Family Medicine Case Presentation
-
Upload
paul-summers -
Category
Documents
-
view
90 -
download
5
description
Transcript of Family Medicine Case Presentation
![Page 1: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/1.jpg)
Family MedicineCase Presentation
Group 7ASMPH 2012
23 July 2010
![Page 2: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/2.jpg)
Purpose of Presentation
• Prolonged hospital stay• Family of limited resources
![Page 3: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/3.jpg)
Identifying Data
• JCC is a 33 y/o, G3P3 (3003), Filipino, Roman Catholic, married woman with 2 children, with a third just delivered. She currently works as a street sweeper; lives as an informal settler near Tomas Morato.
• Self-referred, moderate reliability
![Page 4: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/4.jpg)
Chief Complaint
• Early post-partum abdominal pain and difficulty of breathing, s/p labored NSD
![Page 5: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/5.jpg)
History of Present Illness
• Patient, 33, G3P2(2002), previous “big babies” delivered via NSD, at 40 1/7 wks AOG by LMP, consulted at the OB-ER for persistent vaginal bleeding of few hours duration.
![Page 6: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/6.jpg)
History of Present Illness• Trimestral History– 6 PNCU with 3 prev UTZs done prior to admission. – Biophysical profile done 3 days prior to admission,
EFW = 3731 g; BPP score 8/8
• Abdominal Exam:– FH 31 cm, FHT 120s
• Pelvic examination: – 6 cm dilated, 70% effaced, with cephalic presentation,
station -3, +BOW
![Page 7: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/7.jpg)
History of Present Illness
• Admitting diagnosis– PU 30 1/7 weeks AOG by LMP, CIL, G3P2 (2002);
to consider arrest in descent secondary to feto-pelvic disproportion.
– Patient subsequently consented for BTL
![Page 8: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/8.jpg)
History of Present Illness
• While being monitored, patient was noted to be non-compliant to physician requests to do abdominal and pelvic examinations, noting direct tenderness at sites of examination. No apparent guarding in between contractions.
• No tenderness above the level of the diaphragm. Able to take blood pressure and vital signs, noted to be otherwise unremarkable.
![Page 9: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/9.jpg)
History of Present Illness
• During vaginal delivery of baby, patient was noted to show signs of distress, with vital signs becoming progressively unstable, with palor, hypotonia, tachycardia and tachypnea noted. Blood loss intra-partum was <300 ml.
• Patient was given fluids for resuscitation and Levophed for the suspected shock
![Page 10: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/10.jpg)
History of Present Illness
• Immediately post-partum, patient’s vital signs continued to show signs of instability; little improvement with subsequent decline despite initial PRBCs. CVP showed hypovolemia (~3cm).
• Patient also complained of continued abdominal tenderness, with or without palpation; increasing difficulty of breathing; chest pain initially sharp but progressively becoming heavy “parang may nakadagan”
![Page 11: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/11.jpg)
History of Present Illness
• Initial lab results– CBC: • RBC 2.39 x10 ^ 12 / L LOW• Hgb: 0.59 g/L LOW• Hct: 0.18 LOW• Plt: 191 Normal• WBC: 21.0 HIGH
– Neutrophil 0.909HIGH
– Lymphocytes 0.047 LOW
![Page 12: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/12.jpg)
History of Present Illness
– PT: 15.6s HIGH– APTT: 48.5s HIGH– Glucose: 14.36 mmol/L HIGH– Crea: 116.53 mmol/L HIGH– K+: 2.5 mmol/L LOW– Na+ & Cl- Normal– CKMB: 12 U/L HIGH– Troponin I Normal– Liver Function Test Normal
![Page 13: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/13.jpg)
History of Present Illness
• Patient also repeatedly noted feeling blood dripping/flowing around her genital area, but inspection was negative for external bleeding.
• About 9 hours post-partum, patient again alerted that there was blood gushing out. Inspection revealed heavy vaginal bleeding
• Patient was hence rushed to the OR.
![Page 14: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/14.jpg)
Personal and Social History
• Catholic• Married with 2 children• Non-Smoker, Non-Alcoholic• High school graduate• Lives as an informal settler• Main provider for family; works as a street sweeper• Other Stakeholders: Mother, husband, 2 children
– Husband, 42, is illiterate; unemployed; irregular job as an electrician– Mother is 68 y/o; continues to work as a washer woman to contribute
to finances; does hospital errands for JCC– 2 children 8 y/o and 6 y/o; going to school
![Page 15: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/15.jpg)
Family Genogram
![Page 16: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/16.jpg)
Other Pertinent History
• PMH: Uncertain medical history; Elevated OGTT 50g perinatally.
• FH: Uncertain family history; denies family history of hypertension, diabetes and/or other illnesses.
![Page 17: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/17.jpg)
Review of Systems
• Generalized weakness and fatigue• Lightheadedness• Blurring/dimming of vision• Difficulty of breathing/pleuritic pain• Chest pain and subsequent heaviness• Abdominal pain, whole• Sensations of blood dripping/gushing out her
vagina
![Page 18: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/18.jpg)
Physical Examination
• BP – Persistent hypotension <80 mmHg systole
• RR – Persistent tachypnea > 30 breaths/min• HR – Persistent tachycardia 130-160 bpm • Temp – mild fever 37.8 C axillary
• General survey– Pale, weak, lethargic, coherent
![Page 19: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/19.jpg)
Physical Examination
• HEENT: – Pale palpebral conjunctivae; sclerae anticteric– Pulsating neck veins; no gurgling on auscultation– No lymphadenopathy
• Lungs: – Suprasternal retraction, short breaths, clear breath
sounds• Heart:– Tachycardia, with occasional irregular rate; normal
rhythm
![Page 20: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/20.jpg)
Physical Examination• Abdominal:– Distended and apparently enlarging abdomen– (+) fluid wave– Tympanitic on all four quadrants– Tender on all four quadrants with or without
palpation– No masses felt
• Extremities:– Weak pulses on all extremities; bipedal edema
![Page 21: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/21.jpg)
Assessment
• Post Partum Hemorrhage secondary to Uterine Rupture, s/p NSD, Day 0; consider
• Baby boy, Z, delivered live via NSD, Apgar 1
![Page 22: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/22.jpg)
Diagnostics
• Constant monitoring of vital signs– BP, HR, RR, Temp., CVP
• Laboratory diagnostics– CBC, platelet count, BT, serum electrolytes, CKMB,
Troponin I, urinalysis
• Imaging (X-ray)• ECG
![Page 23: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/23.jpg)
Therapeutic Plan
• Continuous hydration with plain NSS. • Monitoring of vital signs every 30 minutes.• Serial H&H every 4 hours. • Transfusion of packed Red Blood Cells (PRBC)
with hemoglobin < 70 g/L• Electrolyte correction where needed.• Immediate exploratory laparotomy with
continued degradation of vital signs.
![Page 24: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/24.jpg)
Definitive Management
• Serial blood tests• Blood transfusions• Exploratory laparotomy• Subtotal hysterectomy
![Page 25: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/25.jpg)
Course in the Wards
• Unstable vitals requiring 4 day stay at SICU– Intubated• 2 days ambubagging; 1 day mechanical ventilator
– NGT• 4 days
– Intensive monitoring of vital signs and laboratory studies
– On multiple antibiotics, diuretics, IV fluids
• Monitoring at OB High-Risk Ward 5 days
![Page 26: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/26.jpg)
Follow-up Visits
• Baby Z continued to be confined at the NICU, incubated, for 1 month post delivery
• Baby Z currently still being monitored and stabilized at the nursery
• JCC has not gone home, having to breast feed Baby Z every 2-3 hours
• Mother S travels to and from home daily to accompany JCC and bring her food
![Page 27: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/27.jpg)
Family Assessment Tools
• Genogram• Family Timeline• Family Map• Family APGAR• Family SCREEM• Family CEA• Family Meeting• Home Visit
![Page 28: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/28.jpg)
![Page 29: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/29.jpg)
![Page 30: Family Medicine Case Presentation](https://reader033.fdocuments.us/reader033/viewer/2022061614/56812bce550346895d90279a/html5/thumbnails/30.jpg)