CLINICAL CASES REPORT | TERM PREGNANCY | OBSTETRIC AND GYNAECOLOGY HISTORY

Below is Case Report Of Obstetric And Gynaecology Department Of Dx Of Term Pregnancy

DEMOGRAPHY DATA

NAME: ANNA MSUYA.

AGE: 30 YEARS

SEX: FEMALE

ADDRESS: SAME

OCCUPATION: HOUSE WIFE

G2P1L1

LNMP: 11/03/2016.

EDD: 16/12/2017.

GA: 40wks by Date.

DATE OF ADMISSION: 16/12/2016. At 8:30am.

 

REASON FOR ADMISSION:

Labor like Pain 9 hours prior to admission, per vaginal leakage clear.

She booked ANC at GA of 14wks and attended 5 times, received all supplements and she was normal tensive through are visits, PMTCT 2, VDRL non-reactive, B/G B RH –ve and received Ant D at GA 28/40 .

 

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:

1^st Pregnancy delivered by SVD in 2013, 3.8kg well and alive.

 

GYNECOLOGY HISTORY

She attained her menarche at 16 years old

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

No history of pelvic inflammatory diseases.

 

PAST MEDICAL HISTORY:

-This is the fourth admission.

 -No history of history of drug allergy

- No history of blood transfusion.

 

FAMILY AND SOCIAL HISTORY.

-She is 30 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 120/70mmhg

- PR; 74b/min

- RR; 18B/min

- BT; 37 degree centigrade

 

  SYSTEMIC EXAMINATION

PER ABDOMINAL EXAMINATION:

- Fundal height 36/40cm

- EFW 3.7kg

- Longitudinal lie

- Cephalic presentation.

- Fetal heart rate 14b/min

 

CVS EXAMINATION

-no left side chest malformation or enlargement

 -No precordial hyperactivity

 - Apex beat heard at 4^th 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: Term pregnancy in latent phase with Rh –ve.

PLAN: Admit OG 1, Room 3 for monitoring FHR, Bed side ambulation.

INVESTIGATIONS

1. FBP

2. Blood grouping and cross-match.

3. Obstetric ultrasound.

Around 4.00 pm mother delivered by SVD with 3 degree tear, a female baby of 3.6kg who scored 9-10 at 1 and 5 min. Tear was repaired and patient was transferred back to the ward.

TREATMENTS: I/V Metronidazole 500mg 8 hourly for 7/7.

                           I/V Ceftriaxone 1g bid for7/7.

                           I/V R/L 1litre for 24 hours.

1^st day in ward.17/12/2016.

Patient seen during ward round 1^st day post-delivery with third degree of tear.

Today she is doing fine BP 110/70mmhg, PR 84b/min, TEMP 36.6C

Plan: continued with managements.

2^nd day in ward.18/12/2016.

Patient seen during ward round 2^nd day post-delivery with third degree of tear.

Today she is doing fine BP 120/70mmhg, PR 74b/min, TEMP 36.3C

Plan: continued with managements.

3^rd day in ward.19/12/2016.

Patient seen during ward round 3^rd day post-delivery with third degree of tear.

Today she is doing fine BP 110/70mmhg, PR 72b/min, TEMP 36.5C

Plan: Discharge home with metronidazole tabs and ampicloxacilline caps.