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Case report -1
SUBMITTED TO:
Obstetrician)
MEDR 24/05
March, 24/2016
Date- 15/7/08
Case report
HISTORY
IDENTIFICATION:-
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
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.
PHYSICAL EXAMINATION
HEENT:Head:-no scar
Eye:-pink conjunctiva; no icteric sclera.
Ear:-no tenderness or visible discharge
20
- No bulged precordium
No scar on the chest
No palpable murmur
PMI felt at 5th left inter costal space just medial to the mid
clavicular line
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
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