1. WELCOME TO MORNING SESSION
Dr. Amitav Biswas
Intern Doctor
Department of Medicine
Tairunnessa Memorial Medical College
2. PARTICULAR’S OF THE PATIENT :
Name : Khadija
Age :36 years
Sex : Female
Address : Sripur ,Gazipur
Marrital Status : Married
Occupation : House wife
Religion : Islam
Date of Admission :27/11/17 (12:30 pm)
Date of Examination : 27/11/17 (12:30 pm)
3. CHIEF COMPLAINTS :
1. Pregnancy for 4 weeks.
2. Nausea and morning sickness for 4
weeks.
3. Known case of DM for 1.5 years.
4. HISTORY OF PRESENT ILLNESS :
According to the statement of the patient she
was reasonably well 1 month back. Then she
developed amenorrhoea for 4 weeks and she
confirmed her pregnancy by strip test. She also
claimed that she is suffering from DM for last 1.5
years. She also complaints Nausea and morning
sickness for 4 weeks. Her bowel and bladder
habit is normal. She has no other complications.
Now she is admitted in this hospital for better
management.
5. HISTORY OF PAST ILLNESS:
She gave history of recurrent abortion about 5
children and history of C/S 2.5 years back.
There is no history of BA,TB or any other
medical and surgical illness.
FAMILY HISTORY :
Her father is also hypertensive and Daibetic
,other family members are healthy .
PERSONAL HISTORY :
She is a non-smoker and not betel nut
chewer.
6. MENSTRUAL HISTORY :
• MP/MC : Regular
• LMP : 23/10/17
• EDD : 30/07/18.
OBSTETRICAL HISTORY :
• MF: 14 years.
• P- 1(C/S)+ 5 (ab)
• G- 7
• ALC- 2 years.
7. DRUG HISTORY:
She took Tab. Comet (500mg), 0+0+1 for last
1.5 years and anti ulcerant Cap. Maxpro
(20mg).
SOCIOECONOMIC HOSTORY :
She belongs to a middle class family .
IMMUNIZATION HISTORY :
She is fully immunized as per EPI schedule .
8. GENERAL EXAMINATION :
Appearance : Ill looking and anxious
Body build : Average
Co-operation :Co-operative
Decubitus :On choice
Nutrition :Well nourished
Anaemia : Mild anaemic.
Oedema : Absent
Cyanosis :Absent
Jaundice :absent
Clubbing :Absent
Koilonychia :Absent
Leuconychia :Absent
9. CONT……
Pulse :92 beats/min
BP :110/70 mmHg
Temperature :Normal
Respiratory rate :20 breaths /min
Dehydration : Absent
Thyroid gland :Not enlarged
Lymphnode :Not palpable
JVP : Normal
Weight : 60 kg.
Height : 5.1 ft.
10. SYSTEMIC EXAMINATION :
1.CARDIOVUSCULAR SYSTEM :
Pulse :92 beats/min ,Regular
BP :110/70 mmHg
JVP :Normal .
PRECORDIAM EXAMINATION :
Inspection :
There is no chest deformity ,no visible cardiac
impulse or any other scar mark .
11. PALPATION :
Apex beat: In the left 5th intercostal space just
medial to the mid clavicular line and 8 cm from
the mid line..
Thrill :Absent
Left para sternal heave:Absent
Palpable P2 :Absent
Epigastric palsation :Absent .
12. AUSCALTATION :
1st and 2nd heart sound is audible in all
auscaltatory area but 1st heart sound is more
audible in mitral & tricuspid area and 2nd heart
sound is more audible in aortic & pulmonary
area ,there is no murmur or added sound .
13. Inspection:
Shape of the chest: Normal
Movement of chest: Bilateral symetrical
Respiratory rate: 20 breaths/min
Visible impulse: Absent
Any scar marks: Absent
Palpation:
Position of trachea: Centrally placed
Apex beat: In the left 5th intercostal space just medial
to the mid clavicular line and 8 cm from the mid line.
Vocal fremitus: Normal
Respiratory System:
14. Chest expansibility: Normal
Tracheal tug: Absent
Percussion:
Percussion note: Resonance
Upper border of liver dullness: in right 6th intercostal space
Auscultation:
Breath sounds: Vesicular
Added sounds: Absent
Vocal Resonance: Normal.
15. Lips, gums, teeth- normal
Tongue- normal
Abdomen proper:
Inspection:
Shape of abdomen: Scaphoid.
Movement of abdomen: Moves with respiration
Visible pulsation: Absent
Visible peristalsis: Absent
Umbilicus: Inverted, transversly slit
Scar mark: Absent
Alimentary system:
17. Percussion:
Percussion note: Tympanic
Upper border of liver dullness: Right 5th
intercostal space
Fluid thril: Absent
Shifting dullness: Absent
Auscultation:
Bowel sound: Present
No Hepatic bruit and splenic rub
18. Higher psychic function: Intack
Cranial nerve examination: all cranial nerves are
intact.
Signs of meningial irritation:
Neck rigidity: absent
Kernig’s sign: Negative
Brudzinski’s sign: Negative
Motor function: Normal
Sensory function: Normal
Cerebeller function: intack
Nervous system:
19. SALIENT FEATURE :
Mrs. Khadija 36 years old muslim house wife hailing from
sripur gazipur non-hypertensive, she was reasonably well
1 month back. Then she developed amenorrhoea for 4
weeks and she confirmed her pregnancy by strip test. She
also claimed that she is suffering from DM for last 1.5
years and she took anti- diabetic drug like comet (500 mg )
and anti ulcerant sometimes. She also complaints Nausea
and morning sickness for 4 weeks. She gave history of
recurrent abortion about 5 children and history of C/S 2.5
years back. She took Tab. Comet (500mg), 0+0+1 for last
1.5 years and anti ulcerant Cap. Maxpro (20mg).
There is no history of BA,TB or any other medical and
surgical illness.
20. CONT………
On examination she is ill and anxious looking
,pulse was 92 b/m ,BP was 110/70 mmHg,
temperature normal, mild anaemic, Weight
60 kg, height 5.1 ft.
On systemic examination of this patient
cardiovascular system is normal, alimentary
system and respiratory system,nervous system
reveals no abnormality .
27. Advice
1. Take prescribe medicine regularly.
2. Diet : Follow diabetic chart.
3. Avoid heavy work.
4. Give TT vaccine on 5th and 6th month.
5. Drink plenty of water, eat sour fruits and
vegetables and iron containing foods.
6. Take insulin ½ an hour before meal.
7. Avoid long journey and high heel shoes.
28. Follow up :
Follow up after 14 days in medicine OPD with
following reports-
» FBS.
»2hrs after breakfast.
»USG of PP.
