Karina Case

Karina Case

Patient Introduction

Karina is a 29-year- old Caucasian female, Gravida 4, Para 0303. She’s a single mother and has state funded health insurance.

  • HPI: Patient presents to the office today with amenorrhea times seven weeks and the UCG pregnancy test in the office is positive.
  • Allergies: NKDA
  • Past Medical History: Depression and Abuse
  • Medications: Zoloft 25 mg 1 po qd
  • FMH: Negative.
  • Surgical History: 2 prior C/S
  • Gynecologic history: Menarche 10X28X5, normal flow, no pain, no dyspareunia, post-coital bleeding, no history of STD, not using any method of birth control.
  • Obstetrics history: P 0303
3 years ago: 32 week C/S-abruption Male 4 lbs. no sequelae
2 years ago: 24 weeks Preterm Labor SVD-VBAC Male 2 lbs. 2 oz. child is blind
1 year ago: 26 weeks Preterm labor C/S Fetal Dist. Female 2 lbs. 13 oz. no sequelae

Social: ETOH none, tobacco 4 cigs/day; marijuana 1 joint a day, no other substances. She lives with her three kids and works at Dunkin’ Donuts about 30 hours a week.

Initial Physical Exam

  • Wgt: 141 Height: 5-6 VS 98.2-88-16-98/54
  • Urine Dip: neg protein, ketones, glucose
  • UCG: Positive
  • General appearance: alert, no acute distress, tired appearing, under nourished female
  • Neuro: oriented to all spheres, affect and mood is appropriate
  • Head: atraumatic, normocephalic
  • Ears: no external deformities, gross hearing intact
  • Eyes: no external deformities, gross vision intact
  • Nose: no discharge, inflammation or lesions
  • Oral: good dentition, no erythema, exudate, lesions. Tongue protrudes midline, positive gag reflex, uvula rises midline with phonation
  • Neck: trachea midline, no lymphadenopathy, thyroid gland not enlarged, symmetrical, no nodules alpated,
  • Cardiac: 82, regular rhythm, no murmur or gallops
  • Lungs: no respiratory distress, no use of any accessory muscles, lungs are clear to auscultation bilaterally, percussion resonant throughout with symmetrical lung expansion
  • Breasts: symmetrical, medium size, nipples everted, no asymmetry, skin changes, nipple discharge, masses or tenderness. Negative lymphadenopathy
  • Abdomen: non- distended, non-tender, normal bowel sounds in all four quadrants, no hepatosplenomegaly, no hernias. C/S scar note low transverse
  • Extremities: no clubbing, cyanosis, edema or deformities noted. Full range of motion in all joints, warm to touch, good capillary refill
  • External genitalia: normal appearance, normal labia majora and minora, no lesions, masses or lymphadenopathy. Urethra is normal with no discharge
  • Internal genitalia: no lesions, adequate pelvic support, slight amount of white- yellow discharge noted
  • Cervix: multip, posterior with bluish hue, no cervical motion tenderness, no lesions
  • Uterus: is smooth, mobile, non-tender measuring about 8 weeks size, adnexa is normal, no masses, non-tender

Initial Laboratory

  • CBC: Hemoglobin 11.7 Hematocrit 33.6, Platelets 199
  • Blood type: O positive, antibody negative
  • TSH 1.21
  • Rubella: immune
  • Varicella: immune
  • RPR: non-reactive
  • HIV: negative
  • Gonorrhea: negative
  • Chlamydia: negative
  • Urinalysis: SG 1.025, neg ketones, protein, nitrates, leukocytes, blood, urobilogen normal
  • Urine culture: negative
  • Pap Smear: Negative
  • Hepatitis B: HepBAg negative, HepBsAb positive
  • Hepatitis A: negative
  • Hepatitis C: negative
  • Cystic fibrosis: negative

28 Week Prenatal Visit

Karina returns to the clinic at 28 weeks. Karina’s blood pressure is 124/50. She weighs 142 lbs. Fetal heart tones 135 bpm. Fundal exam measures 28 cm. She reports intermittent vaginal bleeding, no discharge and mild inconsistent contractions. She complains that her belly has been itching daily for two weeks. She denies any new use of creams, lotion, perfumes, or laundry detergent. She has not started any new medications or tried any new food. She states her skin is becoming more and more itchy that it is driving her crazy.

PE: Abdomen evident for striae and erythematous plaques with a pale halo around the plaques. Has a slight hive like appearance. No pustules, no exudate, no ulcerations, crosses midline.

Laboratory: LFT’s normal, Uric Acid normal, Amylase normal.

35 week prenatal visit

Karina presents to clinic at 35 weeks. Karina drives from her place of work to clinic. Her blood pressure is 95/40. She weighs 154 lbs. Fetal heart tones are 125 bpm. Her fundus is rigid, tender and measures at 35 cm. She reports decreased fetal movement for 8 hours. Karina has been filling a pad every hour for 8 hours while at work and the blood is bright red. Pt states she got into a physical fight with boyfriend today and her sister kicked her in the abdomen.

Labs: 1 hour gtt done at 28 weeks 109, CBC normal at 28 weeks; Kleihauer Betke 0.9% fetal cells 45 cc.

US: Her 28 week US showed HC/AC consistent with 28 4/7 weeks gestation, EFW 1257 gr (57%), 3 vessel cord, marginal insertion, anterior grade low lying placenta, amniotic fluid index 16 cm, cervix 3.3 cm, no funneling, breech position.