CASE PRESENTATION
Mrs. X, a 22-year-old primigravida, presents with spontaneous conception and a history of amenorrhea. This case study outlines her pregnancy details, including chief complaints, obstetric and menstrual history, as well as medical and surgical background. Follow along as Dr. Asma Shaik navigates through the patient's journey, providing insights into her care and management.
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Presentation Transcript
CASE PRESENTATION by Dr.Asma Shaik
PATIENT DETAILS NAME: Mrs. X AGE: 22years EDUCATION: B com OCCUPATION: Homemaker HUSBAND S NAME: Mr. X AGE: 28 Years EDUCATION: B tech OCCUPATION: software engineer ADDRESS: Pillana garden,BANGALORE. SOCIOECONOMIC STATUS: Upper Middle Class
Chief Complaints Primigravida- spontaneous conception C/o 8 months of amenorrhea Perceiving fetal movements well No complaints of pain abdomen/bleeding p.v / leaking PV Came for routine ANC check up
History Of Present Pregnancy Spontaneous Conception-Booked Case since 19 weeks of gestation 1stTrimester:- Pregnancy detected at 1 and months of gestation with Urine Pregnancy Test.. Viability scan not done Folic acid supplements taken regularly NT NB scan done at 11 weeks showed twin pregnancy ( DCDA Twins) h/o Hyperemesis in first trimester No h/o Fever with rash No h/o bleeding PV / Spotting No h/o radiation exposure/ any drugs exposure
2ndTrimester:- Quickening felt at 4 months of gestation Iron and calcium supplements taken. 1 dose of injection Td taken. Anomaly scan done and was told to be normal. No h/o bleeding PV/Leaking PV No h/o High sugars or high BP recordings
3rdTrimester:- Continued perception of foetal movements Continued taking iron and calcium tablets 2ndTd dose taken No h/o High sugar /high BP recordings
Obstetric History Married life for 3 year, non consanginious marriage Barrier contraception used PRIMIGRAVIDA- spontaneous conception No h/o any treatment for infertility.
Menstrual History LMP:- 6/09/2022 EDD:- 13-06-2023 ( by scan 7/7/23 ) Gestational age:- 32 weeks 4 days Previous cycles:- Irregular 5-6days 30-45 days No h/o passage of clots/dysmenorrhea
Medical / Surgical history No h/o Hypertension/DM/Epilepsy/TB No h/o Heart diseases No h/o any previous Blood transfusions No h/o any Surgeries in the past No h/o any drug allergies
Family history No family history of any medical comorbidities No family history of Multiple pregnancies No h/o any foetal anomalies in family
Personal History Diet :- mixed diet Appetite:- Good Sleep :- Sound Bladder and Bowel movements:- Regular and normal No Addictions
Diet history Dietary requirement : 2400kcal /day Patient intake : 2250kcal/ day Deficit : 150kcal/day Total protein requirement : 60gm/ day Total protein intake- 52gm/day Deficit 8gm/day
Examination Patient is conscious,co-operative,oriented to time, place and person Patient is moderately build and well nourished General Physical Examination:- Tongue,Teeth,Gum,Tonsils:- Normal,No glossitis or No stomatitis No Pallor / Icterus / Cyanosis / Clubbing /Edema / Lymphedenopathy
Thyroid:- normal Prepregnancy weight :- 60.5kg Breast :- normal Weight:- 70.4 kg Spine:- normal weight gain : 9.9kg BMI 23kg/m
Vitals Pulse:- 90bpm,regular,normal volume Spo2:- 99% at Room air BP :- 120/70mmHg Temperature:- Afebrile RR:- 13/minute
Systemic examination CVS :- S1 S2 heard ,No Murmers RS :- Bilateral Normal vescicular breath sounds heard, No Additional sounds heard
Per Abdomen Examination Inspection:- Abdominal longitudinally enlarged, Umbilicus everted Linea nigra present Stria gravidarum present Flanks free Hernial Orifices appears to be free
Palpation:- Patient 32weeks with fundal height Corresponds to 36 weeks gestation Symphysiofundal height- 40 cm Abdominal circumfernce- 40 inches Uterus :- Relaxed Multiple fetal parts felt 3 fetal poles felt 1stTwin cephalic felt
Auscultation:- Fetal Heart Sounds : 2 fetal heart sounds heard with a gap of > 10cm in between around the umbilicus.
Per vaginal examination Not done
Summary A 22year old woman belonging to Upper Middle Socio-economic status has come with Primigravida with 32+4 weeks gestation with DCDA twin pregnancy with 1sttwin cephalic for routine check up
Diagnosis Primigravida with 32+4 weeks gestation with DCDA twin pregnancy,with 1sttwin cephalic presentation , came for routine check up.
Investigations On 25/3/23 1. Hemoglobin:-9.8gm% 2. Platelet: 3 lakh /mm 3. OGCT : 102.9mg/dl 4. TSH : 1.31 Micromol/mm 5. HIV /HBsAg / VDRL Negative 6. Urine routine and microscopy: normal
USG on 25/3/23 DCDA Twin pregnancy with 31+1weeks of gestation Twin1 : Transverse lie, liq- adequate, EFW 1.2kg (45thcentile ), No placenta previa Twin 2 : Cephalic presentation, liq- adequate, EFW- 1.5kg (60thcentile ), No placenta previa
