Inpatient History
Name: Yali Zhou Sex: Female
Age: 38year Ward: No.8 Bed: No.816 Marital status: Married Birthplace: Shanghai Nationality: Han Provider: Patient, reliable. Record date: 2005-12-13
G & O History: GW: 30+5weeks, G2P0, LMP: 2005-5-10; EDC: 2006-2-17
Chief Complaint:G2P0, GW: 30+5weeks. This patient prents hypertension for 3 months, and systemic edema for 2 weeks.
History of Prent illness:
The patient had regular mens previously. LMP: 2005-5-10; EDC: 2006-2-17. Uric HcG test was positive after 40 days of amenorrhea. Fetal movements were felt in 4 months’ gestation. In 12+2weeks’ gestation, the patient’s blood pressure was found 160/90 mmHg when she completed her first ante-partum examination in Hospital of Women and Children’s Health in Huangpu District. There was no symptoms at that time, and she didn’t take any treatment. Half a month ago, she prented edema on
both the lower extremities, which expanded to the whole body gradually. She came to our hospital on Dec, 5th and took her ncond ante-partum examination. The bp was 200/160mmHg, and uric protein(++) on dipstick test. She has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no naua or vomiting, no thoracic pain. She was admitted on 2005-12-6.
After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation.
Past history:Patient denies history of hepatitis and tuberculosis. No history of allergies. Vaccinated regularly. Past medical history is unremarkable. Surgical history denied. No history of vere trauma and transfusion.
Review of systems:
Respiratory system: No history of chronic cough or breathlessness. No hemoptysis or dyspnea.
Cardiovascular system: No precordial pain. No palpation. No syncope. For details e prent history.
Gastroentestinal system: No history of chronic abdominal pain and diarrhea; No naua or vomiting;
No hematemesis and blood stool.
Endocrinic system: No polydipsia or polyphasia or polyuria. No sudden change of character and intelligence.
红枣糯米饭
Hematologic system: No bruis or abnormal hemorrhage. No recurrent oral ulcer and gingival bleeding.
Genitourinary system: No decread libido; No vaginal dryness or vaginal bleeding; History of STD denied; No urinary frequency. No precipitant urination or dysuria. No hematuria or proteinuria.
Neuropsychiatric system: No convulsion or anesthesia. No headaches. No abnormal orientation. No deterioration of memory or intelligence.
Locomotor system: No arthralgia, no muscular atrophies or dystrophies.
Personal History:
Born and grown up in Shanghai. Patient denied history of tobacco or alcohol u. Marital and Childbearing history:Married. 0-0-1-0; She had an abortion in 3 months’ gestation in Dec., 2004. Birth control has been instructed.
Family history:The patient’s Mother and a sister suffered from hypertension. No family history of DM or stroke. No family history of nervous or mental dias.
Physical Examination
T: 37℃P: 89/min R: 20/min BP: 180/120mmHg
黄芩的功效和作用General appearance: Patient is a 38 years old female who appears pleasant, in no apperant distress, given her age, well developed and well nourished. Oriented to person, place and time.
Lymph nodes: Not enlarged.
Skin: No jaundice or rashes. No cyanosis and bruis. No edema.
Head: Skull and scalp normal. No tenderness. No loss of hair.
Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No jaundice. Pupil’s size and shape is normal. Corneal is clear.
No exophthalmos.
Ears: Auditory acuity is excellent. No ear purulent discharge.
No: Shape is normal. No obstruction. No deviation of nasal ptum.
Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.
Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.
日俄战争Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.
Lung:
Inspection: Respiration regular. Degree of expansion is symmetry.
Plapation: Tactile fremitus symmetrical.
Percussion: extensive resonance to percussion.
Ausculation: Clear to ausculation with no rubs noted.
Heart:
Inspection: No abnormal pulsation or retraction.
Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.
Percussion: The border of cardiac is not enlarged.
Ausculation: The heart sounds were of good quality and the rhythm was regular. Heart rate: 96/min. No bruits.
Right(cm) Rib interspace Left(cm)
2.5 Ⅱ 2
2.5 Ⅲ 4
3 Ⅳ 6
Ⅴ 8
The left mid-clavicular line is 9 cm away from front midsternal line.
Radial pul is normal.
Abdomen:
Inspection: Universial abdominal bulge. Dilated veins obrved.
Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details e obstetric examination.
Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.
Ausculation: Bowl sound clear. 4/min.
Spine and extremities: Severe edema in both lower extremities. No clubbed finger.
No disorder of the movement of axial and appendicular bones.
Reflex: Symmetrical, equal without pathological respons. Babinski sign and Kernig sign and hoffmann sign are all negative.
Obstetric examination
Patient appears pleasant, given her age, well developed and well nourished. No jaundice. No enlarged lymph nodes.
Fetus: Abdominal girth: 93cm; height of fundus: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: ; fetal heart rate: 148/min; FM: active.
Pelvis: 24-17-19-9 cm.
Anorectal examination: fetal prentation: N/A; sincipital prentation: N/A; fetal membrane: not ruptured. Amniotic fluid: N/A;
音乐教学Flexion of knee: active.
Laboratory and special examination
Dec. 6th, Blood Rt: Hb: 121g/L; PLT 136×10e9
Urin e Rt: uric protein(++); occlude blood: (+++)
溥谷开来Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL: 51mm; HL: 49mm. fetal prentation: head; Position of placenta: right wall of uterus.冬子的故事
Thickness of placenta: 23mm. Degree of placental maturity:Ⅱ; fetal
雾都孤儿读书笔记heartbeat and fetal movement en; amniotic fluid: 64mm. There is no
hematocoelia or ascites. The lower edge of placenta is 23mm from the
cervix.
Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.
lcd显示Fetal heart rate: 145/min
Dec. 8th, 24h uric protein: 7.5g
Dec.10th, rum potassium: 3.9mmol/L
Scr: 86umol/L
ALT: 25U/L ; AST: 30U/L
Features of the ca:
1.Female, 38years old, G2P0, GW: 30+5weeks.
2.This patient prents hypertension for 3 months, and systemic edema for 2 weeks.
3.PE: BP: 180/120mmHg. Obstetric exam: Fetus: Abdominal girth: 93cm; height of
fundus: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: ; fetal heart rate: 148/min; FM: active.
Pelvis: 24-17-19-9 cm.
Flexion of knee: active.
4.Laboratory and special exam:
Dec. 6th, Blood Rt: Hb: 121g/L; PLT 136×10e9
Urin e Rt: uric protein(++); occlude blood: (+++)
Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL: 51mm;
Degree of placental maturity:Ⅱ; fetal heartbeat and fetal movement
en; amniotic fluid: 64mm.
Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.
Fetal heart rate: 145/min
Dec. 8th, 24h uric protein: 7.5g
Dec.10th, rum potassium: 3.9mmol/L
Scr: 86umol/L
ALT: 25U/L ; AST: 30U/L
Diagnosis and differential diagnosis:
Diagnosis: 1. Severe pre-eclampsia. This patient is a 38-year-old woman, who prents with hyperte
nsion and edema. Pre-eclampsia is hypertension associated with proteinuria and edema, occurring primarily in nulliparas after the 20th gestational week and most frequently near term. Other clinical findings of the patient include uric protein (++), etc. The lead to the diagnosis of pre-eclampsia, which feature the clinic status of the latter. The patient has (1) blood pressure 180/120mmHg(>160/110mmHg);
(2)proteinuria(++) on dipstick testing and 7.5g (>5g)in a 24-hour period. Conclusively, she can be classified as vere pre-eclampsia. Pre-eclampsia is a multisystemic syndrome, primary investigations reveal that she has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no naua or vomiting, no thoracic pain, indicating that there are no many complications at prent. Further evaluations are indispensable, which requires more careful investigations.
2. Chronic esntial hypertension. The patient’s hypertension began from the 12w of gestation, which indicate that she has chronic hypertension. Besides, she has a family
history of hypertension. After all, she doesn’t prent vere complaints when her blood pressure were as high as 200/160mmHg. All the lead to the diagnosis of chronic hypertension. To confirm the diagnosis, the blood pressure after delivery should be evaluated.
Differential diagnosis: 1. chronic esntial hypertension associated with pregnancy. Esntial hypertension associated with pregnancy can also cau a very high blood pressure. However, given the age, proteinuria and edema are possibly not complications of hypertension, indicating that she has superimpod pre-eclampsia. Besides, the symptoms of proteinuria and edema are temporally associated with gestation.
2. Chronic hypertension due to renal dia. This includes chronic hypertension due to interstitial nephritis, chronic glomerulonephritis, SLE, diabetic glomerulosclerosis, and so on. In the occasions, the patient would also possibly prent hypertension, proteinuria and edema, but her proteinuria was found recently and she didn’t have any symptoms associated with renal dias previously. In addition, her rum creatinine is in the normal scale (Scr: 86umol/L), which contradicts the hypothesis that she has a renal dia. So the diagnosis of chronic hypertension due to renal dia is not considered at prent.
Further investigations and treatments:
1.Clo obrvation and monitoring, plus quick evaluation: daily weighing; q4-6h
monitoring of blood pressure; daily monitoring of protein in urine; Regular liver and kidney function te
sting; Ultrasound of the abdomen; Fetus heartbeat monitor;
Conduct ophthalmoscopy examination to evaluate the verity of the patient’s condition; Conduct PT, APTT, FDP, 3P test to evaluate the coagulant function.
2.Rests: Lie in bed on left side.
3.Magnesium sulfate administration with clo obrvation of flexion of knee,
respiratory rate and urine.
4.Control hypertension with Labetalol or Nitroglycerin. The goal of bp control is
diastolic pressure《110mmHg and MAP《140mmHg.
5.Administer furomide to control edema.
6.Cautious evaluation of the maternal and fetal complications and take action
correspondingly. Severe maternal complications include edema of the brain, pulmonary edema; DIC; HELLP syndrome; renal failure. Indicative symptoms include headache, epigastric pain, visual distur
bances, oliguria, naua and vomiting, thoracic pain, etc.
7.U corticosteroids to accelerate fetal lung maturity.
8.Delivery. In an effort to reduce perinatal morbidity and mortality, delivery
should be delayed. If the patient develops into the following conditions: 1.Blood pressure consistently higher than 100mmHg diastolic in a 24h period or confirmed higher than 110mmHg; 2. Rising rum creatinine; 3. Persistent vere headache; 4. epigastric pain; 4. abnormal liver function tests; 5: Thrombocytopnia; 6: HELLP syndrome; 7: Eclampsia; 8: Pulmonary edema; 9: Abnormal antepartum fetal heart rate testing; 10: SGA fetus with failure to grow on rial ultrasound examinations.
