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    UTI History

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    Saber Alasmar
    Mrs. X, a 32 year old pregnant woman at 28 weeks gestation, was admitted to the hospital for pain lasting several hours. She has a history of diabetes. On examination, her temperature was Y degrees Celsius, pulse was Z beats per minute, and respiration was A breaths per minute. Fetal heart monitoring showed a baseline heart rate of B beats per minute with reactivity. Potential diagnoses include UTI, ectopic pregnancy, ovarian torsion, chorioamnionitis, appendicitis, or acute cholecystitis. Complications could include preterm labor, sepsis, renal failure, anemia, peri-renal abscess, or pulmonary insufficiency.

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    UTI History

    Uploaded by

    Saber Alasmar
    47 views6 pages
    Mrs. X, a 32 year old pregnant woman at 28 weeks gestation, was admitted to the hospital for pain lasting several hours. She has a history of diabetes. On examination, her temperature was Y degrees Celsius, pulse was Z beats per minute, and respiration was A breaths per minute. Fetal heart monitoring showed a baseline heart rate of B beats per minute with reactivity. Potential diagnoses include UTI, ectopic pregnancy, ovarian torsion, chorioamnionitis, appendicitis, or acute cholecystitis. Complications could include preterm labor, sepsis, renal failure, anemia, peri-renal abscess, or pulmonary insufficiency.

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    UTI History

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    Mrs. X, a 32 year old pregnant woman at 28 weeks gestation, was admitted to the hospital for pain lasting several hours. She has a history of diabetes. On examination, her temperature was Y degrees Celsius, pulse was Z beats per minute, and respiration was A breaths per minute. Fetal heart monitoring showed a baseline heart rate of B beats per minute with reactivity. Potential diagnoses include UTI, ectopic pregnancy, ovarian torsion, chorioamnionitis, appendicitis, or acute cholecystitis. Complications could include preterm labor, sepsis, renal failure, anemia, peri-renal abscess, or pulmonary insufficiency.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    47 views6 pages

    UTI History

    Uploaded by

    Saber Alasmar
    Mrs. X, a 32 year old pregnant woman at 28 weeks gestation, was admitted to the hospital for pain lasting several hours. She has a history of diabetes. On examination, her temperature was Y degrees Celsius, pulse was Z beats per minute, and respiration was A breaths per minute. Fetal heart monitoring showed a baseline heart rate of B beats per minute with reactivity. Potential diagnoses include UTI, ectopic pregnancy, ovarian torsion, chorioamnionitis, appendicitis, or acute cholecystitis. Complications could include preterm labor, sepsis, renal failure, anemia, peri-renal abscess, or pulmonary insufficiency.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    UTI

    Personal History
    Mrs a year old patient, married for years, Gravida Para + living
    , she is pregnant at gestational age. She is (work) and lives in
    blood group Rh .

    Her partner is , y/o . He is (work) rh?

    She was admitted to hospital at referred via .

    This history was taken by me fifth year medical student Un. at (time) from the
    patient herself who seems to be reliable.

    CC: for duration


    HPI:
    The patient was doing well till prior to admission when she began to suffer from

    Pain? when? Site? Rt or lt?

     Onset –acute or gradual?

     Duration – minutes / hours / days / weeks / months / years

     Severity – scale 0-10?

     Course – is the symptom worsening, improving, or continuing to fluctuate?

     character? Stabbing colicly heaviness?

     Precipitating factors – intercourse?

     Relieving factors – antibiotics?

     Associated features – fever/malaise?

     Previous episodes – has the patient experienced this symptom previously?


     Radiation?

    Fever? Spiky? Continuous? ‫تم قياسها؟ بواسطة ؟‬

    Vaginal discharge composition? amount? Odor?

    Ask for risk factors :

    1- Primi?
    2- Pregnancy? Compression/ relaxtion of ureter / large kidney.
    3- DM?
    4- HTN?
    5- PREVIOUS HISTORY?
    6- ASYMPTOMATIC?
    7- GOUT?

    Systemic Review:
    Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea /
    Peripheral oedema

    Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

    GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain


    / Bowel habit

    Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

    CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

    Musculoskeletal – Bone and joint pain / Muscular pain

    Dermatological – Rashes / Skin breaks / Ulcers / Lesions

    ….

    Current pregnancy:
    The LMP was at and EDD at therefore she is pregnant at
    gestational age.

    This pregnancy was (planned, accidental ), the patient noticed that she is
    pregnant by complaining from (amenorrhea,..) for days duration ,
    associated with (Vomiting …..) , and pregnancy was confirmed by
    (plasma, urine) pregnancy test/US at gestational age.

    The pregnancy was followed up by doing US time at (hospital) and it


    showed
    the patient had no problems early in this pregnancy , the fetal movement was felt by the
    mother at weeks gestational age.

    2ND AND 3RD US?

    Past obstetric History:


    The past obstetric hx was uneventful except for (c.s, PTL, miscarriage ) OR

    The first pregnancy came to full/pre term G.A with (SNVD, assisted Vaginal, CS) in
    (year) , she spent hrs during labour at hospital. Her baby was (sex), and birth
    weight was gm, with complications ( fetal or maternal). The present health is
    .

    The second

    The third

    Gynecological Hx:
    The menarche was at years old, the menstrual cycle is (regular, irregular), it
    occurs each days, the menstruation last days, assocoiated or not with pain
    (when).

    There is/no Hx of inter menstrual bleeding or post coital bleeding.

    Ask about number of pads per days blood clots.


    The patient was on (type of contraceptives) for months and stopped it
    because complication

    The patient is not aware of PAP smear.The last smear was done ago, its result was ,
    she had been treated by , in (year).

    Her last mammogram was in (year), its result was .

    There is no concern to be discussed about her sexual activity.

    Past Medical and surgical Hx:


    There is an ob/Gyn surgical hx of in (year)

    There is a surgical/ medical hx of in (year)

     Thromboembolic disease – high risk for further events in following pregnancy


     Diabetes – tight glycaemic control is essential – risk of congenital defects / macrosomia
     Epilepsy – some antiepileptics are teratogenic – needs neurology input
     Hypothyroidism – TFTs need close monitoring – risk of congenital hypothyroidism
     Previous pre-eclampsia– higher risk to develop it in the current pregnancy

    Hx of PID, endometriosis, STD.

    Smoking, alcohol, exercise

    Drug Hx
    Name, dose, frequency, compliance

    Allergies

    Teratogenic drugs:

     ACE inhibitors
     Sodium valproate
     Methotrexate
     Retinoids
     Trimethoprim

    Family Hx
    Chronic dz, cancer

    Pregnancy loss – recurrent miscarriages in mother and sisters

    Pre-eclampsia – in mother or sister – increased risk

    Social Hx
    Well ventilated house

    Medical insurance

    Smoking?

    Summary
    Mrs a year old patient, G P + L pregnant at gestational age & EDD
    was admitted to hospital (yesterday at ) complaining of pain?...etc For the past
    ??hrs. she has been diagnosed with dm? (as a risk factor). On examination her
    temperature is ? C, pulse ? beat/min and respiration ? breaths/min. complain form
    costovertebral angle tenderness or not?. Electronic fetal heart monitoring shows baseline
    heart rate ?/min with reactivity.
    DDX:

    1- LABOR PAIN

    2- ECTOPIC PREGNANCY

    3- OVARIAN TORSION

    4- Chorioamnionitis

    5- APPENDICITIS

    6- Acute cholecystitis

    COMPLICATIONS:

    1- Preterm labor (E-coli secrete Peptidoglycan hydrolase  PG  contractions).


    2- Sepsis
    3- Renal failure
    4- Anemia (erythropoietin)
    5- Peri-renal abscess
    6- Pulmonary insufficiency.

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