Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Important Topics ANEMIA Clinical obg for MBBS 1st Year Important Topics, MBBS 2nd Year Important Topics, MBBS 3rd Year Important Topics & MBBS Final Year Important Topics.
| am presenting H/o 25 yrs old, Mrs Annu w/oMr
Ramlal,R/0 Jaipur, educated upto 5t standard, she is a
housewife, belonging to lower socioeconomic status,G4 P
3-0-0-3 with 30 weeks of period of gestation presented
for the first time in the ANC OPD with the complains of
1-amenorrhea since 7 months.
2-weakness and easy fatiquability since last 3 months.
3-breathlessness on exertion since last 15 days.
HISTORY OF PRESENT ILLNESS
* Patient complains of easy fatiquability and weakness since last 3
months which has gradually increased over last 15 days to an
extent that she gets tired on doing household activities.
e Patient also complains of breathlessness on exertion since last 15
days.patient gets breathless on climbing two flight of stairs, it is not
associated with palpitations or any chest pain.
* NEGATIVE HISTORY
There is no history of sudden onset of breathlessness,cough or
decreased urine output.
there is no history of of asthma,or chronic cough.
There is no history of chronic fever with chills and rigors
There is no history of passes of worms in stool nor blood loss from
from any site.
There is no history of easy bruisability or petechiae.
there is no history of yellow discoloration of urine,skin
and eyes.
she did not take any iron folic acid prophylaxis in this
pregnancy.
No history of high B.P records,pedal
odema,headache,epigastric pain,blurring of vision
No history of polyuria,polydipsia,polyphagia
No history of pain abdomen,leaking or bleeding per
vaginum
Antenatal History
First trimester
Spontaneous conception
No history of radiation or any teratogen exposure
No history of fever with rash,burning micturation,discharge or bleeding per
vaginum
No history of any drug intake
No history of hyperemesis
Second trimester
She perceived quicking at 3" month
Only single ANC visit
Patient did not take any IFA prophylaxis
She has received one dose of tetanus immunization from local dispensary
* MENSTRUAL HISTORY
Her last menstrual period 22/12/2017
Her expected date of delivery 29/9/2018
Her menstrual cycles were regular with normal blood flow
* OBSTETRIC HISTORY
She is G 4 P 3-0-0-3
All children were full term normal vaginal delivery at home.
First FTND female child 5yrs old
2" conceived in lactational amenorrhea after 7 months of 15t baby FTND
female child 3yrs old
3RD conceived after 11 months of 2nd baby FTND female child 1.5yrs old
All issues are alive and healthy and immunized
All three pregnancies were uneventful
* PAST HISTORY
no history of TB, heart disease,hypertension,
asthma, any chronic illness
No history of hospitalization, surgery, allergic reaction
to any drug, blood transfusion
* PERSONAL HISTORY
She is vegetarian,non-smoker, non- alcoholic with
normal bowel bladder habits
She has h/o pica in this and earlier pregnancies
* FAMILY HISTORY
there is no history of repeated blood transfusions or
thalassemia in any of the family member.
SOCIOECONOMIC HISTORY
she belongs to lower middle class according to
modified Kuppuswamy scale.
DIETARY HISTORY
total calorie intake is 1500 Kcal and protien intake 17
gm per day which is grossly inadequate,iron intake
is around 15 mg/day
GENERAL PHYSICAL
EXAMINATION
She is lying comfortable in bed and well oriented to time
,place and person
she is thin built poorly nourished
her height is 5 feet,weight is 50kg bmi= 22.22 kg/m?2
her gait is normal.
VITALS
Her pulse rate is 80/minute regular,good in
volume,bilateral synchronous without any radiofemoral
delay.
Her B.P is 120/80mmHg
she is afebrile.
Her respiratory rate is 20/min
GENERAL PHYSICAL EXAMINATION
* Hair shows signs of malnutrition,
* Pallor is present in the conjuctiva and skin
* Nails shows platonychia
* Thereis no icterus, no pedal odema, no
lymphadenopathy,no cyanosis
* Neck veins are not visible, no other neck swelling
* There is no angular stomatitis,glossitis or cheilosis
SYSTEMIC EXAMINA
ION
* CVS(cardiovascular)-apex beat is present in 5t
intercostals space and is hyperdynamic S1S2 normal
Ejection systolic murmur grade 2/4 is heard best over
pulmonary area are not radiating to any site.
* RESPIRATORY- air entry equal on both the sides
no added sounds or crepts heard.
* CNS;-no abnormality detected
BREAST EXAMINATION
breasts shows normal changes of pregnancy, nipple are
everted
ABDOMINAL EXAMINATION
* Inspection
Abdomen uniformly distended
umblicus central and inverted
Linea nigra and stria gravidarum present
No scar mark
No visible vessel
All hernia sites are free
No hepatosplenomegaly
P/A
* Palpation
Fundal height is around 28 weeks
Symphysiofundal height is 28.5cm
Abdominal girth is around 29 inches
Fundal grip-broad irregular mass suggestive of breech
Lateral grip-back felt on right side and limbs on left side
Pelvic grip-smooth hard ballotable mass suggestive of head
felt
* Auscultation-fetal heart rate is 140/min regular in left
spinoumblical line
FINAL DIAGNOSIS
e 25 years old G4P3-0-0-3 with 30 weeks
periods of gestation with single live fetus in
longitudinal lie,cephalic presentation with
anemia not in failure.
* MANAGEMENT
This post was last modified on 24 July 2021