISTORY
● Patient:
○ College graduate and a housewife
○ Non-smoker, non-alcoholic beverage drinker, no
illicit drug use
● Husband:
○ College graduate
○ Non-smoker and occasional alcoholic beverage
drinker
● Lives with children on their own house
MENSTRUAL HISTORY
● M: 13 years of age
● I: Monthly
● D: 3-4 days
● A: 3 moderately soaked napkins per day
● S: (-) dysmenorrhea
OBSTETRICAL HISTORY: G5P3 (3013)
MANNER OF PLACE OF BIRTH COMPLI-
PREGNANCY DATE AOG SEX
DELIVERY DELIVERY WEIGHT CATIONS
HOSPITAL
G1 2003 TERM VSD MALE 3.0 kg NONE
/ DOCTOR
HOSPITAL
G2 2006 TERM VSD MALE 3.1 kg NONE
/ DOCTOR
HOSPITAL
G3 2008 TERM VSD FEMALE 3.1 kg NONE
/ DOCTOR
ABORTION HOSPITAL
G4 2014 2 MOS. - - NONE
S/P D&C / DOCTOR
G5 PRESENT PREGNANCY
GYNECOLOGICAL HISTORY
● No history of breast diseases nor any gynecologic
diseases or surgeries
CONTRACEPTIVE HISTORY
● No history of contraceptive use of any forms
SEXUAL HISTORY
● First sexual contact at 22 years of age
● 1 lifetime sexual partner
● 3-4x a week
● Last sexual contact: August 2018
● (-) post coital bleeding
● (-) dyspareunia
HISTORY OF PRESENT PREGNANCY
● LNMP: JULY 15, 2018
● EDC: APRIL 21, 2019
● AOG BY LNMP: 37 2/7 WEEKS AOG
● QUICKENING: 2ND WEEK OF NOVEMBER, 2018
HISTORY OF PRESENT PREGNANCY
● 7 months PTA (9 2/7 weeks AOG)
○ Amenorrhea
○ (+) pregnancy test
HISTORY OF PRESENT PREGNANCY
● 5 months PTA (17 weeks AOG)
● Consulted at DLSUMC for 1st prenatal check-up
● Early UTZ: Single live intrauterine pregnancy
compatible with the AOG
● Referred to IM for Hypertension
● BP 160/100
● Methyldopa 250 mg TID
HISTORY OF PRESENT PREGNANCY
● 4 days PTA
● Nape pain and headache
● Continued Methyldopa 250mg TID
● 3 hours PTA
● Severe headache and nape pain
● Prompted consult at DLSUMC ER
REVIEW OF SYSTEMS
● (-) blurring of vision
● (-) abdominal pain
● (-) convulsion
PHYSICAL EXAMINATION
GENERAL SURVEY
● Well-developed, well-nourished, awake, conscious,
coherent, oriented to time, place and person
● Appears her chronological age of 40
VITAL SIGNS
● BP: 200/120 mmHg, supine, right arm
● HR: 78 bpm
● PR: 78 bpm
● RR: 21 cpm
● Temperature: 36.4 C
SKIN
● (-) pallor (-) erythema (-) jaundice
(-) hyper/hypopigmentation
● (-) lesions
● Normal hair texture and distribution
● Normal nails
● Good skin turgor
HEENT
● Hair: normal texture
● Head is symmetrical, (-) mass (-) tenderness
● (-) facial asymmetry
● Eyes: pink palpebral conjunctiva, 2-3 mm EBTRL
● Ears: (-) mobile pinna (-) masses (-) discharge (-)
swelling (-) tenderness
● Mouth: (-) oral lesions (-) masses
CHEST AND LUNGS
● Symmetrical chest expansion
● (-) use of accessory muscles
● Clear breath sounds
● (-) rales (-) wheezes (-) stridor
HEART
● Regular rate, regular rhythm
● S1>S2 on the apex, S2>S1 on the base
● (-) extra heart sounds
● (-) murmurs
ABDOMEN
● Globular, soft
● (-) masses
● Normoactive bowel sounds
● (-) uterine contractions
ABDOMEN
● FH: 33 cm
● FHT: 158 bpm at the LLQ
● Leopold maneuvers
○ LM1: Soft, nodular mass
○ LM2: Hard, resistant at the maternal left and small
nodular mass at the maternal right
○ LM3: Hard ballotable mass
GENITALIA
● External: (-) lesions (-) discharge
● Internal Exam: cervix posterior, closed,
uneffaced, (+) BOW, cephalic, station -1
EXTREMITIES
● (+) Grade 2 bipedal pitting edema
● (-) varicosities
● (-) masses
● (-) deformities
● (+) Full and equal peripheral pulses
NEUROLOGIC
● GCS 15
● MSE: Awake, cooperative towards examiner, normal
stream of talk, conscious, oriented to time, place and
person, good immediate, recent and remote memory,
good judgement, concentration, and attention span,
appropriate mood and thought content
● Intact Cranial Nerves
● No sensory nor motor deficits
SALIENT FEATURES
● 40 years old
● G5P3 (3013)
● Chief complaint of headache
● No blurring of vision, abdominal pain and convulsion
● Hypertensive for 5 years
● BP 0f 160/100 on initial prenatal consult
● Maintained on Amlodipine 5mg OD
● Methyldopa 250 mg TID
● BP of 200/120 mmHg, supine, right arm
ADMITTING IMPRESSION:
A. Comorbidities
No. Preeclampsia with the following situations were
excluded: multiple pregnancy, gestational diabetes
mellitus, pre-pregnancy hypertension, intrahepatic
cholestasis of pregnancy, hysteromyoma, cystic salpinx,
fetal malformations or aneuploidies, stillbirths.
IV. ASSESSING APPLICABILITY
B. Race
Yes. The study population were all Chinese pregnant
women
C. Age
Yes. The maternal age in the cases who develop into
preeclampsia where significantly higher than the control.
Control= 26.57+/-3.5
Cases= 27.69+/-3.62
IV. ASSESSING APPLICABILITY
D. Pathology
There were no mention of other pathologies
mentioned in the study.
IV. ASSESSING APPLICABILITY
6. Are there socioeconomic issues that may affect the
accuracy of the test?