MERCADO, Reuben Mari S.

OBGYN 250
2012 – 15366 Date of consult: December 16, 2019
MINI CLINICAL EXAM PAPER
SUBJECTIVE
General Data: K.C., a case of hyperthyroidism in pregnancy and suspected enlargement of the posterior horn of the left
lateral cerebral ventricle of the fetus, in a 25-year old G2P1 (1001) at 38 5/7 weeks AOG by LUTZ, who was referred to
PGH due to findings of abnormal thyroid function test and late ultrasound results.
Past Medical History: Congenital bilateral impaired hearing; (-) Asthma, DM, HTN, TB, CA, Allergies, Thyroid Diseases,
Blood Dyscrasias.
Family Medical History: (+) Asthma: Farther; (-) Allergy, HTN, DM, Thyroid diseases, CA, Congenital disorders
Personal/Social/Sexual History: The patient is from Bagong Bario Caloocan City, roman catholic, single with a live-in
partner. She is a high school graduate and is currently a homemaker. She is a 2nd hand smoker from her neighbors, an
occasional alcoholic beverage drinker, and denies illicit drug use. Her diet consists of different viands (pork, beef, chicken)
and rice. The patient had her first coitus at age 20 with 1 non-promiscuous partner. There is no history of IUD use and STD
but had history of injectable contraceptives for 5 months.
Menstrual History: The patient had her menarche at age 14. The patient had regular intervals of 28 days with duration of
3-4 days, soaking 3 pads/day, and the patient noted irregular intervals of dysmenorrhea for the first day of her
menstruation. Her last normal first menstrual day is May 21, 2019.
Obstetric History: The patient is G2P1 (1001). The first of which was an uncomplicated pregnancy last 2014, delivered via
SVD by a doctor in Fabella Hospital to a live term baby boy, AGA, without fetomaternal complications. This is her second
pregnancy, 38 5/7 weeks AOG by LUTZ. Quickening was felt at 18 weeks AOG.
History of Present Illness: 6 months PTC (32 weeks AOG), patient performed a urine pregnancy test due to alleged 1 month
history of amenorrhea. 5 months PTC (33 weeks AOG), patient consulted a local hospital for check-up and labs were done
(HbsAg and VDRL: nonreactive), no medications were given. 4 months PTC (34 weeks AOG), the patient experienced sore
throat and mild fever (temperature unrecalled) which she consulted for in her local hospital but no medications were
given but labs were done (Urinalysis, CBC, Blood typing, and thyroid function test). 3 months PTC (35 weeks AOG), the
patient had her transvaginal ultrasound done which had general survey and biometry resulting in an abnormal size of
posterior horn of the left lateral ventricle. Patient was referred to PGH due to her thyroid function test results and
ultrasound results.
Review of System
(-) Headache, nondependent edema, blurring of vision, prolonged vomiting, fever, epigastric pain, decreased fetal
movement, dysuria, watery vaginal discharge, and bloody vaginal discharge.
(-) Seizures, agitation, insomnia, diarrhea, vomiting, tremors, weight loss, weakness, excessive sweating, and heat
intolerance.
OBJECTIVES/DIAGNOSTICS
Physical Examination
 General Survey: The patient’s vitals were stable and is not in cardiorespiratory distress.
 Vital Signs: BP – 100/60 mmHg, HR – 105 bpm, RR – 16 bpm, Temperature – 36.7 ⁰C, O2 – 97%
 Pre-pregnancy: unknown to the patient; Pregnancy (38 5/7 AOG by LUTZ): W: 62.73 kg, H: 1.60 m, BMI: 24.5
kg/m2
 HEENT
o Face: (-) facial edema, masses, hyperpigmentation, (-) exophthalmos
o Eyes: Anicteric sclerae, pink palpebral conjunctivae
o Hair and scalp: thin hair with good distribution
o Nose: Intact midline nasal septum
o Ears: Symmetrical, (-) secretions, masses, tenderness
o Mouth: pink oral mucosa, (+) dental caries, (-) oral thrush, tonsils not enlarged
o Neck: (-) CLAD, tenderness, and trachea is midline. 3x2 cm bilateral doughy, movable, and non-tender
thyroid mass which moves with deglutition.
  Chest Exam: normal rate and regular rhythm, distinct heart sounds, S1 > S2 at apex, S2 > S1 at base, (-) murmur,
(-) heaves or thrills
 Pulmonary Exam: (-) cardiorespiratory distress; symmetric thorax, equal chest expansion, clear breath sounds,
(-) abnormal or adventitious breath sounds
 Extremities: No deformities upon inspection, no clubbing. (+) Bilateral pitting edema. Normal capillary refill at < 2
seconds.
 Abdominal Exam: Leopold’s Maneuver: Cephalic Presentation and right occiput; Fetal heart tone 140s heard at
right lower quadrant of the abdomen; Fundic height: 32 cm; Estimated fetal weight: 3,000-3,200 grams by cupping
method.
 Pelvic Exam: Normal external genitalia, no lesions, masses, and pigmentations. The vagina is violaceous with no
apparent masses or lesions. The cervix is violaceous with no apparent masses or discharge. Upon bimanual
examination, the cervix is smooth and posterior, open at 4 cm dilatation, and non-tender. The uterus is enlarged
to AOG and non-tender. Good sphincter tone, intact rectal vault, no intraluminal mass. Rectovaginal septum is
intact, parametria is soft, thin, smooth, pliable, with no masses. There is blood per vaginal examining finger but
not on the anal examining finger.
HbsAg and VDRL (July 27, 2019): non-reactive
Blood Chemistry (August 27, 2019)
Test Result (NV) Test Result (NV) Test Result (NV) Test Result (NV)
WBC 13 (4-10) H Basophil 0 ( 0-1) MCH 29.2 (27-34) MPV 8.3 (6.5-12)
Neutrophil 69.4 (50-70) RBC 4.71 (3.5-5) MCHC 341 (320-360) PDW 15.8 (15-17)
Lymphocytes 23.5 (20-4)) Hgb 137 (110-150) RDW-CV 13.1 (11-16) PCT 0.267 (0.108-.282)
Monocyte 4.4 (3-12) Hct 40.3 (37-47) RDW-SD 48.5 (35-56) P-LCR 29.9 (11-45)
Eosinophil 2.7 (0.5-5) MCV 85.6 (80-100) PLT 321 (100-300) H P-LCC 96 (30-90) H
Urinalysis (August 27, 2019): Yellow, hazy, acidic, SG 1.030, (-) sugar and albumin
Labs (August 27, 2019): Blood Type B+; Thyroid function test – T3: 3.951 (NV 0.69-2.15 ng/mL), T4: 219.4 (NV 52-127
ng/mL), TSH: 0.010 (NV 0.3-4.5 µIU/mL)
Ultrasound (August 27, 2019): PU 24 1/7 weeks AOG by fetal biometry. Live, singleton, in cephalic presentation. Adequate
amniotic fluid volume, anterior placenta, grade II, high lying. Left posterior horn of the left lateral ventricle measures 0.33
cm (NV < 0.3 cm)
ASSESSMENT
 Pregnancy uterine, 38 5/7 weeks AOG by LUTZ, cephalic in presentation, in labor
 Hyperthyroidism in Pregnancy (Burch-Wartofsky Criteria for Thyroid Storm: 5, Storm unlikely)
 G2P1 (1001)
PLAN
 Refer to OBAS
 If the patient was not in labor:
Diet: Diet as tolerated and advice regarding weight gain of 15-25 kg all throughout the pregnancy.
IV Fluids: Increase or maintain oral fluid intake
Diagnostics: ICC ELISA, IgG Rubella, 75-g OGTT, Pap Smear, Urine CS, repeat BPP and Biometry
repeat thyroid function test, maternal serum thyrotropin receptor antibodies (TRAb),
thyroid ultrasound
Medications: Calcium Carbonate 500 mg, twice a day
Ferrous Sulfate 325 mg, once a day
Since the patient is mildly symptomatic to asymptomatic, the patient still does not warrant
therapeutic intervention . Follow-up labs and assessment of symptoms should be done every
check-up to evaluate the need for therapeutic interventions.
Others: Perineal hygiene, full body bath daily
Fetal movement counting - 4x a day (10 movements within 2 hours) - 3 times post-prandial and
1 time before bedtime
Monitor: thyroid function tests, serum TRAb, and fetal monitoring (heart rate and growth rate)