CPC Case for August 1, 2003

Discussant: James Strauss, MD

Case presented by:

CC

 

HPI The patient is a 34-year-old G5P4 female with headaches for 2 days. She was thought to be 27 weeks pregnant, but she had no prenatal care. She was transferred to an ICU at PHD for hypertension and anemia on hydralazine and magnesium sulfate. En route to PHD, she delivered a nonviable fetus.
KDA Allergies: none
MEDICATIONS Tylenol
PMH

Hepatitis A and 4 previous vaginal deliveries at term with mild hypertension at the end of the pregnancies

PSH  

SH

  
FH

Social Hx, and ROS: non-contributory

ROS  
PHYSICAL EXAM:

Alert in no distress. Vital Signs: BP 155/95; afebrile; pulse and respiration not recorded.
HEENT: Normal
Chest: Lungs clear to auscultation; Heart: Regular Rate and Rhythm; no murmurs noted.
Abdomen: Postpartum uterus, firm, nontender fundus
Extremities: Nontender with no other abnormalities noted


LABS:

WBC 15, HGB 7.6, HCT 21.3, PLT 102, MCV 88.3, RDW 12.3,

Sodium 135, Potassium 4.2, Chloride 109, CO2 23, Glucose 105, BUN 8, Creatinine 0.6, Calcium 5.4, Magnesium 5.2,

AST 818, ALT 646, Total protein 5.4, Albumin 2.5, Alk Phos 133, Total Bilirubin 0.9, Direct Bilirubin 0.0, LDH 2905

Coagulation Studies: Protime 12.7, INR 1.0, aPTT 27.9, Fibrinogen 493.9, D Dimer >1050, Platelet function assay - EPI 261 seconds (Normal 68-184), Platelet function assay - ADP 86 seconds (Normal 44-130);

Cardiolipin IgG Antibody 2 (-); Cardiolipin IgM Antibody 5 (-); Protein C – Functional 58 (Normal 80-166); Protein S – Functional 24 (Normal 68-128);

Antithrombin III 79 (Normal 73-125); Factor V Leiden (-); Homocysteine 5.18 (Normal 4.00 – 10.00); Prothrombin G 20210a mutation (-).

HBs Antigen (-) and HIV – 1 Antibody (-)

STUDIES:

CT of abdomen: 1) Heterogeneity within the right lobe of the liver consistent with a hemorrhage; 2) subcapsular liver hematoma; 3) Ascites; 4) Small bilateral pleural effusions, R>L. 

HOSPITAL COURSE (Short) Her high blood pressure was managed with magnesium sulfate and hydralazine. She was also given dexamethasone for her anemia. Dilatation and evacuation of uterine remnants was performed and a clinical diagnosis was made.