• Patient name- Gauri

• Age -24years
• W/O- Rajkumar
• Residence of Allahpur ,Prayagraj
• Chief complaints of
• Swelling in both lower limbs since 20 days
• Headche since 1 day
• Following 8 months of pregnancy
History of present illness
• According to patient she was apparently asymptomatic 20 days back when she
developed swelling in both lower limb which was insidious in onset ,initially around
the ankle and progressing unto the abdomen ,it was present throughout the day and
not relieved on resting overnight or limb elevation.
• She also complaints of headache since 1 day , it was localised to forehead ,was
gradual in onset ,throbbing in nature. No History of nausea and vomiting,epigastric
pain and blurring of vision,no history of reduced urinary output ,hematuria, shortness
of breath,palpitations,yellowish discoloration of urine

• With these complaints she visited to Kamla Nehru hospital on 21/11/2020. her blood
pressure was told to be raised ,got admitted and her routine blood and urine
investigations were sent,USG was advised and she received some medications in the
form of iv and im injections and oral medications and got relieved in her symptoms.
.
History of first trimester
• Spontaneous conception
• LMP-30/3/20
• Pregnancy was confirmed by UPT test done at home after overdue of 20
days
• Her first antenatal visit was at 2 ½ months of pregnancy,her routine
blood ,urine investigations,Ultrasonography were done and was said to be
normal
• H/o folic acid intake
• No history of fever with rashes, excessive nausea vomiting, pain in
abdomen, bleeding per vaginum, radiation exposure and self medication.
History of Second Trimester
• Quickening was felt in 5th month
• 2 doses of Tetanus vaccine was administered
• Iron and calcium tablets were taken
• No history of pedal edema , epigastric pain, blurring of vision and
headache
• No history of pain abdomen, leaking or bleeding per vagina
• No history of easy fatigability,palpitations
• She had 2 antenatal visits , routine blood investigations and USG were
done and was told to be normal
History of 3rd trimester
• She continued to take Iron and calcium tablets

• No history of vomiting ,blurring of vision ,epigastric pain .

• No history of bleeding per vaginum, pain abdomen and leaking per
vaginum.
• She came with the complaints of headache and swelling of lower
limbs at 8 months of pregnancy and got admitted.
Obstetric History
• Gravida 1 para 0+0
• Married life 2 years
Menstrual History-
• LMP-30/3/20
• EDD-6/1/21
• Previous Menstrual History-2-3 days/28-30 days/average/regular
• Past History- No history of Tuberculosis, Hypertension, Diabetes
Mellitus, Bronchial asthma, Thyroid and seizure disorder .
• Family History- No history of tuberculosis, hypertension, diabetes
mellitus, bronchial asthma ,thyroid and seizure disorder in her family
member.
• Personal History-
She is graduate
Housewife, vegetarian , no history of addiction , normal bowel and
bladder habit and sleep pattern
Dietary History-
• Calorie requirement-2,000 Kcal
• Calorie intake- 1900 Kcal
• Protein requirement -70 gm/day
• Protein intake- 60gm/day
• Diet was deficient in 100 Kcal and 10gm protein .
• She was advised to take deficient calories and protein.
Socioeconomic Status-
• Lower middle class
General Examination
• Built- average , Height- 154 cm, Weight - 55 kg (Prepregnancy
weight) ,BMI-21.64 kg/m2
• Pallor –absent
• Icterus- absent
• Clubbing- absent
• Cyanosis-absent
• Lymphadenopathy-absent
• Edema –present (grade 3)
• PR- 92/ min
• Bp-130/88 mm of Hg, at the time of admission -162/114 mm of hg
• RR- 16 /min
• Thyroid gland not enlarged
• Both breast bilateral symmetrical ,nipple everted , no underlying
lump palpable
Systemic examination
• Central Nervous System -Patient was well oriented to time place and
person.
• Cardiovascular System -S1 S2 heard ,no added sound heard

• Respiratory System-Bilateral vesicular sound heard all over the

chest ,no added sound heard.
 Per abdomen examinaton
• Inspection-Abdomen uniformly distended, ovoid in shape , umbilicus
centrally placed , linea nigra and stria gravidarum present
• Palpation
• FH- 32 weeks (corresponding to the period of gestation)
• Lie – longitudinal
• PP- Cephalic( 5/5 palpable)
• Symphysiofundal height – 32 cm (corresponding to period of gestation)
• Abdominal girth – 33 inches ( corresponding to period of gestation)
• Liquor seems to be adequate
• FHR- +R 132/ min( Rt spinoumbilical line)
• Provisional diagnosis- 24 years old,Primigravida 34 weeks pregnancy
with single live intrauterine pregnancy with longitudinal lie with
cephalic presentation with severe preeclampsia