Prepared by : Ayalew, Frehiwot, G/Hiwot, Kassaw, MesfinPoorly controlled type I DM with 3rdtrimester Pregnancy + UTI
1.Patient details 2.Subjective & Objective findings3.Assessment 4.Current medications 5.Background 6.Pharmaceutical Care Plan and Follow up7.Patient Counseling 8.Reference 2
Name: GMAge: 26Years Sex: Female (G2A1)Admission Date: 14/09/09 E.CCard no (MRN): ######GOW: Room and Bed No: ###-#Weight: 59KgGestational Week: 31 weeks + 2 days3
CC: Decrease fetal movement for 4 days of duration.HPI: This is a 26 years old G2P1, LNMP unknown and known type I DM mother on NPH 28/14 U, RI 10/10 U admitted to Gyn-Obs ward with the assessment of poorly controlled DM with 3rdTM pregnancy. She is adherent to her medication. She has ANC follow up in ACSH and screened for RVI, VDRL, and HBSAg all are negative. Now she come with decrease fetal movement of 4 days duration. 4
She completed TT vaccine at high school and supplemented Iron. Otherwise she has no subjective compliant like Poly symptoms, Cough, fever and urinary Complaints, NV, and bleeding. And pregnancy is planned, wanted and supported.PMHx: She is known type I DM for the last 4 yearsPMxHx: Insulin (NPH and Regular)FH: Not Known history of CMISH: She is married and has one baby boy. She didn’t take alcohol and other substances including caffeine.5
Physical examinationsGA: well lookingHEENT: pinc conjunctiva and NIS.LGS: NSLAPResp: clear and resonanceCVS: S1 and S2well heard.Abd: 30 weeks sized gravida (US), long lie/cephalic, positive FHB (162b/min), no uterine contraction6
GUS: no CVAT, and no active bleedingPV: Cervix is closedMSS/IS: no edema.CNS: COTTP7
Date BP (mm Hg)PR (b/min)RR (b/min)T0CFHB24/09/09110/809521ATT13025/09/09110/708021ATT13826/09/09112/728620ATT13627/09/09100/60912135.713828/09/09118/759721ATT14529/09/09110/709020ATT1438
Date FBS2 Hrs after BF2 Hrs after lunch2 Hrs after Dinner8:00 PM24/09/099319334015320125/09/099514222914913926/09/0912320219923716627/09/09877322127019628/09/091009224922214829/09/09981322681641409
10Test nameResults (15/09/09)Normal RangesALP13680 to 306 U/LAST170 to 37 U/LALT150 to 42 U/LBUN1010 to 50 mg/dLSCr0.60.6 to 1.1 mg/dLNa+136135 to 145 mEq/LCl10495 to 106 mEq/LK+4.003.5 to 5.5 mEq/L
Test NameResult (15/09/09)Normal RangeWBC5.63.2 to 9.8 × 103/mm3 RBC4.54.2 to 5.4× 10 6/mm3Hgb12.912 to 16 g/dLHct37.333 to 43%MCV82.980 to 100μm3MCH28.727-32pg/cellMCHC34.632-36g/dLLymph %31.025-50 % of WBCSeg Neutrophil %63.3Plt329140 to 450 cells/mm3Other: HgA1c (21/09/09): 9.2% 11
Test NameResult (21/09/09)Normal RangeBilirubinNegativeNegativeBloodNegativeNegativeGlucose+++NegativeKetonesNegativeNegativeLeucocytes++NegativeNitrateNegativeNegativePH65-7ProteinTraceNegativeAlbuminNegativeNegative to traceSpecific gravity1.0301.002-1.030BacteriaManyNegative12
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- Diabetes, Blood sugar