GYNECOLOGY AND OBSTETRICS

WARD
Case report -1
SUBMITTED TO:

Dr. SAMUEL B. (Gynecologist &

Obstetrician)

BY:- Balesew Enawgaw ( C-1)

ID

MEDR 24/05

March, 24/2016

Date- 15/7/08

Case report
HISTORY
IDENTIFICATION:-

Name : Emebet Asegdew

Age: 36 years
Address : Debre Berhan town kebele 09
Marital status:- married
Educational status;- she did not attend any formal education
Religion:- Orthodox Tewahido
Admission date:- on 06 /07/08.

SOURCE OF REFERAL: Tebasse Health Center

SOURCE OF HISTORY: The patient herself.
PAST ADMISSION: No previous admission

C/C: Abdominal pain of 25 days duration .

HPI:

This is a 36 years nulliparous lady whose LNMP was on and para-

mother whose LNMP was on 11/04/08and making EDD 16/01/09 and GA of

8+4weeks by date.She had been using injectable family planning method for
the last 3 years until she discontinued it before 4 months. She had an
irregular menstrual cycle while she was on contraceptive, which came every
two or three months, spotting in amount and it was dark and none clotted.
She had one menstruation after one month of discontinued. She had one
ANC visit before 15 days at the nearby health center. Urine and blood
laboratory was done; blood pressure and weight were measured. Pregnancy

was confirmed; she was HIV negative.She was told all the laboratory findings
were normal, but she cant remember the results. She was given TT vaccine
and counseled on nutrition and about danger symptoms of pregnancy and
when she returns.
She was relatively health until 02 days back at which time she develops
vaginal bleeding. The bleeding started suddenly in the morning while she
was using a toilet.It was bright red and non-clotted whichbleeds continuously.
The amount was minimal just like menstruation. Associated with this she had
abdominal pain which is colicky type and more worsen at the lower abdomen
and radiate to the back. She used to have a rest at her home for 03 hours
after the onset of bleeding but there was no any improvement. She went to
the nearby health center(Mollale HC)and stayed there for 15 hours. She was
given 02 bags of IV fluid, antipain andreferred to this hospital for the reason
of not sure that whether it is abortion or ectopic pregnancy. She arrived here
after 8 hours of referral. She has generalized body weakness, palpitation,
dizziness, dryness of mouth nausea and decreased appetite. She had no
syncope. She has no vomiting, fever, headache, chills or sweating. She has
no urinary frequency, urgency, pain during urination or hesitancy.
She had history of fall dawn accident before three days of the onset of
symptoms. She sustained the accident while she was fetching water. She
failed on a flat ground by her front and had mild abrasion to the left knee
area and there was minimal bleeding from the site of injury and stopped
immediately and healed by itself without any intervention. She felt sever
pain to the site of injury. There was no vaginal bleeding at the time of fall
down accident. She had no history of alcohol, drug or herbal medication use,
hot or cold preference, any pelvic surgery or dilatation and curettage. She
had no history of vaginal discharge, lesion around the genital area or
treatment history of STD. She had no history of abortion, ectopic pregnancy
or molar pregnancy. She has no problem of wealth and usually eats 3-4 times
per day mainly on cereals and sometimes meat and vegetables. She had no

personal and family history of hypertension, diabetes mellitus or kidney

disease. The pregnancy was planned, wanted and supported.

Past obstetrics history -In 2004, she gave a female live birth neonate at term
with unknown weight. She delivered at the nearby health center through virginally
after laboring for 12 hours. There were no antepartum, intrapartal or postpartum
complications.

Gynecological history-Family planning history:-mentioned in HPP

-sexual history:-mentioned in HPP
-Menstrual history:- her age of menarche was at 15 years. Before 3
years, when she had not using contraceptive, her menstrual cycle
came every 21-25 days. It was minimal in amount which was constant
in every cycle, each cycle lasts for about 4 days and the bleeding was
dark and non-clotted which was not associated with pain.
Past medical history:- mentioned in HPP
Personal and social history:- she was born in Mollale, North Shoa and grew
there with her family. She has 2 brothers and 2 sister of all are alive and healthy.
She didnt attend any education program and spent her time by helping her parents
till married and started to live with her husband. She has good interaction with her
family and husband including her community.
Family history:-both her mother and father dead in her child hood age with
unknown reason. (Others mentioned in HPP)

SYSTEMIC REVIEW:HEENT- Head:-no history of head trauma

-Eye:- no pain, tearing, or yellowish discoloration
-Ear:-no hearing problem, earache or ear discharge.
-Nose:- no nasal stuffiness, nasal discharge or bleeding.
-Throat and mouth:- no toothache, sore tongue, hoarseness
LGS:-no swelling around axilla or groin area
RS:-no chest pain, cough, hemoptysis
CVS:-no orthopnea, PND, leg or body swelling
GIT:-mentioned in HPP
GUS:-mentioned in HPP
IS:-no skin rash, dryness, or itching sensation
MSS:-no joint pain, swelling or movement restriction
NS.no numbness, tingling, body weakness

PHYSICAL EXAMINATION

GA:-Acutely sick looking

V/S:-

BP 100/70 mmhgat rightbrachial artery in left lateral position,

PR 92bpmat left radial artery which is regular and full in volume, RR bpmT- 36.7 0c(axillary)

HEENT:Head:-no scar
Eye:-pink conjunctiva; no icteric sclera.
Ear:-no tenderness or visible discharge

20

Nose:-no nasal polyps; nofrontal and maxillary sinuses tenderness, no nasal

deformity
Throat and mouth:-dry oral mucosa, no oral thrush,no gum hypertrophy;
no tonsilar enlargement.

LGS:-no lymphadenopathy in the cervical, supraclavicular, sub mental and

submandibular, post and preolicular, axilla and inguinal areas. No
thyroidgland enlargement.
-Breast:-symmetrical in size, no discharge from the nipples,no skin
depigmentation, no breast tenderness or palpable mass.

RS:-Inspection-chest is symmetry, no use of accessory muscles. No SC

and IC retraction; no flaring of analasi, no lip or tongue cyanosis.
Palpation-no tracheal shift, no tenderness all over the chest, normal chest
expansion.Auscultation-no decreased air entry, vesicular sound, no rale or
crepitation.
Percussion-resonant sound all over the chest.

CVS:-Arterial examination:-No radio femoral delay. (others mentioned in V/S)

Venous examination:- JVP= 3cm of water above the sternal angle with
ahead of examining tableraised to 45 degree.
Precordial examination:Inspection- -quite precordium
-

- No bulged precordium
No scar on the chest

Palpation- -No apical and parasternal heave

-

No palpable murmur
PMI felt at 5th left inter costal space just medial to the mid
clavicular line

Auscultation -S1 & s2 are well heard, no murmur or gallop

-

There is no friction rub

Peripheral vascular system:-

No visible varicose vein

Homans sign is negative

GIT:- - Inspection -symmetry and flat abdomen without flank fullness

- Abdomen moves with respiration, no visible scar and lesion,no
visible distended vein
- inverted umbilicus
- There is no linianigra and striagravidarum

Palpation:-superficial palpation- there is tenderness in the lower

quadrants, no palpable superficial mass, no rigid abdomen
-deep palpation- there is deep tenderness in the lower quadrants,
-both kidneys are not palpable
- nohepatosplenomegaly
-TLS= 8cm at the right
mid clavicular line
- Fluid shift and fluid thrill both are negative.
- Leopolds maneuver:-uterus is not palpable

Auscultation:- normoactive bowl sound

-no bruit is heard over abdominal, renal, iliac and femoral arteries
-no friction rub and bruit over the spleen and liver

Percussion:-tympanic all over the abdomen

PR examination:-

There is no scar, hemorrhoid, wart, protruding mass around

the anal area
No tenderness,
Normal sphincter tone
Little fecal matter in the rectum but no palpable mass

No blood and brown stool color on the examining finger

GUS:-Genitalia examination: Inspection:G - normal female type pubic hear distribution with
inverted triangle in shape
G - no scar around the external genitalia
G - there is no active vaginal bleeding, but there is dried
blood with some clots around the vulvar area
PV examination:- Cervix is 3cm dilated
- No cervical motion tenderness
- No palpable adnexal mass (under bimanual examination)
- There is clotted blood and tissue on the examining fingers
Speculum examination:- there is minimal leakage of blood through the cervix
which increases under cough reflex.
- there is visible concepts tissue at the cervical os
- cervix is not erythematous or no cervical lesion
- no vaginal wall laceration
-no CVA tenderness
IS:-no rash all over the body
-no skin depigmentation
MSS:-no edema
-no joint deformity
-no bone and joint tenderness
-good range of motion in the hand, wrist, elbow, shoulder, hip, knee
and ankle
CNS:Mental status:-alert and cooperative
-thought coherent

- oriented to time, person and place

Cranial nerves:- cranial nerves are intact
Motor:- good muscle bulk and tone
-strength 5/5 throughout
-rapid alternative movement and point to point movement are
intact
Sensory:- light touch, position sense, are intact.
Reflex:- normal(+2)
Meningeal sign:-negative

DIFFERENTIAL DIAGNOSIS
Abortion (incomplete, inevitable)
Ectopic pregnancy
Molar pregnancy(gestational trophoblastic
disease)
INVESTIGATION
o Pregnancy test
o CBC
BG
RH
HCT/HGb
WBC with differential
Platelet count
o U/S
o HCG titer

o Cludocentesis