OB CASE
You are taking care of Julia, a 40-year-old multigravida woman, who is in her third
pregnancy. She is currently being seen for prenatal care at 30th week gestation at the
nearest primary hospital. Her weight is 200 pounds, and her blood pressure is 140/90
mmHg. Uterine size seems to be appropriate for gestational age as estimated.
Family Profile
Julia is married to Gerald for almost 15 years now. She works as a house help. They live
in a single unit house, and the husband’s source of income is a farmer. Her family history
reveals that her mother has type 2 diabetes mellitus and on her paternal side has
hypertension and asthma.
Pregnancy History
Julia’s past obstetric history includes her first pregnancy with blighted ovum at 6 weeks 5
years ago. Her second pregnancy is a female infant at 40 weeks gestation, with good
APGAR score delivered via NSVD last June 2019, and reportedly the child is doing well.
Past Medical History
No other reported diseases. She reported that she was able to complete all of her
immunization and she received a dose of tetanus toxoid from her nearest hospital facility
in this pregnancy last December 2020. She is due for her TT2 dose this month.
Menstrual History
Patient had her menarche @ 14 years of age. She had a regular menstruation which falls
from 28-30 days cycle lasting 3-5 days, in moderate to heavy flow. She usually changes
her pads 6-8 times a day and is soaked in the first 3 days and moderate to light flow in
the succeeding days. She experiences menstrual cramps (dysmenorrhea) in the 1st 2 days
of menstruation but not all the time. Whenever she experiences the discomfort, she just
took any over-the-counter pain reliever (Analgesics) for it. Her LMP was on June 15, 2020.
Physical Examination:
Generally, the patient looks pale, tired, and sleepy. Patient is hypothermic, and
tachycardic.
Vital Signs:
BP: 140/90 mmHg
Temp: 35.4 degrees Celsius
PR: 102 bpm
RR: 25 cpm
SS: Weight: 200lbs
Height: 5 feet and 5 inches
Blood type: AB+
Fundic height: 31 cms
FHT: ranges from 140-155 bpm via Doppler in Left upper quadrant. There were no
variability noted when patient had her non-stress test a week ago at a nearby clinic.
PHYSICAL ASSESSMENT
The patient has fair-colored complexion. The head is rounded, normocephalic and
symmetrical. Pallor is noted. Neck veins are visible, and no enlargement is noted. The
pupils of the eyes are black and equal in size. The nose has no presence of discharge or
flaring, it is clear. The neck muscles are equal in size, no palpable nodules. Mask of
pregnancy is visible on the face. The abdomen is globular and a faint linea nigra and stretch
marks are still visibly noted. Breasts are symmetric, no dimpling and discoloration noted,
nipples and areolas are dark in color, according to the patient her breast seems to appear
larger and firmer. The chest is symmetrical. She reported that once in a while, difficulty
of breathing is experienced especially when she is lying flat on bed and doing household
activity. Lower extremities were checked, and no edema was noted. On musculoskeletal,
no pelvic girdle pain or back pain was noted. Extremities have a good range of motion,
sometimes felt leg pain due to prolong standing at work and some varicosities were noted.
Palmar erythema noted. Capillary refill actively returns to its normal color in less than 2
seconds. Able to digest food but like to consume fried chicken from a known food chain
store. She seldom eats green-leafy vegetables. The patient is constipated, hemorrhoids
are present. Urine dipstick result shows 3+ glycosuria and negative ketones.
Lungs have normal breath sounds without dyspnea. Clear to auscultation in all lobes.
Cardiac rate of 102 beats per minute, no signs of crackles, wheezing, stridor. Abdomen
has audible bowel sounds.
In the interviews conducted with the patient, Patient Julia stated the following:
“Magpa prenatal raman unta ko pero nikalit lang ug kalian akong paminaw, nalipong ko
ug kalit”
“Ika tulo na nako nga pag buros, ang una kay wala man daw to mi pitik ang kasing
kasing, ang ika duha ok ra sakto ra sad cya sa bulan pag anak nako niya, Mao ning mag
2 years old na cya krn June puhon”.
“ Katong mga una nga pag buntis nako wala koy ginabati sama karon. Maayo kaayo akong
paminaw kay walay mga komplikasyon. Akong BP sa una kay dli sad taas 120/90 o 100/80
ra gyud. Wala sad ko kaagi nga nag dugo-dugo ko”.
“Akong mama mismo kay diabetic ug high blood ug sa iya nga side nga akong mga ayaan
mga diabetic pud halosa. Sa papa nako nga side kay mga tag-as pud ug presyon sa dugo.
Ug si papa mismo mi agi napud ug ka stroke ka isa”.
“Ok ra kaha ko maam?ang baby nako ok ra kaha cya?mahadlok ko nga mahitabo sa ako
utro ang nahitabo sa ako sauna katong permiro nako nga pag buntis maong gusto sad ko
makabalo unsa ni akong kondisyon ug unsaon nako nga ma ok rako ug ang akong baby”.
DOCTOR’S ORDER SHEET
Doctor’s Order
Progress Notes
DATE/TIME
February 20, 2021@ 8:00AM (+)
vomiting x 2 eps
CBG – 102 mg/dL
T- 36.8 ˚C
PR- 98 bpm
RR- 22 cpm
BP- 140/90 mmHg
O2 sat: 98%
Received 1st TT dose
last December 2020
− Please admit under the service of Dr. Chua
− VS q 4, I/O q shift
− DAT
− IVF: PLR 1L at 100mL/hr x 2
− Labs:
− CBC
− UA (MSCC)
− CBG now then BID
− OGTT
− FBS
− Meds:
− Metoclopramide 10mg/amp 1 amp IVTT STAT then 1 amp IVTT PRN
for active vomiting Ferrous sulfate + Folic acid tab 1 tab PO daily
Vitamin C 100mg/tab 1 tab PO daily Vitamin D 5000IU/cap 1 cap
PO daily
− Tetanus toxoid 1 vial IM single dose
− Relay results once in
Dr. Chua
HBsAg: Non –Reactive
VDRL: Non-Reactive
Noted by:
Sofronio Davilla, RN
Doctor’s Order
Progress Notes
February 20, 2021 @ 12:00NN
(+) itchiness at genital area; vaginal
reddening
(+) thick, cream cheese like
discharge in vaginal outlet
A: Genital candida infection
T- 37.0
PR-86
RR-20
BP-130/80
O2Saturation-96%
Start Miconazole 50mg/tab 1 tab PO daily x 7 days Give
regular insulin SQ PRN if:
151 to 200 mg/dL: 3 units RI
201 to 250 mg/dL: 5 units RI
251 to 300 mg/dL: 8 units RI
301 to 350 mg/dL: 10 units RI
351 to 400 mg/dL: 12 units RI
More than 400 mg/dL: 15 units RI Repeat CBG 30 mins
post RI administration Facilitate pending labs; NPO at
10:00PM For biophysical scoring; please facilitate IVF: Shift
PLR to PNSS 1L 100 mL/hr Refer for unusuality
Dr. Chua
Noted by:
Sofronio Davilla, RN
Progress Notes
February 20, 2021
@4:00PM
Doctor’s Order
− Continue meds
− IVF TF: PNSS 1L at 100mL/hr x 2
− Facilitate pending labs today, refer results once
in − IVF TF: PNSS 1L at 100mL/hr x 2
T- 36.8 ˚C
PR- 98 bpm
RR- 22 cpm
BP- 140/90 mmHg
O2 sat: 98%
Dr. Chang
Noted by:
Matet Lawas, RN
Progress Notes
February 21, 2021 @
5:30AM
(+) OGTT
(+) GDM, candida infection
(vaginal)
T- 36.0 ˚C
PR- 90 bpm
RR- 20 cpm
BP- 150/90 mmHg
O2 sat: 98%
Doctors Order
− Start Lispro 10 units SQ TID pre-meals
− Start Levimir 10 units SQ BID pre-meals
− Change diet from DAT to Diabetic diet; inform − dietary department
− Cont. other meds
Dr. Roa
Noted by:
Gavin Taal, RN
Progress Notes
Doctors Order
February 21, 2021 @
5:00PM (+) headache
Give Paracetamol 500mg/tab 1 tab q4 PRN for fever and headache
Dr. Roa
T- 36.4 ˚C
PR- 100 bpm
RR- 24 cpm
BP- 160/90 mmHg
O2 sat: 98%
Noted By:
Gavin Taal, RN
DIETARY RECORD
WATER
SOUP
FRUIT JUICE
URINE AND
BOWEL MOVEMENT
RECORD
URINE
BOWEL MOVEMENT
2/20/22 AM
SHIFT
2/20/22 PM
SHIFT
2/21/22 NOC
SHIFT
2/21/22 AM
SHIFT
2/21/22 PM
SHIFT
400 CC
100 CC
200
500 CC
80 CC
0
0
0
0
600
100
200
500
100
0
2/20/22 AM
SHIFT
2/20/22 PM
SHIFT
2/21/22 NOC
SHIFT
2/21/22 AM
SHIFT
2/21/22 PM
SHIFT
500 cc
1x
500 cc
0
300 cc
0
600 cc
1x
600 cc
0
Laboratory Results
COMPLETE BLOOD COUNT
Date: Feb. 20, 2021
Examination Results
WBC 15.6/uL RBC 4/uL Hemoglobin 11g/dL Hematocrit 45
MCV 110fL MCH 39pg MCHC 33g/dL RDW 14
Platelets 275/uL Neutrophils 4/uL Lymphs 3/uL Monocytes
8
Eos 2
Basos 1
Urinalysis
Date: Feb. 20, 2021
Examination Results
Appearance Cloudy Specific Gravity 1.010 pH 6.0
Glucose Negative Bilirubin Negative Ketone Negative Occult
Blood 2+
Protein 3+
Leukocyte Esterase 1+
WBC 30-50/HPF RBC 15-30/HPF Squamous Epithelial 8-10
Bacteria TNTC
OGTT and FBS
Date: Feb. 21, 2021
Examination Results
OGTT Fasting: 125mg/dL 1 hour post-prandial: 200mg/dL
2 hour post-prandial: 170mg/dL
FBS 7mmol/L
Biophysical Scoring: February 21, 2021
Name: Julia Salazar 40 y.o
LMP: 06/15/2020
Exam date : February 20,
2021 General Survey:
No. of fetus : Single (1)
Presentation: CEPHALIC
FHT : 138 bpm
Amniotic Fluid index:
2.87Average Ultrasonic age:
30W 2D
Ultrasonic EDC: 03/25/21
Estimated Fetal weight : 2845
grms Gender : Female
Placental location: Left
Posterolateral
Placenta Grade: 2
Biometry
BPD: 8.51 cm
HC: 30.2cm
AC: 28.7 cm
Impression: With good cardiac and somatic activity, female, cephalic, 30 weeks & 2 days, by
biometry with adequate fluid, BPP=8/8, grade 2 left posterolateral placenta (2.0 cms from the
internal os). Estimated fetal weight is large for gestational age .
After 5 days Julia was discharged in improved condition with a final diagnosis of Gestational Diabetes Mellitus.