Clerking Patient #3 February 20, 2009

Clerking Patient #3 February 20, 2009

Name: FatouFaal

Bio: Age 25, from the area of Newjoswan, a Wolof Muslim married woman who has worked in business marketing.

Pregnancy history: This patient is Primagravida. Gestational age of the fetus is from the beginning of last menstrual period: from 7 September, 2008, it is 24 weeks. Her EDD, according to Nagel’s rule, is June 14.

Gyne history: She states that she attained menarche at age 15. Her periods areregular, usually lasting four days during a cycle of 30 days, and using approximately three pads per day. Bleeding has always been regular, with no clotting or malodorous content, and with little pain associated with the period.

She has no stated history of sexual contact before her first marriage in 2008 and had no understanding of contraceptives before my interview with her. During October of 2008, she said her husband noticed she had missed her period, and in early November she went to a Serekunda family planning clinic and was diagnosed as being pregnant with a positive HcG urine test. She received booking at 8 weeks.

Presenting Complaint: From the Serekunda area, she was admitted to the Gamtel Ward two days prior to interview with the complaint of vomiting and lower abdominal pain. She claims to have been vomiting about four times a day for the previous two days before admission. The condition seems to have been associated with intake of food and water but did not occur at any specific time of the day.

Medical history: At age 20, she was diagnosed and successfully treated for a period of six months for tuberculosis. He has no recollection of significant or immobilizing childhood illnesses. In November of 2008 she was admitted to RVTH three times, and once again in December via MOPD for vomiting and dehydration. In each of those times, she claims to have revived after being given IV medications whose names she cannot remember. However, she says some of the tablets were red, and she continues to take them. She has no recollection of UTIs or other infections that caused any ongoing discomfort. She claims to have regular bowel and urinary tract movements without memory of diarrhea or constipation.

Psychosocial history: She comes from a family of three siblings, she being the youngest. There is no history of diabetes, heart disease, or morbidity in pregnancy, although as I said, she was treated for TB some five years ago. There is no history of twinning. She says that during her sister’s first pregnancy, she had similar symptoms of vomiting. She lives in a compound with her husband. She does not use any tobacco or alcohol products and only occasionally uses caffeine in the form of soft drinks. I asked if she slept under a mosquito net, to which she answered that she began doing so as of five days before coming to the hospital this time.

Summary of complaints: Her presenting complaint is that of vomiting and lower abdominal pain which has disturbed her over the last four months. The symptoms have been severe enough to cause her to seek medical treatment five times during this period. The symptoms are not regular but subside once she is treated with oral medications about which she does not know the name.

Physical examination: The patient is fair skinned though not pale and does not appear anemic. She is slender, her skin is supple. She had no scars on her abdomen but has an umbilical hernia. There was no lineanegra. Her uterus and fetal outline was palpable. The fundal height was 18 cm. There was no indication of unusual masses in her abdomen. I did not do a digital vaginal exam, and I did not listen for a fetal heartbeat but could have expected to hear one with a hand held Doppler as early as 10 weeks gestation or with a fetoscope by 18-20 wks. Her breasts were without masses. There was no cervical or axillarylymphadenopathy. There was no cyanosis, no pedal edema, noorganomegaly. Her thyroid was not palpable. Her vital signs were as follows:

Weight: 45kg, Height: 66inches, BMI:

Temperature: 98.4 F/Respiration: 20 cycles per minute

Pulse: 86, Blood pressure: 98/56

Review of systems:

CVS: 1st and 2ndheartsounds heard in the 5th intercostals space along the midclavicular line

Pulmonary: both lungfields were clear, there was no nasal flaring or chest indrawing

CNS: pupils and reflexes were normal

Abdomen: bowel sounds were present; no organomegaly

Diagnosis: Malaria in pregnancy

Differential diagnosis: Recurring UTI (i.e., cystitis)

Treatment and plan:

Ultrasound to examine fetal development (fundal height was low for gestational age)

Lab- In addition to request for blood film, I would request the escort purchase one rapid test dipstick called Paracheck, for an indication of P. falciparum, as a confirmation of any BF results.

Full blood count as well as differential blood count to add credence to any diagnosis of malaria or UTI. Eosinophil count raised in malaria; leukocyte concentration raised in bacterial infection; platelet count raised in iron deficiency anemia

ESR: The higher the ESR, the lower the erythrocyte concentration. An anemic person will appear to have an increased ESR. However, ESR may also be increased In pregnancy.

Request for urine culture for possible UTI

Request for hemoglobin count to determine if malaria has left her anemic. Further, if Hb is below 8, I would try to determine if the anemia is macrocytic or microcytic

Medications- Septrim PO 500 mg tds X 7/7 to cover for possible UTI. Continue all common antenatal prescriptions, including Ferrous sulfate 300 mg PO tds X 9/12 and folic acid 800 micrograms/day.

Based on both tests for malaria, if positive, then IV 1000 ml stat of NS along with infusion of quinine, then afterwards, NS 500 ml q 4 hrs for 24 hrs. to manage any fluid loss from vomiting.