CASE PRESENTATION by Dr.Asma Shaik PATIENT DETAILS NAME: Mrs. X AGE: 22years EDUCATION: B com OCCUPATION: Homemaker HUSBANDS NAME: Mr. X AGE: 28 Years EDUCATION: B tech OCCUPATION: software engineer ADDRESS: Pillana garden,BANGALORE.
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Presentation Transcript
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CASE PRESENTATION by Dr.Asma Shaik<br>
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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
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<br>
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History Of Present Pregnancy Spontaneous Conception-Booked Case since 19 weeks of gestation
1st Trimester:-
Pregnancy detected at 1 and ½ 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<br>
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2nd Trimester:-
Quickening felt at 4 ½ 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<br>
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3rd Trimester:-
Continued perception of foetal movements
Continued taking iron and calcium tablets
2nd Td dose taken
No h/o High sugar /high BP recordings<br>
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Obstetric History Married life for 3 ½ year, non consanginious marriage
Barrier contraception used
PRIMIGRAVIDA- spontaneous conception
No h/o any treatment for infertility.<br>
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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<br>
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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<br>
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Family history No family history of any medical comorbidities
No family history of Multiple pregnancies
No h/o any foetal anomalies in family<br>
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Personal History Diet :- mixed diet
Appetite:- Good
Sleep :- Sound
Bladder and Bowel movements:- Regular and normal
No Addictions<br>
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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<br>
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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
Per Abdomen Examination Inspection:-
Abdominal longitudinally enlarged,
Umbilicus everted
Linea nigra present
Stria gravidarum present
Flanks free
Hernial Orifices appears to be free<br>
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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
1st Twin cephalic felt<br>
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Auscultation:-
Fetal Heart Sounds :
2 fetal heart sounds heard with a gap of > 10cm in between around the umbilicus.<br>
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Per vaginal examination Not done<br>
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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 1st twin cephalic for routine check up<br>
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Diagnosis Primigravida with 32+4 weeks gestation with DCDA twin pregnancy,with 1st twin cephalic presentation , came for routine check up.<br>
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Investigations On 25/3/23
Hemoglobin:-9.8gm%
Platelet: 3 lakh /mm³
OGCT : 102.9mg/dl
TSH : 1.31 Micromol/mm³
HIV /HBsAg / VDRL – Negative
Urine routine and microscopy: normal<br>
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USG on 25/3/23 DCDA Twin pregnancy with 31+1weeks of gestation
