Chief Complaint : Pregnancy at 36 +5 th gestational week with preeclampsia Past History : 1. Systemic disease : preeclampsia 2. Previous OP history : denied 3. Drug or food allergy : denied 4. Previous pregnant history : G2P0AA1(GA10 wks with IUFD) Present Pregnant History and Menstrual History : G2P0SA0AA1E0 Menarche :14 y/o MC Interval/Duration :28-30/5-6 LMP : 94/02/06 EDC : 94/11/13 Prenatal condition : elevated BP was noted since GA 33 weeks under medicine control(trandate 1# bid). Proteinuria(++) was noted on 10/21. Present Illness : This 32 y/o woman, G2P0SA0AA0E0 , is pregnancy for 36 weeks. She received prenatal care at Dr.李木生’s OPD. Elevated BP was noted since GA 33 weeks and under trandate 1# bid control. There was no headache, dizziness, blurred vision nor decreased urine output. She was transferred to Dr. 徐’s OPD today and was admitted due to high BP(179/108mmHg) and proteinuria. No lower legs pitting edema was noted now. Physical Examination : Consciousness : alert & oriented ; clear Vital sign : T/P/R : 36.1/68/20 BP : 169/109mmHg HEENT : grossly normal Conjunctiva : not pale Sclera : anicteric Pupil : isocoric, light reflex : +/+, throat : not injected Neck : supple, no LAP, no JVE, no goiter Chest : symmetric expansion, breathing sound : clear Heart : regular heart beat, no audible murmur Abdomen : ovoid; bowel sound : normoactive Extremities : freely movable, no cyanosis, no pitting edema, no petechiae Obstetrical Finding : not checked Rupture of membrane : - (Nitrazine test :-) Uterine contraction : irregular Vaginal bleeding : - Sonar Finding : BPD : 8.7cm AC : 26.7cm FL : 6.4cm EBW : 2100gm AFI : 2.9+3.4+1.5+1.6 Placenta location : fundus , grade II Presentation : vertex FHB : + Lab Data : 項 目: Appearance Sp. Gr.(C) pH(C) Protein(C) Glu.(C) Ketones(C) 日期 (時間) * * mg/dL g/dL * 0941022 (0919) Y;C 1.019 6.0 100 - - 項 目: O.B.(C) Urobil.(C) Bil.(C) Nitrite(C) WBC(C) 日期 (時間) * EU/dL * * * 0941022 (0919) - 0.1 - - 1+ 項 目: Appearance RBC(S) WBC(S) EpithCell(S) Cast(S) 日期 (時間) /HPF /HPF /HPF /LPF 0941022 (0919) Y;C - 8-10 8-10 - 項 目: UN CRE Na K T-BIL Mg AST ALT 日期 (時間) mg/dl mg/dl mmole/l mmole/l mg/dl mmole/l U/l U/l 0941021 (2028) 26.5 0.9 134 4.7 0.43 0.85 79 156 項 目: WBC RBC HB HCT MCV MCH MCHC PLT 日期 (時間) K/μL M/μL g/dL % fL pg g/dL K/μL 0941021 (2023) 6.22 4.19 13.0 39.7 94.7 31.0 32.7 101.0 0941023 (0943) 10.1 3.99 12.3 37.5 94.0 30.8 32.8 102.0 3P : 1+ D-dimer : 1.55 項 目: C-Reactive Protein 日期 (時間) mg/dl 0941021 (2028) 1.35 Impression : Pregnancy at 36+5 th gestational week with preeclampsia Suspect HELLP syndrome Management : Admission routine, preparation for BP control. Apresolin 2# q6h Trandate(10) 1# bid MgSO4 1btl 200ml run 10cc/hr Check RR, DTR, U/O q8h --

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