Case Presentation #2: Cassio's OB Patient

[Robert F]

First off, please join me in saying thanks to Cassio (Our Resident OB Expert here at Ultimate nurse) for providing us with the excellent case study you are about to read.

1) Initial Presentation
Female patient, age 24, slightly overweight, and 25 weeks pregnant is admitted to the High Risk OB unit complaining of epigastric pain, which she says is a 10+ on the pain scale.

BP: 130/90 Pulse: 90 Resps: 13 SAT: 92 on room air

You notice when you walk in the room that the patient has some moderate swelling. She reports to you that she does not drink, does not smoke, nor does she do drugs.

Chief Complaint:
Pain in my belly.

2) History/Allergies/Medications

Para: II Gravida: 1

NKDA, No Previous Medications other than Prenatal Vits.


4) Clinical Findings

Pre-natal labs are normal, rubella immune, HIV non-reactive, Hep negative,
24 hr urine: Normal
UA: Normal
CBC: WNL
Liver Enzymes: Normal
OB Sono: Normal, no abruption

5) Discussion Points

What is your next step?

Where do you think the pain is coming from?

What steps can you take to find out.

[cassioo]

I know I know

[orionseal]

What is her hight and weight?
Where is the swelling? Face/ feet/ legs/ ankles/ arms?
Grade of swelling? +1? +2? +3? Moon face?
Recent trauma? EX:car accident
Is a cat in the house? If so, who changes the litter?
History of GERD?
What is her running B/P? slightly elevated @ 130/90. (P.I.H.?)
Need more information to achieve a N/D.
Give us some more info please.
Pre natal labs normal, was a CBC with diff drawn? How about general chemistry?
Is she currently sexualy active?
was a Fetal activity strip run? what was the finding?
Is she currently contracting? is she being monitored?
Did she have an accurate due date established by a doctor or N/P, or did she base it off the date of her positive home preg. test?

lots of questions need to be answered here.

[AmandaWIRN]

I agree with Orion... need more info. Could be something as minor as GERD, but could be early pre-eclampsia.

[cassioo]

What is her hight and weight? 5'5 190
Where is the swelling? Face/ feet/ legs/ ankles/ arms? legs, little hands
Grade of swelling? +1? +2? +3? Moon face? 1-2+
Recent trauma? EX:car accident no trauma
Is a cat in the house? If so, who changes the litter? no cat
History of GERD? no
What is her running B/P? slightly elevated @ 130/90. (P.I.H.?) normal to slightly high nothing over 90 even low at night and with pain med
Need more information to achieve a N/D.
Give us some more info please.
Pre natal labs normal, was a CBC with diff drawn? How about general chemistry? prenatal labs WNL, had prenatal care starting at 8 weeks, kept appoints, uneventful prenatal course, married with 1 previous healthy delivery 5 yrs prior...pre op labs are CBC, UA, HIV, HepB, Blood type, rubella
Is she currently sexualy active? yes married
was a Fetal activity strip run? what was the finding? reactive strip for 28 weeks accels no decels no contractions, fetal activity less with phenergan and stadol
Is she currently contracting? is she being monitored? yes monitored no not contracting
Did she have an accurate due date established by a doctor or N/P, or did she base it off the date of her positive home preg. test?[/QUOTE] correct dates

Severe epigastric pain and preliminary dx prior to 24 hr urine was normal tensive preeclampsia but that wasn't it....didi lip and amy to r/o GB pancreatitis those came back normal also...she had the stadol every 2 hours and it wasn't holding her 2 hours for the most part and phenergan which didn't stop it either.

[AmandaWIRN]

And this, boys and girls, is why I'm not an OB nurse....

I'm still guessing early pre-eclampsia, but in reality, my words to her would be this: How many weeks pregnant are you? 25? OK, let's get you upstairs to L&D!

[cassioo]

good guess but not it. We were actually looking at sectioning her after steroids but with normal labs and normal pressure and a good baby there was more hhmmmmmmmm this is also at a community hospital but there is a level II nursery so 25 weekers are doable.

[orionseal]

Pica maby?
I trust you did a vag slide for amnio.
Lipids normal, neg on the inflamed panc. all labs were normal.
Gastric herniation? I hear that with that one, pain is hard to controle.

Pluricy is also out, that would have ben knocked out with the pain med.

Gallstones are an obvious, or kidney stones.

By the way was her First delivery a section or vag?
Previous abd surgery might lean toward adheasions stretching and if they pulled on the bowel that could drive you out of your mind with pain and discomfort.

If thats not itthen we have to look for an infection, possably of the gallblader. This as well as the stones "could" show up with normal labs.

Besides gallblader attacks with a second pregnancy are almost textbook.

BTW Cass: She would have presented as "A" "Para:II" Gravida:I
Not a Para:I Gravida:I

[Robert F]

Originally Posted by orionseal

Pica maby?
BTW Cass: She would have presented as "A" "Para:II" Gravida:I
Not a Para:I Gravida:I

Sorry, that was an error on my part. (Which is exactly why I sought an OB Nurse for an OB Case Presentation, lol.)

[orionseal]

Originally Posted by RNmedicTN

Sorry, that was an error on my part. (Which is exactly why I sought an OB Nurse for an OB Case Presentation, lol.)

No harm, No foul my friend.

Interesting case study so far, still think it's gallstones.