CLINICAL CASES REPORT | NORMAL PREGNANCY | OBSTETRIC AND GYNAECOLOGY HISTORY

DEMOGRAPHY DATA

NAME: ROSE MREMA.

AGE: 27 YEARS.

ADDRESS: MOSHI.

OCCUPATION: ACCOUNTAT.

PRIME GRAVIDARUM.

LNMP: 04/03/2016

EDD: 11/12/2016

GA: 40wks+4.

PMTCT 2

DATE OF ADMISSION: 13/12/2016.


MAIN COMPLAINT

Per vaginal mucous discharge creamy in colour and sticky non smelling 4 hourly prior to admission. She booked ANC at GA of 15wks and attended 6 times, received all supplements and she was normal tensive through are visits, PMTCT 2, VDRL non-reactive, B/G A RH +ve.


REVIEW OF OTHER SYSTEMS:

RESPIRATORY SYSTEM:

- No difficulty in breathing

 - No chest pain

  -No coughing

 - No chest tightness.


CARDIOVASCULAR SYSTEM:

 -No palpitation

 -No paroxysmal nocturnal dyspnea

 -No chest tightness.


MUSCULAR SKELETAL SYSTEM:

No joints pain.

No joints swelling.

OBSTETRIC HISTORY: She is Prime gravidarum.


GYNECOLOGY HISTORY:

She attained her menarche at 14 years old

Regular menstrual cycle, duration is three days, cycle is 28 days and she use two pads per day.

No history of pelvic inflammatory diseases.

PAST MEDICAL HISTORY:

-This is the first admission.

 -No history of history of drug allergy

- No history of blood transfusion.


FAMILY AND SOCIAL HISTORY.

-She is 27 years old female married.

-No history of alcohol consumption.

-No history of cigarette smoking

-No history of inherited diseases in the family.


ON EXAMINATION.

-Well looking afebrile, conscious, and oriented to people, place and time.

-No jaundice

-Not pale

-No lower limb edema

- Not dehydrated

- No lymph nodes enlargement.

 

VITAL SIGN

BP is 130/80mmhg

PR: 74b/min

RR: 18b/min

BT: 36.2 degree centigrade

 

SYSTEMIC EXAMINATION

PER ABDOMINAL EXAMINATION

Fundal height 40/40cm

Longitudinal lie

Cephalic presentation.

Fetal heart rate 140b/min


CVS EXAMINATION

-no left side chest malformation or enlargement

 -No precordial hyperactivity

 - Apex beat heard at 4th intercostal space mid clavicular left side of the chest.

- S1 and S2 sound heard clearly no added sound

 

RS. EXAMINATION

No chest malformation

No surgical scar on the chest

Chest move with respiration

Normal resonant sound heard on percussion

Normal vesicular sound heard on auscultation.

 

 

   DIAGNOSIS: Normal pregnancy at term not in labour.

INVESTIGATIONS

1. FBP: HB 13.9g/dl

2. Blood grouping and cross-match. A RH + ve.

3. Obstetric ultrasound:

PLAN: Admit OG 1. Monitor vital signs and cancel the mother on danger signs.

            SVD anticipated.

1st day in ward 14/12/2016.

1. Patient seen during ward round, reported to reduce fetal movement.

2. Stable vitals BP 110/70mmgh, PR 72b/min, FHR 140b/min.

3. USS Result: EFW 4.5kg, placental fundal mild calcified, other measurement were beyond measurement.

PLAN: For mechanical induction with balloon.

           Fetal kick chart, Cancel patient on danger signs to report in R3.

           Monitor FHR.

           RBG and FBS.

Around 12:32pm patient reviewed again and planned for C/S due to big baby.

Pre Op management as per protocol.

Intra op Findings: Male baby 4.2kgs who scored 8-10 at 1 and 5 min respectively delivered and baby was sent in P3 due to overweight.

Post Op management as per protocol

 

 

   Follow up investigations.

2nd day in the ward 18/12/2016.

1. Patient seen during ward round, no any complains.

2. Stable vitals BP 110/80mmgh, PR 74b/min, FHR 144b/min.

3. GA 39wks+2 by date.

PLAN: Prepare for elective C/S tomorrow.

3rd day in the ward 19/12/2016.

4. Patient seen during ward round, no any complains.

5. Stable vitals BP 120/70mmgh, PR 78b/min, FHR 140b/min.

6. GA 39wks+3 by date.

PLAN: Prepare for elective C/S today.

            I/V Ceftriaxone 1g stat.

            I/V metronidazole 500mg stat.

Caesarean section done around 1:00pm INTRA OP FINDINGS: a male baby, body weight of 2.9kg scored 8-10 at 1 and 5 min respectively extracted and IUCD inserted.

POST OP ORDERS as per protocol.

1stday post-operative.20/12/2016.

1. Patient seen during ward round no new complain, baby breast well.

2. Stable vitals. BP 120/80mmhg, PR 74b/min, TEMP. 36.8C.

3. Remove catheter and encourage ambulation

4. Start oral sips and continue with managements.

2nd day post-operative.21/12/2016.

1. Patient seen during ward round no new complain, baby breast well.

2. Stable vitals. BP 110/80mmhg, PR 78b/min, TEMP. 36.5C.

3. Continue with managements.

3rd day post-operative.22/12/2016.

1. Patient seen during ward round no new complain, baby breast well.

2. Stable vitals. BP 110/70mmhg, PR 72b/min, TEMP. 36.2C.

3. Discharge home TCA after 7 days for stiches remove.

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