CASE PRESENTATION

Altiveros, Ann JacquelineSan beda College – Medicine level IV

GENERAL DATA

C.B. is a 24 year old Filipino Born Again Christian Married Housewife Admitted for the second time at QMMC

on April 25, 2011.

CHIEF COMPLAINT:

Severe abdominal pain

HPI

8 days PTA - admitted and gave birth to a live baby girl

via normal spontaneous delivery with no complications noted.

6 days PTA discharged from the institution take home medications

Mefenamic acid 500 mg q6 for pain, cefalexin 500mg TID for 7 days, Ferrous sulfate 1 tab once daily, vitamin C 1 tab once daily with instruction of full body bath and

perineal hygiene

3 days PTA abdominal pain of 6/10 scale watery diarrhea No consult was done.

2 days PTA (+)abdominal pain (+) diarrhea (+) undocumented fever

Few hours PTA persistence of the above symptoms with

increasing severity in abdominal pain of 9/10 pain scale

high grade fever (undocumented) visual and auditory hallucinations

consult at the institution

OBSTETRIC HISTORY

G1P1 (1001) G1- 2011 via NSD with no

complications noted.

MENSTRUAL HISTORY

Menarche at 13 y/o moderate flow 3 to 4 days 2-3 napkins a days no associated signs and symptoms.

SEXUAL HISTORY:

Coitarche at 19 only one sexual partner 2-3 sexual intercourse/week. 

CONTRACEPTIVE HISTORY:

denies using oral contraceptives use barrier or withdrawal method

during coitus

PAST MEDICAL HISTORY AND FAMILY HISTORY

(+) paternal hypertension

REVIEW OF SYSTEM: (UPON ADMISSION) 

Constitutional No loss of appetite,(+) weakness, (+) easy fatigability, (+)fever and chills

Skin No pruritus, rashes, pigmentation, easy bruising

Head No headache, (+)dizziness

Eyes No eye pain, discharges, doubling of vision

Ears No ear pain, discharges, hearing loss

Nose No colds; No pain, changes in smell, epistaxis, snoring

Throat & Mouth No dysphagia, hoarseness of voice, bleeding gums, toothache, changes in taste

Neck No neck pain, limitation of movement

Breast No pain, lumps

Chest/Lungs No cough, dyspnea; No chest pain, hemoptysis, wheezing

Cardiovascular No orthopnea, palpitations, shortness of breath, cyanosis, pallor, syncope

Gastrointestinal (+)abdominal pain, (+) diarrhea, nausea, vomiting, dysphagia, hematemesis, melena, hematochezia

Genitourinary No dysuria, polyuria, hematuria, incontinence, urethral discharges

Musculoskeletal No swelling of feet; No weakness, joint pains, muscle pains, numbness, limitation of movement

Neurologic No convulsions, sensory loss, weakness, syncope

PE UPON ADMISSION

BP: 90/60 mmhg HR: 81 beats per minute RR: 20 cpm Temp: 40 C

General Survey on a wheel chair Conscious Coherent cooperative, not in cardiorespiratory distress.

Skin Palms and soles are dry and pale in color. No clubbing of fingers. No redness or rashes. No jaundice and cyanosis. No ulceration and eruption.

Head Has fine dry black straight hair. No palpable mass or tenderness. Head is symmetric and round.

Eyes Orbits are symmetrical in position. No tenderness. Both eyes has pale palpebral conjunctiva. Scleras are anicteric.

Eyeballs are not sunken. No scleral or conjunctival discharge. No exopthalmos.

Pupils are equally reactive to light (3mm) Ears Both ears have minimal cerumen. Intact tympanic

membranes of both ears. No lumps, discharge, redness and tenderness.

Nose Nasal septum is midline. Mucosa is pink. No discharge, swelling, obstruction. No tenderness.

Mouth & ThroatMoist buccal mucosa. Gums are pink in color. Uvula is midline. Tongue is midline with no atrophy. No swelling or

redness of pharynx. No redness or swelling of tonsils. No tenderness. Neck Neck is supple, No palpable lymph node Trachea midline and

thyroid not enlarged Chest and Lungs

Inspection: Thorax was symmetrical in shape at rest (AP<transverse diameter) with symmetrical expansion during breathing. No retraction of costal muscles on inspiration. Does not use accessory muscles during respiration. Spine is in midline position. Palpation: No palpable mass. No tenderness. Equal tactile fremitus on both lungs. Auscultation: Lungs are equally resonant on all lung fields. Equal vocal fremitus on both lungs. Breath sounds are vesicular on both lungs (I>E on both lungs). No egophony or whispered pectoriloquy. No crackles, wheezing or friction rub.

Heart No precordial bulge or heave. PMI is tapping, adynamic in the 5th ICS at the left midclavicular line with a diameter of 2.5 cm. S1 is best heard at the apex while S2 is best heard at the base with premature contractions. No expiratory splitting of S2. There are no S3 and S4 sounds. No murmur or clicks were heard. No thrills or friction rub.

Abdomen flabby abdomen, soft and tender on light and deep palpation

Pelvic exam: (+) wound dehiscence 2nd degree 4 cm long

  Internal exam: warm vault, cervix is

open, uterus is enlarged

Extremities Upper Extremities: No clubbing of fingers or

hyperpigmentation. Finger nails are pink in color. Capillary refill is 2-3 seconds. No palpable mass. No atrophy or tenderness. No pitting or non-pitting edema.

Lower Extremities: No clubbing of toes or hyperpigmentation. Toe nails are pink in color. No palpable mass all over. No atrophy or ternderness. No pitting or non-pitting edema.

ADMITTING DIAGNOSIS:

.G1P1 (1001) s/p NSD day 8 institutional

delivery wound dehiscence, to R/O puerperal sepsis, t/c retained

secundines

PROPOSED DIAGNOSIS

G1P1 (1001) s/p NSD with right mediolateral episiotomy repair, institutional delivery, Acute gastroenteritis, wound dehiscence, puerperal sepsis secondary to retained secundines with concomitant hypokalemia corrected and anemia s/p blood transfusion 4 units PRBC and 4 unit FFP, corrected

COURSE IN THE WARD

Day Doctor’s order PE findings Medications laboratories procedures Lab findings

Day 1 (8th day s/p nsd)April 25

- admit to LR/DR- NPO temporarily- IVF D5LR 1L for 6 hrs-

- Temp 40 CClear breath sounds- Initial CXr: normal- Plain abdomen: normal

- Ampicillin 2 gm TIV then 1 gm q6- Metronidazole 500mg TIV q8- Gentamycin 240 mg then 80 mg q8- Paracetamol 300 mg TIV g4 for fever

- CBC, platelet ct-PT, PTT- urinalysis-fecalysis- Na, K, Cl, BUN, Crea- blood gs/cs- chest xray-plain Abdominal xray

- wound flushing with Daikin solution TID c/o OB residents

u/adark yellow, hazy, pH 5.0, sp g. 1.020, wbc- 25-30, albumin +++, course granular cast 3-6/lpf

Day 2 (9th day s/p NSD)April 26

- NPO temporarily

6:50 amBP 100/60HR 92 cpmRR 20 bpmTemp 37.6(+) pelvic pain in deep palpation - IE: cervix 1 cm open, uterus is enlarged to 20 weeks size- (+) wound dehiscence secondary degree

- Continue meds- Vit K 1 amp TIV q8- stat KCl drip in 1L PNSS to run for 1 hr

- rpt PT/PTT -transfused 2 unit PRBC, 1 unit FFP- completion curettage-placental tissue gs/cs

RBC- 3.3 Hgb- 0 .91Hct – 0.27 Wbc- 30.2 N- 0.96PT – 16.7PTT – 57.8Crea – 124.45BUN- 7.26K – 2.8 Fecalysis: Brown, watery, wbc 0-2, rbc (-), NOPS,

Day 3 ( 10th day s/p NSD)April 27

- transferred to ward- vs q4- perineal hygiene

12 midnightIE: intact suture, minimal bleeding, contracted uterus(-) pallor 6:40 amBP 110/60HR 124 cpmRR 34 bpmTemp 37.2

- Discontinue Ampicillin, shift to Pen G 8 million units slow IV q6 then 4 milion units IV q6.- Metronidazole 500 mg TIV q6-Gentamycin 240 mg TIV once daily

Rpt. Na, K, ClHgb/Hct

Rbc – 3.13Hgb – 85Hct – 0.26Wbc – 20.2 N – 0.904K – 4.1 normalPT – 19.2PTT – 61.2

Day 4 ( 11th say s/p NSD)April 28

-soft diet for 12 hrs then DAT- IV med monitoring

6 amBP 120/80HR 112 cpmRR 21 bpmTemp 37.4(+) slight pallor2:30 pm-temp 39 C- (+) phlebitis on both hands-IVF out

-continue medications- 1 amp diphenhydramine IV 30 mins prior BT-discontinue all IV med start oral meds-cefuroxime 500mg BID-paracetamol 500mg q4-pen G 1million OD gluteal area

Rpt cbc 6 hrs after BT

- transfused 1 “u” PRBC and4 unit FFP

Hgb – 85Hct – 0.26

Day 5 (12th day s/p NSD)April 29

- DAT-vs q4

BP 110/70HR 89 RR 19Temp 37Patient is clinically pink

-continue meds as previously ordered-FeSO4 tab OD- Vit K 1 amp TIV

Rpt PT, PTT, CBC, PT 16.2 normalPTT 44.7 normal

Day 6 (13th day s/p NSD)April 30

DAT Slightly tender epigastric and LLQ on light palpation,Soft globular abdomen,(+) watery stool 4x

Vit k 1 amp q8Hydrite tab +1/2 galss of water-continue medications(FeSO4 BID, Cefuroxime 500mg BID x 7 days, Metronidazole 500 mg TID x 7 days, Paracetamol 500 mg every 4 hours for fever)

Transfused 1 unit PRBC

S I R S I R

Ampicillin ciproflocaxin

Ampicillin sulbactam

imipenem

Cefepime Piperacillin tazobactam

Cefotaxime Sulfamethoxasole w/ trimetoprim

Cefoxitine

Ceftriaxone

Cefuroxime

May 1, 2011 May 2, 2011 Normal values

Rbc count 3.8 3.66 4.2 – 5.4

Hgb 104 100 120 – 160

Hct 0.32 0.31 0.36 – 0.47

Wbc 16.4 16.1 5-10

Neutrophil 0.825 0.767 0.50 – 0.70

DISCUSSION

Peurperal infection term used to describe any bacterial

infection of the genital tract after delivery lethal triad

preeclampsia obstetrical hemorrhage puerperal infection

PEURPERAL FEVER

temperature of 38.0 C or higher, which occur on any 2 of the first 10 days postpartum, exclusive of the first 24 hours

taken by a standard technique at least four times daily

RISK FACTORS

Route of delivery prolonged membrane rupture and labor multiple cervical examinations internal fetal monitoring adverse perinatal outcomes

stillbirths low birth weights preterm delivery

OTHER RISK FACTORS:

Anemia Nutritional state of the patient Bacterial colonization of the lower

genital tract Multifetal gestation Young maternal age and nulliparity Prolonged labor induction Meconium stained amniotic fluid

Bacteria commonly responsible for female Genital tract infections

Aerobes

Grp A,B and D streptococci

Enterococci

Gram (-) bacteria – Escherichia coli, Klebsiella, and Proteus species

Staphylococcus aureus

Staphylococcus epidermidis

Gardnerella vaginalis

Anaerobes

Peptococcus species

Peptostreptococcus species

Bacteroides fragilis group

Prevotella species

Clostridium species

Fusobacterium species

Mobiluncus species

Others

Mycoplasma species

Chlamydia trachomatis

Neisseria gonorrhea

PATHOGENESIS

Bacterial contamination

Inoculation and colonization of the uterine segment, incision or laceration

Favorable bacterial conditions

Proliferation and tissue invasion

METRITIS

CLINICAL COURSE

Fever and chills

Abdominal pain

leucocytosis

TREATMENT

oral antimicrobial agent is usually sufficient For moderate to severe infections,

intravenous therapy with broad spectrum antimicrobial regimen is indicated. Improvement follows after 48 to 72 hours in nearly 90%

Typically the patient is discharged after she has been afebrile for at least 24 hours. Further antimicrobial therapy is not needed.

END…