GYNECOLOGY AND OBSTETRICS

WARD
Case report -1
SUBMITTED TO: - Dr. Samuel (gynecologist &

obstetrician)

BY:-

MOLAWORK AYELE ( C-1)

ID = MEDR 31/06

Feb, 6/2016

Date- 27/5/08
Case report
HISTORY
IDENTIFICATION:- This is Asnaku Shume with the age of 24 years come from
Sheno. She is a farmer, literate, married and orthodox. She was admitted in
GYN/OBS ward on bed no 09.
SOURCE OF REFERAL:- No
SOURCE OF HISTORY:- The patient herself.
RELIABILITY OF THE HISTORY:- Seems reliable
PAST ADMISSION: No
C/C:- pushing down pain of 8 hours

HPP:- This is gravid- mother whose LNMP was on 21/08/07 making EDD and
GA of 25/05/08 and 40+2 weeks respectively. She had been using implant
family planning method for 3 years and had regular menstrual cycle prior to
her pregnancy. But she didnt remember the exact day of the first fetal
movement. The pushing down pain started gradually and become intense
through time and she came to the hospital. She had gush of fluid out of the
vagina after she had arrived the hospital. She can appreciate the fatal
movement. The pregnancy is planned, wanted and supported. She had four
times ANC follow up at Sheno Health Center since the third month of missed
period. In the first visit she was investigated with urine and blood laboratory
test. Pregnancy was confirmed and her sero status was negative. But she
didnt remember other laboratory results, but she was told that no abnormal

finding was there. Blood pressure, weight and height were measured but she
didnt remember the value. After she was counseled on nutrition, importance
of ANC, about danger symptoms of pregnancy and when to return, she was
given TT vaccine and drug which was taken once per day for two months for
the purpose of preventing anemia. In the consecutive visits she was given
the same counseling and follow up and about birth preparedness and place
of birth. In her early pregnancy she had nausea, vomiting 2-3 times per day
and aggravated during meal, and decreased appetite. She was counseled
that it was normal and to return back if it persists and more severe, but it
disappeared after 4 months of her pregnancy. Starting from 8 months of
pregnancy she has swelling to both legs around the foot area which is more
at day and disappeared at night, palpitation and short ness of breath during
her daily activity. 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 eats 4-5 times per day during her
pregnancy majorly enjera with wot and sometimes cooked vegetables and
meat. She had no history of diabetes mellitus, hypertension, thyroid disease
or history of blood transfusion. 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 has no past obstetrics history.
Gynecological history-Family planning history:- mentioned in HPP
-sexual history:- she had no history of sexually transmitted
disease
-Gynecological operation:- no FGM, no any past operation
-Menstrual history:- her age of menarche was at 15 years and
her menstrual cycle comes every 25-28 days. It is minimal in amount
which is constant in every cycle, each cycle lasts for about 4 days and
the bleeding was dark and non-clotted which is not associated with
pain.

Past medical history:- mentioned in HPP

Personal and social history:- she was born in 1984 at sheno and grew there with
her family. She has 2 brothers and 1 sister of all are alive and healthy. She learnt up
to grade 5 and spent her time by helping her parents till married and started to live
with her husband at the age of 20. She has good interaction with her family and
husband including her community.
Family history:- both her mother and father are alive and healthy. (Others
mentioned in HPP)

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

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

PHYSICAL EXAMINATION

GA:- Acutely sick looking (in labor pain)

V/S

:- BP 110/70 mmhg at right brachial artery in left lateral position,

PR 84 bpm at left radial artery which is regular and full in volume, RR 25 bpm T- 37.2 0c(axillary)

HEENT:Head:- no scar; black and normal distribution of hair.

Eye:- pink conjunctiva; no icteric sclera.
Ear:- no tenderness or visible discharge
Nose:- no nasal polyps; no frontal and maxillary sinuses tenderness, no
nasal deformity
Throat and mouth:- wait 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 thyroid
gland enlargement.
-Breast:- symmetrical in size, no 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 SC

and IC retraction; no flaring of analasi, no lip or tongue cyanosis. Palpationno 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 table raised to 45 degree.
Pericardial examination:-

Inspection- - Silent pericardium

-

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

Palpation
-

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

Auscultation
-

-No apical and parasternal heave

-S1 & s2 are well heard

There is no friction rub

No murmur and pallop

GIT:- -

Inspection - symmetry with grossly distended abdomen without

flank fullness
- abdomen moves with respiration, no visible scar and lesion, no
visible distended vein
- inverted umbilicus
-no visible fetal movement
- there is linia nigra below the umbilicus, but no stria gravidarum
Palpation - there is no superficial and deep tenderness or mass;
no abdominal rigidity
-Leopolds maneuvers:- fundal height = 36 wks
- the funds of the uterus is occupied by- soft, bulky, irregular, non
ballotable part of the fetus
- the lie is longitudinal

- the back of the fetus is at the right side of the

mother.
- cephalic presentation
-the attitude is military
- Decent =2/5
Auscultation:- FHB =156 bpm
GUS:-Genitalia examination: Inspection:G - normal pubic hear distribution with inverted triangle in
shape
G - no scar around the genitalia
G - moist perineum
G - no vaginal bleeding
PV examination:- Cervix is fully dilated
- Station = 0
- Cephalic presentation
- Membrane is raptured
- No blood or meconium under the examining fingers
- no CVA tenderness
- no 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
- 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
-Second stage of labor
INVESTIGATION
o HCT and BG
o U/A