Pregnancy Induced Hypertension

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OBSTETRICS POSTING

CASE WRITE-UP

PREGNANCY INDUCE HYPERTENSION

Name: Muhammad Azraie B. Mat Ali
Matrix Number: 1090265

Patient Identification
Name: Nur Asilah Bt. Johari
Age: 23 year old
Race: Malay
Sex: Female
Address: Taman Raja Abdullah
Occupation: Student
D.O.A.: 13 March 2013
I/C: 900208035442

LMP: 27 June 2012
- sure of date
- not on breast feeding
- not on contraceptive
- regular menses
POA: 37/52
EDD: 4 April 2013

Chief Complaint(s)
This is a referred case from Klinik Kesihatan Jalan Raja Abdullah for high blood pressure during regular ante-natal check-up for 1 day duration.

History Of Presenting Illness
Patient was apparently well until 1 day ago when she was diagnosed to have high blood pressure during her regular antenatal check-up at Klinik Kesihatan Jalan Raja Abdullah. She was normotensive throughout the antenatal check-up before until yesterday when the doctor noticed that her blood pressure was high which was 170/100 mmHg for three time consecutively. She denied of having an essential hypertension before and no positive family history of hypertension.

On further questioning, she had headache, otherwise she not had any sign and symtoms of impending eclampsia such as blurring of vision, vomiting, epigastric pain and syncope prior to the admission. She claimed the first episode of headache was during last antenatal check up where she was diagnosed to have high blood pressure. History Of Presenting Pregnancy

Pregnancy was suspected when she missed her menses for 4/52. It was confirmed by doing urine pregnancy test (UPT) at private clinic. At that time, no early ultrasound was done. She claimed that she experienced symptoms of early pregnancy such as nausea, vomiting and headache that last until 20/52 POA.

Booking was done during 13/52 POA at Klinik Kesihatan Jalan Raja Abdullah. At that time, blood and urine investigation was done. Her blood pressure at that time was 112/70 mmHg. Blood group was O positive and VDRL was non-reactive. Urine investigations also normal.

She attended all the ante-natal clinic regularly and all was uneventful. Symphyseal-fundal height was correspond to the date throughout the check-up. She was also normotensive throughout the visit until the last visit when her blood pressure was rise up.

Quickening was felt at 20/52 POA and it was increasing in the frequency and intensity.

Past Obstetric History
She married in year 2011 at the age of 21 and this is her first pregnancy.

Past Gynaecology History
She attained menarche at the age of 13. She had a regular menses flow of 5 to 6 days duration with 28 to 30 days per cycle. It peaks on day 2 with no history of menorrhagia and dysmenorrhea. She denied of having any history of intermenstrual bleed and post-coital bleed. She not practicing any method of contraceptive and no pap smear was done before.

Systemic Review
Systemic review was unremarkable. She had no heart disease symptoms that can cause by hypertension, no headache, no nausea and vomiting, and also no blurring of vision.

Past Medical and Surgical History
This is her first admission to the hospital. There was no history of asthma, essential hypertension, diabetes mellitus and heart disease in this patient. He denied of having any surgical intervention before.

Family History
All of her siblings were in good health. There was no history of twin or congenital abnormalities in her family. Both of her parents are still alive and in good health.

Social And Personal History
She live with her husband at Taman Jalan Abdullah. She is a student,and she denied smoking and consume alcohol. Her husband also a student, non smoker and not consume alcohol.

Diet And Drug History
There was no known drug and food allergies.

Summary
My patient, a 23 year old lady primigravida at 37/52 POA was admitted due to increased...
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