Case study presentation on DM-

1. CLINICAL CASE PRESENTATION
GESTATIONAL DIABETES MELLITUS
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2. Name : ABC
Age : 26 years
Education : 10th standard
Occupation : Home maker
Date of examination : 15.01.2020
Husband’s name : XYZ
Age : 30 years
Education : 2nd PUC
Occupation : Tailor
Income : Rs. 8,000/month
Socioeconomic status : Lower middle class
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3. CHIEF COMPLAINTS
A G2P1L1 women has come for a regular ANC check-up, found to have high glucose levels.
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4. HISTORY OF PRESENT PREGNANCY
Patient came for a regular antenatal check-up and was found to have high blood sugar level and
hence admitted
No history of increased thirst or frequency of micturition
No history of abdominal pain
No history of bleed PV or leak PV
No history suggestive of UTI
No history of breathlessness, palpitations, limb oedema
No history of headache, visual disturbances, epigastric pain
No history of increased urinary output
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5. OBSTETRIC HISTORY
Married life: 5 years
Consanguinity : Non consanguineous marriage
Obstetric score : G2P1L1
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6. I TRIMESTER of Present Pregnancy
Pregnancy confirmed by urine pregnancy test at 2 months
It is a booked case
Folic acid supplementation taken
Ultrasound scan was done and reported to be normal
1st dose of dT injection was given
No history of excessive vomiting
No history of fever with rashes
No history of increased frequency of micturition, burning micturition
No history of drug intake/ radiation exposure
No bleed PV, discharge PV
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7. II TRIMESTER of Present Pregnancy
Quickening felt at 18 weeks of gestation
2nd dose of dT was taken
Ultrasound scan was done and reported to be normal
Iron and folic acid supplementation taken
No history of bleed PV, leak PV
No history of headache, visual disturbances, palpitations, pedal oedema
No history of increased frequency of micturition, burning micturition
No history abdominal pain
Routine blood investigations were done and found to be normal
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8. III TRIMESTER of Present Pregnancy
Continued perception of foetal movements
Iron, folic acid supplementation taken
Ultrasound scan was done and reported to be normal
Blood investigations were done ,found to have high blood glucose level
No history of headache, blurring of vision, pedal oedema
No history of burning micturition
No history of bleed PV, leak PV
No history of abdominal pain
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9. HISTORY OF PREVIOUS PREGNANCY
1st PREGNANCY
It was 2 years ago
Diagnosed by urine pregnancy test, regular ANC visits
3 USG scans were done
1st , 2nd ,3rd trimesters uneventful
No history of gestational diabetes mellitus
No history of pregnancy induced hypertension
Full term vaginal delivery, institutional delivery
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10. Female baby
Birth weight : 3 kg
Baby cried immediately after birth
Np history of NICU admission or any complaints
Immunized up-to-date, aged 3 years
No history of any use of contraception
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11. MENSTRUAL HISTORY
Age of menarche : 12 years
Past cycles :Duration Of flow: 3 to 4 days , regular cycles
Duration of cycle : 28 days cycle
no history pain or passage of clots
LMP : 16.05.2019
EDD : 23.02.2020
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12. PAST HISTORY
Not a known case of diabetes mellitus, hypertension, tuberculosis, epilepsy, asthma
No history of previous surgery
No history of blood transfusions
No history of thyroid disorders
No history of cardiovascular disorders
No history of drug allergies
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13. FAMILY HISTORY
History of diabetes mellitus (type 2) in mother
No history of congenital malformations in the family
No history of twinning in the family
No history of hypertension, epilepsy, tuberculosis in the family
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14. PERSONAL HISTORY
Mixed diet, good appetite
Calories consumed : 1,700 kcal/day
Calories required : 2350 k cal/day
Calorie deficit : 650 kcal/day
Sound sleep
Bowel and bladder function is normal and regular
Habits : no habits of tobacco chewing or smoking
no recreational drug abuse
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15. Diet
Morning: 2 Idli - 150kcal
1 cup sambar -110 kcal
1 cup milk -180 kcal
Afternoon : 1 cup rice - 170 kcal
1 cup rasam 60kcal
2 Chapatis -200 kcal
1 cup Curd -100 kcal
Evening : 2 Bananas -180 kcal
Tea - 90 kcal
Night : 1 Cup rice 170
1 cup Sambar -110
1 cup milk - 180 kcal
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16. GENERAL PHYSICAL EXAMINATION
Mrs. Usha, 26 years old G2P1L1 is moderately built and nourished, conscious, alert,
co-operative, oriented to time place and person.
Temperature : afebrile
Pulse : 80 beats/min, regular rhythm, good volume, normal character, no radio-radial delay,
no radio-femoral delay, all peripheral pulses felt
Blood Pressure: 120/80 mm of Hg, over right upper arm in sitting position
Respiratory rate : 15 cycles/ min, regular, thoracoabdominal type
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17. GENERAL PHYSICAL EXAMINATION
Pallor : absent
Icterus : absent
Clubbing : absent
Cyanosis : absent
Lymphadenopathy : absent
Oedema : absent
Height : 150 cm
Pre pregnancy weight : 68kg
Present body weight : 78 kg
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18. GENERAL PHYSICAL EXAMINATION
BMI ( pre pregnancy ) : 30.22
Thyroid examination : normal
Breast examination : normal
Spine examination : normal
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19. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Normal vesicular breath sounds heard, no added sounds
CARDIOVASCULAR SYSTEM
S1 ,S2 heard, no murmurs
CENTRAL NERVOUS SYSTEM
No focal neurological deficits
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20. OBSTETRIC EXAMINATION
INSPECTION
Abdomen is uniformly distended and has an ovoid shape
Corresponding quadrants move equally with respiration
Umbilicus is everted
Hernial orifices are intact
Striae gravidarum, linea nigra seen
No scars, dilated veins over the abdomen
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21. PALPATION
Fundal height : corresponds to 32 weeks of pregnancy
Abdominal girth : 85 cm
Symphysiofundal height : 34 cm
Leopold-sporelein’s first grip/Fundal grip : soft, irregular, broad and not independently ballotable mass at
fundus
INFERENCE: Breech of fetus is at fundus of uterus
Leopold-sporelein’s second grip/Lateral grip :
Right – knob like structures suggestive of limbs
Left – uniform continuous curved resistance suggestive of spine
INFERENCE: 1.LIE= Longitudinal lie
2.Position = left occipitoanterior
3.Liquor amnii= Adequate
4.fetal movements well perceived=fetus viable
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22. Leopold-sporelein’s third /PAWLIK’s/1st pelvic grip : smooth, hard, globular,independently ballotable mass,
suggestive of head
INFERENCE:1.Engagement=not engaged
2.Attitude= well flexed with thumb at higher position palpating sinciput
Leopold-sporelein’s 4th grip/2nd pelvic grip : fingers converge, head not engaged
AUSCULATATION
Foetal heart sounds heard along spino-umbilical line
Foetal heart rate : 140 beats/min, regular rhythm
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23. SUMMARY
26 year old, G2P1L1, with history of 8 months on amenorrhea came for regular ANC check-up,
found to have high blood glucose level, had a positive family history of diabetes mellitus.
On examination, her BMI was 30.22, with single live foetus in longitudinal lie, cephalic
presentation, not in labour, and perceiving foetal movements well.
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24. PROVISIONAL DIAGNOSIS
26 year old G2P1L1 at 34 weeks + 4 days of period of gestation diagnosed with gestational
diabetes mellitus.
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