GYNECOLOGY AND OBSTETRICS WARD

Case report
SUBMITTED TO: - Dr. Samuel
(gynecologist & obstetrician)
BY:- NEGA SIMA
MEDR 32/06

13/06/2008

ID No

Date: 28/5/08 E.C

IDENTIFICATION:- This is Tigist Habtemariam a 38 years old female
cames from Agere Mariam semen shewa who follow orthodox religion and
she is married, literate and farmer in occupation.
SOURCE OF REFERAL:-Referred from Armenian health center

Mode of arrival:- Ambulance

SOURCE OF HISTORY:- The client herself.
RELIABILITY OF THE HISTORY:- Seems reliable
PAST ADMISSION: No history of past admission
C/C:- pushing down pain of 3 days duration
This is Para 4, abortion and ectopic pregnancy zero female having alive
male, 3 kg neonate on 27/05/08 at around 9:00 oclock by cesarean
section. She was referred from Armenian health center after following her
24 hours by explaining it is difficult for us you have to be operated to save
your fetus due to abnormal position of your fetus. She arrived this hospital
at 3:00 oclock and she had gush of fluid out of the vagina after she had
arrived the hospital. After followed for about 5:00 oclock with no response
they were told to her to be operated due to abnormal lie of the fetus and
she was agreed. Her LNMP on 21/08/07 and her EDD was on 25/05/08.She
gave birth at gestational age of 40+2 weeks. She had been using inject
able family planning method every 3 months for 4 years and had regular,
painless ,non clotting and small in amount menstrual cycle monthly for
consecutive 1 year after discontinuation of the family planning. She knew
her pregnancy after cessation of menstrual cycle for consecutive 3
months. The pregnancy is planned, wanted and supported. She had ANC
follow up at Armenian health center starting from 4 month of gestation for
4 visits. She was investigated blood, urine and stool during the first visit
and she confirmed the pregnancy and she knew her blood group O+ and
other laboratory results are normal including HIV/AIDS. Blood pressure,
weight and height were measured but she didnt remember the value.
After she was counseled about danger symptoms of pregnancy and when
to return, she was given TT vaccine and drug of red color which was taken
once per day for 3 months. In the consecutive visits she was given the
same counseling and follow up. She eats commonly enjera with wot and
sometimes cooked vegetables.

She had no severe headache, blurring of vision, epigastric or right upper

quadrant pain, swelling to the face and hands or vaginal bleeding
throughout her pregnancy.
She had no history of diabetes mellitus, hypertension, thyroid disease or
history of blood transfusion.She has no urinary frequency, urgency or
burning sensation during urination. She has no history of cigarette
smoking, alcohol or any type of drug usage. No family history of
hypertension, diabetes mellitus or twins pregnancy.
Past obstetrics history She have 4 children.2 male and 2 female .The
first is female born in 1994 E.C at gestational age of 9 month, she was
fully vaccinated and she is now learning grade 7 .The second was born in
1996 E.C at a term and fully vaccinated and have vaccine certificate, now
she is learning grade 4.The third is male born in 2003 E.C at a term and
certified for full vaccination .All childrens are born at home by traditional
birth attendance except the presenting male neonate. She had no any
complication before and after delivery during all childbearing time.
Gynecological history-Family planning history: - mentioned in HPP
-Sexual history:- she had no history of offensive,painfull vaginal
discharge
-Gynecological operation:- she had FGM, no other past operation
-Menstrual history:- She did not remember her first time of
menstruation started, but after she started menstruation she have regular
menses between 21 to25 days monthly without pain and small in amount
that lasts for 3 to 5 days.
Past medical history: - She has no history of allergic reaction for
medication. Others are mentioned in HPP
Personal and social history:- she was born in 1970 at armenia and
grew there with her family. She was learned up to grade 3 and

discontinued to marry; she started to live with her husband at the age of
19 years. She has 4 brothers and 3 sisters of all are alive and healthy. She
has good interaction with her family and husband including her
community.
Family history: - both her mother and father are dead due to aged.
(Others mentioned in HPP)

SYSTEMIC REVIEW:HEENT- Head:- no head injury, headache

-Eye:- no pain, redness and excessive tearing,
-Ear:- no hearing problem, tinnitus and ear discharge.
-Nose:- no nasal stuffiness, nasal discharge or bleeding.
- Throat and mouth:- no toothache, sore tongue or bleeding
gum.
LGS:- no swelling around the neck, axilla or groin area
RS:- no chest pain, cough, shortness of breath
CVS:- no orthopnea, PND or palpitation
GIT:- no diarrhea ,heart burn,dysphagia
GUS:- mentioned in HPP.
IS:- no skin rash, dryness, or itching sensation
MSS:- no joint pain, swelling or movement restriction
CNS . no numbness tingling, body

PHYSICAL EXAMINATION

GA:- Healthy looking

V/S :-

BP 100/70 mmhg from left brachial artery in sitting position,

PR 84 bpm at right radial artery which is regular and full in

volume,
RR -

25 bpm

T- 37.2 0c from axillary

HEENT:Head:- no scar; black and normally distributed traditionally
haired(shuruba) hair.
Eye:- pink conjunctiva; no icteric sclera.
Ear:- no mastoid tenderness,no lesion in the external canal or
visible ear discharge
Nose:- no nasal polyps; frontal and maxillary sinuses tenderness,
unusual discharge or nasal deformity
Throat and mouth:- wet oral mucosa, no oral thrush and ulcer, no
gum bleeding; no tonsilar enlargement.
LGS:- no lymphadenopathy in the cervical, supraclavicular, sub mental
and submandibular, post and preolicular, axilla and inguinal areas. No
thyroid gland enlargement.
-Breast:- symmetrical in size, no abnormal discharge from the
nipples, no nipple retraction, symmetrical and well developed areola, no
breast tenderness
RS:- Inspection- chest is symmetry, no use of accessory muscles. No
flaring of annals, 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 strider or crepitation.
Percussion- resonant sound all over the chest.
CVS:- Arterial examination:-No radio femoral delay. (others mentioned in V/S)
Pericardial examination:-

Inspection- - Silent pericardium

- No bulged pericardium
- No scar on the chest
-Apical beat is visible at the left 5th intercostals space
1cm medial to the mid clavicles line
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

There is no friction rub , murmur and pallop

GIT:- - Inspection - abdomen moves symmetrically with respiration and

grossly distended abdomen without flank fullness
-She has incised and dressed lesion at lower right quadrant of
abdomen.
- there is linia nigra below the umbilicus, but no stria gravidarum

Palpation

- She has superficial and deep tenderness at incised

site.
- uterus is palpable two finger below umbilicus.
GUS:-Genitalia examination: Inspection:G - no scar around the genitalia
G - moist perineum
G - no vaginal bleeding
PV examination:- Cervix is around 2cm dilated
- There is small blood under the examining fingers
- no CVA tenderness
- She has supra pubic tenderness

IS:-

no rash all over the body

-no chloasma

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 and

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

DIAGNOSIS
Early puerperal period
PLAN:- follow maternal vital sign
_Follow infant breast feeding
-advice about family planning
-advice about infant immunization