Name- birhan Adebirhan Nationality - Ethiopian

Age – 27 Date of Admission- July 28- 2022

Sex - Female

Marital Status – Married Date of Clerking -July 29- 2022

Educational status – university degree Source of history - Patient

Occupation- house wife Reliability - Reliable

Religion – Orthodox

Address – Addis Ababa, Ethiopia

Patient Identification -

History of Previous Admission – None

Chief Complaint – body swelling of 05 days duration

HPI –This is a 27 years primigravida whose LMP was on January-09-2022 with

calculated Gestational age of 28 +5 weeks and EDD on October-16-2022, Menses was
regular, coming every 28-30days and lasting for 3-4days, she usually used 2-3 normal
pads per day, and flow wasn’t associated with clot or any abdominal discomfort. She
never used any contraception means.

The pregnancy was confirmed by urine test and ultrasound on the fifth week after
she missed her period. She then started her ANC follow up at MCM hospital at the
time of confirming pregnancy when she started to have nausea & vomiting, which
was usually in the mornings. Blood and urine tests were done during her visits. She
was informed her HIV, syphilis and hepatitis-B were negative. Blood group was B
negative and took her first anti-D at her seventh month. She started taking prenatal
vitamins at the fifth week and received her first tetanus vaccine at that time. Fetal
quickening was felt around fourth month of pregnancy.
Patient currently presents with a complaint of body swelling of 05 days duration. The
swelling started from her legs progressing to her arm and face in the past week and
the swelling doesn’t resolve after sleep. Associated with it, she has a new onset
shortness of breath when lying flat on back, abdominal discomfort, foaming of urine
for the past week and raising heart beat for which she went to local health center
where she was told to have a high blood pressure with recording of 160/100 mmHg
and 162/104 mmHg on two occasions four hours apart. Patient had her regular
follow up here with a normal range of BP till now.
Patient has a family history of unspecified thyroid disease on her mother and her
mother’s sibling. She has had only one sexual partner and was married 8 months
back. She doesn’t smoke or use any other illicit drugs. She hasn’t tried any form of
assisted reproductive technology, she has no family or personal history of chronic
kidney disease, DM, cardiac disease.
Patient ultrasound showed she has a male single fetus, she also noticed decreased
fetal movement in the past couple of days with abdominal sense of stretching and
fatigue and sleepiness.
Otherwise, patient doesn’t have sense of blurring vision, headache, ABM, loss of
consciousness. No history of epigastric pain, right upper quadrant pain, no history of
bleeding per vagina or any bleeding disorder. No history of fever, excessive vomiting,
cough, waking up at night hungry for air. No decreased urine output, blood in urine,
blueish discoloration of lips and yellowish discoloration of eyes. no history of
multiple sexual partners, no yellowish discoloration of skin or eye, no history of
vomiting blood and no history of blood in stool.

Past obstetric history - None

Gynecologic history- mentioned on HPI, has no history of intermenstrual bleeding or

postcoital bleeding. No history of painful coitus, no history of STI, no history of
contraceptive use, no history of pap smear screening
Past medical and surgical history – She has no chronic medical illnesses or had any
surgery. She has no history of using any drugs. neither does she have any allergy
history.

Family history – mentioned on HPI

Personal and Social History –

o She lives with her sister; her husband is abroad most of the time.
o Has degree in library information science
o No history of substance use
o Drinks alcohol on occasions

Review of Systems –
Systemic: no fever, weight loss
HEENT Head: No Headache, head injury, Normal hair distribution

Eyes: No Lacrimation, blurring of vision, pain or itching in the eyes

Ears: No Tinnitus, deafness, vertigo,

Nose: No nose bleeds, discharge

Mouth and throat: No gum bleeding, sore throat.

Lymphoglandular: No swellings in the neck, axillae, and groin, breast swelling or

pain, or enlargement of the thyroid.

Respiratory system: No wheezing, stridor, no cough.

Cardiovascular system: HPI

Gastrointestinal system: no change in bowel movement, change in stool color, no

blood in stool
Genitourinary system: No suprapubic pain, polyuria, frequency, dysuria, urgency,
hesitancy, dribbling, incontinence, abnormal vaginal discharge

Integumentary system: No dry or moist skin, ulcers, urticaria, or nail changes.

Locomotor system: No Joint pain, joint deformities, bony deformities, limping,

Central nervous system: No speech disturbance, seizures, vision disturbance,

dysarthria, urinary incontinence or retention, fecal incontinence or stool
impaction, disturbance in sensation, insomnia, or nervous breakdown.

Physical exam

General appearance
The patient is comfortable.
Vital signs
BP: 146/96 mmHg on left arm, supine position
Pulse rate: 90 beats/min, regular, full volume, left radial artery.
RR: 20 breaths/min, regular.
T0: 36.5oC axillary.
SPO2: 97% on room air.

HEENT
Head: The skull is normocephalic, with no deformities, no depressions, and no
tenderness.
Eyes: symmetrical, non- icteric sclera, pink conjunctiva.
Ears: No lesion, no deformity, no masses, no discharge, no tenderness on mastoid
palpation or tragus pulling.
Nose: Symmetric, no swelling, septum midline, no nasal discharge, no sinus
tenderness.
Throat and mouth: Lips-no cyanosis, no lumps, no ulcers, no cracking. Pink oral
mucosa, no cleft lip or palate.
Lymphoglandular system:
Preauricular, post auricular, occipital, sub mental, submandibular, anterior cervical,
posterior cervical, supraclavicular, axillary, epitrochlear and inguinal lymph nodes
were not palpable.
The thyroid gland is not enlarged. No retrosternal dullness.
The breast was symmetrical with no palpable lump

Respiratory system
Inspection: No cyanosis over lips and nails, no clubbing of fingers, no retraction,
chest in drawing or use of accessory muscles. The chest is symmetrical, with no
deformities and scars.
Palpation: Trachea is midline, symmetric expansion of the chest, tactile fremitus is
normal bilaterally.
Percussion: Resonant bilaterally. Diaphragmatic excursion- 5cm
Auscultation: Vesicular breath sounds bilaterally, good air entry.
Cardiovascular system
Arteries: BP and pulse (see under vital signs). Pulse volume can be tabulated as
follow:
Carotid Brachial Radial Femoral popliteal PT DP

Right +++ ++ ++ +++ ++ ++ ++

Left +++ ++ ++ +++ ++ ++ ++

No radio-femoral delay was detected. No bruit over the carotid or femoral artery.
Veins: There are no distended veins over the neck, or chest wall, no hepato-jugular
reflux.
Precordium
Inspection: There is no precordial bulge. The precordium is Quiet. Apical impulse was
not visible.
Palpation: PMI was felt medial to the midclavicular line at the fifth intercostal space.
The heart sounds are not palpable. There is no parasternal or apical heave. There is
no thrill.
Auscultation: Both heart sounds are normal over the valvular areas. There are no
added heart sounds (split, gallop, ejection click, opening snap) or murmurs.
Abdominal –
Inspection: The abdomen is distended with flank fullness, a 29-week sized gravid
uterus, symmetrical, and moves with respiration. There are no surgical scars, masses,
or dilated veins over the abdomen. Hernia sites are free. No visible pulsation or
peristalsis. No caput medusae.
Auscultation: The bowel sound is normo-active. There is no bruit over the renal
artery, abdominal aorta, or liver areas.
Palpation: no tenderness, rigidity, no superficial mass, no organomeglay or palpable
mass
Leopold 1- four fingers from the umbilicus, 29 cm from the pubic symphysis
to the fundus. Soft, bulky, non-ballotable, irregular, quadrilateral mass
occupying the fundus.
Leopold 2- longitudinal lie, regular and smooth surface on the left side of the
abdomen with an irregular, knob like structure on the right side
Leopold 3- hard ballotable mass on the lower uterine pole
Leopold 4- flexed attitude, decent is 5/5
Fetal heart beat: 155bpm

Percussion: There is shifting dullness with fluid thrill. The total vertical span of the
liver along the right mid-clavicular line is 10 cm.
Genitourinary – no costovertebral angle tenderness or suprapubic tenderness
Musculoskeletal system
Generalized +2 pitting edema. No joint tenderness, redness, or swelling.
Integumentary system
No yellowish discoloration, no suspicious nevi, no rash, no petechiae or ecchymoses.
Nails without clubbing or cyanosis.
Central Nervous system
Mental status: GCS 15/15 patient is alert and oriented to persons only, not to time or
place
CNI: can smell alcohol through both nostrils
CNII: Intact visual acuity and color differentiation.
CNIII, IV, VI: Symmetric ocular movements. Pupils are round and have a regular
outline, reactive to direct and consensual light.
CNV: Pain, touch, and temperature are intact at ophthalmic, maxillary, and
mandibular distributions, normal masseter, and temporalis contraction
CNVII: symmetrical face on smiling, frowning, and blowing air.
CNVIII: intact hearing to a ticking watch.
CNIX and X: Soft palate rises in the midline; uvula is in the midline. Intact gag reflex.
CNXI: The Sternocleidomastoid and trapezius muscles contract on turning the head
and on shrugging the shoulder against resistance, respectively.
CNXII: the tongue is midline on protrusion and shows no fasciculation or atrophy.
Motor
Bulk: normal and symmetric muscle bulk, no spontaneous or induced fasciculation.
Muscle tone – normotonic on the right and left extremities.
Strength- 5/5 in all extremities.
Sensory: intact to light touch, pain, and temperature sensation
Reflexes
 Superficial reflexes: Abdominal reflex is present both in the upper and lower
quadrants. The corneal reflex is intact in both eyes. Plantar reflex is down
going on both sides
 Deep tendon reflexes:

Biceps Triceps Supinator Patellar Ankle

Right ++ ++ + ++ +

Left ++ ++ + ++ +

 Clonus: No clonus
 Meningeal signs: Negative Kernig and Brudzinski’s signs.

Coordination: Finger to nose and rapid alternating movement of the arm was done
without any abnormalities
Subjective Case summary

This is a 27 years primigravida with calculated Gestational age of 28 +5 weeks from

LMP who currently presents with a complaint of generalized body swelling of 05 days
duration that doesn’t resolve after sleep. Associated with it, she has a new onset
shortness of breath when lying flat on back, abdominal discomfort, foaming of urine
for the past week, raising heartbeat and high blood pressure recording of 160/100
mmHg and 162/104 mmHg on two occasions four hours apart.

Objective case summary

The patient is comfortable, vitals were; BP: 146/96 mmHg on left arm, supine
position, Pulse rate: 90 beats/min, regular, full volume, left radial artery, RR: 20
breaths/min, regular, T0: 36.5oC axillary, and SPO2: 97% on room air.
Abdominal –
Inspection: The abdomen is distended with flank fullness, a 29-week sized gravid
uterus, symmetrical, and moves with respiration. There are no surgical scars, masses,
or dilated veins over the abdomen. Hernia sites are free. No visible pulsation or
peristalsis. No caput medusae.
Auscultation: The bowel sound is normo-active. There is no bruit over the renal
artery, abdominal aorta, or liver areas.
Palpation: no tenderness, rigidity, no superficial mass, no organomegaly or palpable
mass
Leopold 1- four fingers from the umbilicus, 29 cm from the pubic symphysis
to the fundus. Soft, bulky, non-ballotable, irregular, quadrilateral mass
occupying the fundus.
Leopold 2- longitudinal lie, regular and smooth surface on the left side of the
abdomen with an irregular, knob like structure on the right side
Leopold 3- hard ballotable mass on the lower uterine pole
Leopold 4- flexed attitude, decent is 5/5
Fetal heart beat:155bpm
Percussion: There is shifting dullness with fluid thrill. The total vertical span of the
liver along the right mid-clavicular line is 10 cm.
Musculoskeletal system
Generalized +2 pitting edema

Differential Diagnosis from most to least likely

 Pre-eclampsia
 Nephrotic syndrome
 Chronic Hypertension with Superimposed Preeclampsia
 Gestational HTN
 Congestive heart failure
 Chronic liver disease

Discussion of differentials from least likely to most likely

 chronic liver disease - the presence of body swelling is for this diagnosis;
however, the swelling of hepatic cirrhosis starts from the abdomen (in this
patient it started in the lower limb), no risk factor for acquiring hepatitis, no
yellowish discoloration of skin or eye, no UGIB and no melena

 Congestive heart failure – the presence of body swelling that starts from the
leg makes CHF one of our differentials. In order to diagnose for heart failure,
the patient should fulfill one major and two minor Framingham criteria of
diagnosis of HF (this patient only has PND which is one major criterion but
doesn’t fulfill any minor criteria). On chest physical exam we have findings
like rales, crackles and crepitation due pulmonary edema.
 Gestational HTN – The presence of new onset elevated blood pressure after
20 weeks of gestation is for this diagnosis where as presence of severe BP
measurements, presence of frothy urine, presence of generalized body
swelling, presence of SOB when lying flat are against this diagnosis.

 Chronic Hypertension with Superimposed Preeclampsia – the presence of

body swelling, frothy urine, SOB when lying flat and severe BP measuring are
for this diagnosis whereas absence of hypertension prior to pregnancy or
diagnosis before 20 weeks of gestation are against this diagnosis.

 Nephrotic syndrome - the presence of body swelling, frothy urine and

hypertension are for nephrotic syndrome. However, the swelling in nephrotic
syndrome starts around the periorbital area and progresses (in this patient it
started from the leg and progressed upward). and this patient doesn’t have
any history of chronic kidney disease

 Pre-eclampsia with severity feature – for the diagnosis for pre-eclampsia this
patient has a new onset increased blood pressure after 20 weeks of gestation
and frothy urine (which is indicative of proteinuria). The severity feature is
SOB when lying down and BP recording of 160/100 mmHg and 162/104
mmHg on two occasions four hours apart. She also has body swelling that
doesn’t resolve after sleep (unlike normal physiology of pregnancy).
 MYUNGSUNG MEDICAL COLLEGE

Obstetrics and Gynecology clerkship C-I

Case Report

Mikiyas Sharew
MD/025/18

September 13, 2022

Investigations:
 CBC
 Blood group and RH
 Urinalysis
 Liver function test
 Renal function test
 LDH
 Uric acid level
 Abdominal Ultrasound
 Coagulation profile
 CXR
 Peripheral morphology
 To rule out congestive heart failure
 ECG/EKG
 Echocardiography
 Cardiac biomarkers