🚀 go-pugleaf

OK, for all of you out there who have responed, here's a summary of
what you have asked. I've broken this down into two posts, this one
with the additional information requested, and another with the
differential diagnosis list. A couple of folks have made pretty good
guesses but no one has twigged to the extent of the problems.

 good luck and keep trying. 

>-  Skin color, turgor?
color is good, skin warm and moist, no evidence of dehydration
 
>      -When did  the edema start, (date) does the edema begin in the mornig, or is it worse in the AM? Wt before wt loss.
puffiness has been getting worse over the last couple of days, present
in the am but worse in the pm. Wt. gain of 25# this pregnancy to total
175, 10# loss at delivery (including 8# baby) and 15# since then, to
current wt 150.

>        -  PsO2?
not available at this time, but mucus membranes are pink and there is
no frank respiratory distress.

>         -  Blood glucose?
fingerstick glucose of 135 (normal on the machine 80-125)

>         -  Nausea, vomiting, diarrhea?
mild nausea, no current or recent vomiting or diarrhea

>         -  Gravida/para -  Has she had similar problems in the past?  If so, what was the dx then?
G3, now T2P0A1L3 (three preg, two term, one miscarriage, three living
children) only problem a miscarriage at 8 wks ega, cause unknown.

>         -  Has mom ever spent the night in a hospital?  What for?
Only previous hospitalizations for deliveries and as a child for a
t&a.

>         -  Medications?  Both prescription and OTC
>          -Is the mother on any form of medication? e.g. Aspirin or other anticoagulant.
none current. takes acetominophen for headaches.

>         -  Allergies?
Sulfa

>         -  Has mom resumed sexual activity?  When?
no, still breast feeding and only two weeks post partum

>         - How long have she had the scant  discharge?  
The discharge has been decreasing over the last two weeks since
delivery. 

>          -How many pads have you/were you going through before. 
one to four a day, depending on how often she goes to the bathroom


>         -  Does mom still have her appendix?  
see above.

>         -  Did mom have an ultrasound prior to deliver?  Has a necrotic twin been ruled out by physician?
routine antenatal testing demonstrated single infant with anterior
placenta. placenta delivered intact.
 
>        -  Any recent significant trauma?
none

>         -  From nurse, recent record (trend) of vital signs.
no significant deterioration since arrival of visiting health nurse 10
minutes prior to yours. moderate increase in pain at time of nurse's
arrival caused her to call 911.

>         -  EKG?  (we can do a 12 lead in my system.  I'd consider it en route)
Sinus Tachycardia at 100 bpm

>         -  Most insurance companies only pay for 24 hours.  Why was patient in hospital 3 days post partum? 
She was delivered at a teaching hospital under direct supervision of
her regular staff attending physician who is goes to the same church
she does. (with the recent changes in federal law, 48 hours would be
near mandatory in most cases, and three nights would not be unusual
depending on time of delivery.)

>        -  Urinary hx. How often has pt. urinated? Color of urine?    
>        - Pain on urination? Urinary output?
recent increase in urination, no dysuria, color varies with amount she
drinks and breast feeds.

>      -  Bowel sounds?
decreased with a few tinkles and rushes

>      -  Last bowel movement, color, smell, bloody, etc?
last bm this morning after breakfast, scanty and very soft. no change
in color or odor

>      -  Hx. pid or uti?
>       -Is there a partner?
no history of uti, but visiting nurse there to check on report of
sexual contact of active case of gc, chlmydia and syphilis. (and you
thought she was there to check the baby!)

>      -  Was delivery vaginal or by C-section?
normal spontaneous vaginal delievery with out episiotomy

>      -  Has the patient been actively ambulatory?  Performing tasks of daily living?
patient has been doing well until last night, when the discomfort
started to slow her down. 

>       -  Where does the patient hurt when she breaths?  (RUQ of abd??) 
>       - Please describe the pain felt when breathing? 
>        -when pain started? does anything relieve pain?
pain is dull and aching at rest, with a stabbing, cramping quality
with deep breathing. Mostly in the RUQ of abdomen, it radiates to the
pelvis when things get worse. pain was first really noticed yesterday,
and got worse today shortly before the visiting nurse got there,
nothing has really releaved the pain, intensity is 6/10.
 

>        -When is it the hardest to breath? (early am, later in the day, etc.) 
It has gotten harder to take a deep breath over the last two days-
gradually.

>         -Has paroxysmal nocturnal dyspnea been noted?
no

>         -Hx of bleeding disorders? (though that surely would have been mentioned...)
none

>        - Has she had any weak spells? 
She has felt weaker over the last two days.

>        - any similar complaints from baby(ie. bruising); 
 baby has been doing fine and gaining weight, 
 
> 2.  I won't drag my feet on this one, but frankly it's because my gut tells me to.  Thus far the pt. "seems" stable.
 
gut feelings like this are good!, and most of you have had the same
feeling.

> 3.  O2 based on PsO2, IV NS TKO until I'm more certain of Dx, EKG (see above), 
>     contact Leo (my Medical Director).
 
also good, even the advanced medics would not want to give pain
medications until after an assessment by a physician, preferably one
with some OB training (eg OB/FP/ED/General Surgery)

A couple of folks asked about lab work- we are still at the home, and
only the finger stick glucose is available.

ck
Charles S. Krin, DO FAAFP
KC5EVN Krin135@AOL.com
"Reckless, Hell! I hit just where I was aimin'"
"Bubba Shot the Jukebox," Mark Chestnut 1995