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Family Medicine Case Presentation

Family Medicine Case Presentation. Group 7 ASMPH 2012 23 July 2010. Purpose of Presentation. Prolonged hospital stay Family of limited resources. Identifying Data.

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Family Medicine Case Presentation

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  1. Family MedicineCase Presentation Group 7 ASMPH 2012 23 July 2010

  2. Purpose of Presentation • Prolonged hospital stay • Family of limited resources

  3. 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

  4. Chief Complaint • Early post-partum abdominal pain and difficulty of breathing, s/p labored NSD

  5. 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.

  6. 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

  7. 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

  8. 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.

  9. 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

  10. 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”

  11. 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 0.909 HIGH • Lymphocytes 0.047 LOW

  12. 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

  13. 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.

  14. 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

  15. Family Genogram

  16. 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.

  17. 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

  18. 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

  19. 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

  20. 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

  21. Assessment • Post Partum Hemorrhage secondary to Uterine Rupture, s/p NSD, Day 0; consider • Baby boy, Z, delivered live via NSD, Apgar 1

  22. 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

  23. 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.

  24. Definitive Management • Serial blood tests • Blood transfusions • Exploratory laparotomy • Subtotal hysterectomy

  25. 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

  26. 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

  27. Family Assessment Tools • Genogram • Family Timeline • Family Map • Family APGAR • Family SCREEM • Family CEA • Family Meeting • Home Visit

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