SGD CASE PROTOCOL

General Data R.O. Age: 21 years old Obstetric Score: G1P0 Civil Status: Single Address: Cavite Religion: Born-again Christian Date of Admission: August 9, 2012 Chief Complaint: Labor pains Past Medical History: No history of diabetes mellitus, hypertension, pulmonary tuberculosis, bronchial asthma No allergies to food and drugs No history of previous surgery Family History: (+) Diabetes mellitus - Mother No hypertension, bronchial asthma, thyroid disease, heart disease, cancer Personal and Social History Vocational Course graduate Previously worked as a production operator No vices First coitus at 20 years old 1 nonpromiscuous sexual partner (-) contraceptive use Menstrual History Menarche at 11 Regular monthly interval lasts 3 days Uses 4-5 pads per day, fully-soaked (+) dysmenorrhea Obstetric History G1P0 LMP: December 13, 2011, unsure AOG: 31 4/7 by LMP; 33 6/7 by early ultrasound Quickening at ~20 weeks 9 prenatal checkups care of private lying-in clinic History of Present Illness: One month prior to admission, patient had productive cough and colds but no associated fever. No consult was done, no medications were taken. Two weeks prior to admission, patient noted dyspnea, easy fatigability after walking ~3 meters described as hinihingal ako. There was noted progression of dyspnea which prompted patient to absent herself from work. She sought consult with her private Obstetrician who diagnosed her with pneumonia and was prescribed with a mucolytic with no relief of symptoms. Patient was then referred to a cardiologist and X-ray was done which revealed cardiac enlargement. A 2D-echocardiogram was also requested which showed markedly dilated left ventricle with normal wall thickness; global hypokinesia; only anterior left ventricle from base showed normal contractility; dilated left atrium; normal right atrium and right ventricle dimensions; depressed systolic function and stage II diastolic dysfunction and aortic regurgitation. Patient was then prescribed with Digoxin and Fenoterol + Ipratropium. One week prior to subsequent admission, there was increase in the severity of dyspnea and easy fatigability. Patient noted bounding chest wall which she described as kumakabog ang puso. Patient was no longer able to sleep lying down and was only able to do so while sitting. Patient also noted of edema in bilateral lower extremities reaching up to her knees. Interval history revealed persistence of symptoms. Six hours prior to consult, patient noted uterine contractions every 5-10 minutes, moderate. Patient had no watery vaginal discharge, no vaginal bleeding, but with good fetal movement. Persistence of above symptoms prompted consult at PGH and subsequent admission. Review of Symptoms: (+) anorexia (+) malaise (+) weight loss, 4kg (-) headache (-) blurring of vision (-) changes in smell/taste (-) abdominal pain (-) changes in bowel movement (-) diarrhea (-) constipation (-) hematuria (-) dysuria (-) myalgia (-) arthralgia Physical Examination at Admission: General Appearance: Ambulatory , coherent, speaks in full sentence Vital Signs: BP = 110/70 HR = 132 RR = 31

Block V Sunglao, Suratos, Symaco, Tababa, Tagal, Taganas, Talusan, Tan C., Tan K.

SGD CASE PROTOCOL

Temp = 36.3 Ht = 150cm Wt = 56 kg BMI = 23.05 HEENT: Anicteric sclerae, slightly pale palpebral conjunctivae, (-) palpable CLAD, (-)tenderness, (-) anterior neck mass,Trachea midline, (-) carotid bruits, JVP 5 cm Lungs: equal chest expansion, clear breath sounds, (+) crackles over bilateral lower lung fields, no wheezes Cardiovascular: dynamic precordium, distinct S1 and S2, normal rate, regular rhythm, Apex beat and PMI not appreciated due to heave, (+) splitting of S1 heard best at aortic area, (+) grade 3/6 holosystolic murmur heard best at the left parasternal border Gastrointestinal: globular, soft, normoactive bowel sounds, (-) masses/organomegaly, no tenderness; FH: 26 cm; EFW: 1.82.0 kg; cephalic, FHT: 160s LLQ Internal Examination: Normal external genitalia, nulliparous vagina, cervix 2 cm dilated, 50% effaced, intact bag of water, station -3 Extremities: Full equal pulses, pink nail beds, (-) cyanosis, edema, jaundice,(-) non-healing wound/lesions Neuro Exam: Well-kempt, able to speak in full sentences, coherent, oriented, CNs intact, No slurring of speech, no preferential movement of extremities, No facial asymmetry, No limitation of movement both on passive and active actions 5/5 muscle strength for B upper and lower extremities, Full ROMs, no spasticity/flaccidity, DTRs ++ in all four extremtities, (-) Babinski, clonus Admitting Impression: PU 34 weeks AOG by EUTZ, CIPTL Gravidocardiac Functional Class III probably secondary to Rheumatic Heart Disease probably severe mitral regurgitation G1P0 Course in the Wards: The patient upon admission was seen by CVS and was reviewed with a 2-week history of progressive heart failure symptoms of exertionaldyspnea, orthopnea and easy fatigability. At that time she had a BP of > 110/70 mmHg, HR of 116bpm regular, RR of 24, and was afebrile. She had LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at left lower parasternal border with gr II bipedal edema. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm, PU 34 weeks AOG by EUTZ, CIPTL. Patient was maintained on O2 support and was run with IVF PNSS at KVO rate. A 2D Echo with doppler studies was requested and patient was prescribed with the following medications: Furosemide 40mg/IV prn for congestion, and Digoxin 0.25 mg/tab OD. A foley catheter was placed and I & O were recorded accurately. CVS preferred Assisted Vaginal Delivery for the patient. Patient had rupture of her bag of water at 10:40am. st nd Her 1 stage of labor was 5 hours, 2 stage of labor was rd approximately 25 minutes, and her 3 stage of labor was 1 minute in duration. Baby was delivered at 10:58 am and placenta was subsequently delivered at 10:59 am. She delivered a preterm, 35 weeks by pediatric aging, 1800 grams, appropriate for gestational age in cephalic presentation, via vacuum-assisted delivery under epidural anesthesia (CLEA), a live baby girl, with an APGAR score of 8,9. A mediolateral episiotomy with repair was done. Immediately post-partum, the patient had a BP of 85/55, but subsequently became normal ranging from 90-100/60-70. st On the 1 hospital day, patient had BP of 100/70 mmHg, HR of 98 regular, RR of 28, and was afebrile. She had equal chest expansion, (+) crackles, LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at left lower parasternal border. Patient was then assessed with CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. At that time patient was given Furosemide 20mg/IV stat dose. Patient was maintained on O2 support and Foley Catheter and was advised complete bed rest with no bathroom privileges. Patient was still for 2D Echo with doppler studies. nd On the 2 hospital day, patient had no difficulty of breathing, no chest pain, and no fever. At that time, BP was 90/60 mmHg, HR 88 regular, RR 20, and was afebrile. She had equal chest expansion, (-) crackles, LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at apex. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. Patient was started onMetoprolol tartrate 50mg/tab tab BID and her Digoxin was decreased to 0.25mg/tab tab OD. Patient was still advised complete bed rest with no bathroom privileges and was still for 2D Echo with doppler studies. rd On the 3 hospital day, patient had 1 episode of BP 80/60, no difficulty of breathing, no chest pain, and no fever. Her BP was 90/60 mmHg, HR 115 regular, RR 20, and was afebrile. She had equal chest expansion, (-) crackles, LV

Block V Sunglao, Suratos, Symaco, Tababa, Tagal, Taganas, Talusan, Tan C., Tan K.

SGD CASE PROTOCOL

heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at apex. Assessment was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. Her Digoxin was decreased to 0.25mg/tab tab OD, and her Metoprolol tartrate 50mg/tab tab BID was put on HOLD, and her BP trend was observed. Oral fluid intake was restricted to not >1.5L/day. She was hooked to O2 via FM at 6LPM and maintainedon mod-high back rest. Complete bed rest with no bathroom privileges was advised and she was still for 2D Echo with doppler studies. th On the 4 hospital day, patient had no difficulty of breathing, no chest pain, and no fever. BP was 90/60 mmHg, HR 100s regular, RR 20, and was afebrile. She had equal chest expansion, (+) crackles at the RLLF, LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at apex. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. Patient was started on the following medications: Furosemide 20mg/IV q12h, Captopril 25mg/tab 1/4 tab q8h, Laboratory Worksheet: Complete Blood Count Date WBC RBC Hgb Hct MCV MCH MCHC RDW-CV Platelets Neut% Lymph% Mono% Eo% Baso% Arterial Blood Gas Date FiO2 Temp Hb pH PCO2 PO2 HCO3 8/9 21 37 12 7.349 24.5 62.9 13.4 8/9 8/11 9 4-11x10 /L 9.50 12.30 12 4-6x10 /L 4.17 3.86 120-180g/L 127 123 0.370-0.540% 0.399 0.367 80-100fL 95.7 95.0 27-31pg 30.5 32.0 320-360g/L 319 337 11-16% 14.1 14.4 9 150-450x10 /L 278 263 DIFFERENTIAL COUNT 0.5-0.7 0.766 0.770 0.2-0.5 0.163 0.157 0.02-0.09 0.062 0.060 0.0-0.06 0.006 0.010 0.0-0.02 0.002 0.003 8/13 11.20 4.11 131 0.392 95.5 32.0 335 14.2 298 0.746 0.169 0.058 0.025 0.002 hold for BP <90/60 and Digoxin 0.25mg/tab 1 tab OD. Patient was kept on O2 support. th On the 5 hospital day, patient had no difficulty of breathing, no chest pain, and no fever. BP was 90/60 mmHg, HR 100s regular, RR 20s, and was afebrile. Patient had equal chest expansion, (-) crackles at RLLF, LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at apex. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. Furosemide was shifted to 20mg/tab OD. th On the 6 hospital day, patient had no difficulty of breathing, no chest pain, and no fever. BP was80/60 mmHg, HR 100s regular, RR 20s, and was afebrile. Patient had equal chest expansion, (-) crackles at RLLF, LV heave, (-) S3, tachycardic, regular, AB displaced, (+) 3/6 holosystolic murmur at apex. Assessment at that time was CHF FC III t/c (1) periportal cardiomyopathy vs (2) RHD; in sinus rhythm; PU delivered. Furosemide was then shifted to Spironolactone 25mg/tab 1 tab OD.

7.35-7.45 35-45mmHg 90-100mmHg 22-28mEq/L

Block V Sunglao, Suratos, Symaco, Tababa, Tagal, Taganas, Talusan, Tan C., Tan K.

SGD CASE PROTOCOL

TCO2 Be O2 Sat Blood Chemistry Date BUN Creatinine Sodium Potassium Chloride Calcium Magnesium Albumin 12-L ECG 3.2-8.0 mmol/L 53-133umol/L 135-145mmol/L 4.0-4.5mmol/L 99-110mmol/L 2.12-2.75mmol/L 0.70-1.05/1.4-2.1 38-51g/L 8/9 2.40 57 141 4.0 105 2.32 0.75 29 8/12 4.5 60 140 8/14 14.2 -10 90.7

3.7

0.76

0.74

Sinus Tachycardia Left Ventricular Hypertrophy

2D Echocardiography Eccentric LVH with multi-segmental wall motion and severely depressed overall systolic function Doppler evidence of diastolic relaxation abnormally Dilated LA Mitral sclerosis Thickened pulmonic and tricuspid valves Severe MR Moderate TR Moderate to severe pulmonary hypertension

Block V Sunglao, Suratos, Symaco, Tababa, Tagal, Taganas, Talusan, Tan C., Tan K.