A 24 yrs female from
Boudha was admitted here on 23/8/2072
with
C/O : Cessation of menstruation for 8
months
generalised body swelling-15 days
History of present illness
Caessation of menses – 8months
LMP (Last Menstural Period) :22nd Chaitra,2072
EDD (Expected Date of Delivery) :29th Poush,2072
By Date: 34 wks+1 day
Generalised body swelling-15 days
Started from lower limbs, gradually progressed
to thighs, abdomen and face
Perceiving good fetal movement
Cough (+): on and off, non productive, no diurnal variation
No chest pain, shortness of breath, orthopnea
No Headache, epigastric pain, blurring of vision, high blood pressure
No per vaginal bleeding or leaking, no pain abdomen
Had taken iron and calcium
Had taken two doses of injection tetanus toxoid
Bowel/Bladder-Normal
Sleep/Appetite-Normal
Menstural History:
Menarche at 16 years
Flow-3 days,
Cycle-28+/-2 days,
Dysmenorrhoea (-)
IMB/Intermenstural Bleeding (-)
PCB/Post Coital Bleeding (-)
Obstetric history:
Married for 2 years,
Primigravida
Contraceptive history:
Not used till date.
Past history:
No Hx of TB, DM, HTN & any surgical
intervention done
Family history:
No Hx of DM, HTN, TB, twin pregnancy
Personal history:
Non-vegetarian
Does not smoke and consume alcohol
Allergic history :
Not known till date
On Examination:
General Condition = Fair,
facial puffiness present
Bilateral pitting edema present over lower limbs
Pallor(+)
Icterus (-)
Vitals:
Pulse : 82 beats/min
BP:140/90mmhg
Temperature : 97 degree Farhenheit
Respiration Rate : 22 breaths/min
Chest:
Bilateral Vesicular Breath Sound
No added Sound
CVS:
1st and 2nd heart sound
No murmurs
Per-Abdominal Examination:
Inspection:
Abdomen distended up to midway between umbilicus and
xiphisternum
Linea nigara and striae gravidarum seen
No visible peristalsis or pulsation seen
Flanks were full
All quadrants moving symmetrically with respiration
Palpation:
Symphysio-fundal height 32cm
Uterus 32 wk size
Longitudinal lie
Cephalic presentation,free
Contraction absent
FHS-140 beats/min
Fundal grip-soft,broad-suggestive of fetal buttocks
Right lateral grip-curved,resistant-suggestive of fetal back
Left lateral grip-irregular,knob like structure suggestive of fetal back
Per-Vaginal Examination:
No loss
Provisional diagnosis:
Primi at 34weeks+1day
period of gestation with generalised body
swelling
Advice:
Admission for observation and furthur
evaluation
all ANC and PET(Pre-Eclampsia Test) investigation
