OG 1

CASE REPORT 1

NAME: JS
AGE: 25 years old

SEX: Female

OCCUPATION: Farmer

RELIGION: Christian

MARITAL STATUS: Married

ADMITTED ON: 21/01/2021

PARITY: G1P0L0

LNMP: 11/04/2020

EDD: 06/01/2019

GA: 38 weeks by date

MAIN COMPLAINT: Headache for 1/7

HISTORY OF PRESENTING ILLNESS

Patient was apparently well until one day ago when she started to experience
severe headache which was more in the frontal region and at times radiating
to the back of the head. It had a sudden onset and progressively worsening
with time with no specific periodicity. It was associated with blurry vision
and on and off dizziness. However, she reported to have no history of
convulsions, fits, seizures or loss of consciousness. She had a history of
lower limb swelling which was mild and not accompanied with pain or pin
prick/ tingling sensation in the lower limbs.

She had no history of difficulty in breathing on lying flat, no awareness of

heart beat, no easy fatigability and no generalized body weakness. She has
no history of chest tightness, chest pain, no history of vomiting, no history of
abdominal pain, and no change of bowel habits and has normal urine output
with no pain during micturition.

She has no history of per vaginal leakage, no history of vaginal bleeding, she
has no history of hypertension disease or Diabetes Mellitus before
pregnancy and she has no family history of hypertensive disease during
pregnancy.

REVIEW OF OTHER SYSTEMS

Ear, nose and throat: No history of ear or nasal discharge, difficult in

swallowing or nose bleeding

Musculoskeletal system: No history of joint pain or muscle pain

OBSTETRIC HISTORY
Index Pregnancy

She is a Primigravida. The index pregnancy was booked at 17 weeks

Gestational Age (GA) and she made a total of 5 visits to date. She received
hematinic, SP prophylaxis for malaria, 2 doses of tetanus toxoid. She is
PMCT-2 and VDRL was unreactive. Her blood group is A positive and her
last Hb being 13.8 g/dl. She reported to still feel the presence of fetal kicks.
Blood Pressure was normal until on the last visit, which she reported to be
told were high.

GYNAECOLOGICAL HISTORY

Attained her menarche at the age of 13 years oldHaving a regular normal 28

days menstrual cycle with 3-5 days of menses, using 3 sanitary pads per day
not fully soaked. No pain during menstrual period that could interfere with
her daily activities. No history of use of oral contraceptives or other methods
of contraceptives. No history of prior treatment of any Sexually Transmitted
Infections (STI’s)

PAST MEDICAL HISTORY

This is her first admission.

No history of surgery

No history of blood transfusion

No any known allergies to food and drugs

No history of any chronic illness like Hypertension, Diabetes Mellitus,

Asthma or any Kidney diseases.
FAMILY AND SOCIAL HISTORY

She is the second born out of four children in her family.She is married
living with her husband. There is no history of chronic diseases in first-
degree family member. Her level of education is university level. She is
entrepreneur.

She doesn’t smoke but occasionally takes alcohol of which she hasn’t used
since she knew she was pregnant.

SUMMARY I

J.S 25 years old primigravida at 38 GA weeks by date came presenting with

chief complaints of headache for one day which was associated with blurry
vision, dizziness and lower limb edema. Had no history of fits or
convulsions, no difficulty in breathing when lying flat, no abdominal pain or
genitourinary symptoms.

PHYSICAL EXAMINATION

GENERAL EXAMINATION

Alert, afebrile, not dyspneic, not pale, no angular stomatitis, not jaundiced,
no palpable peripheral lymphadenopathy but has pitting lower limb edema
(up to the knee level)

Vital signs
 • Blood pressure: 144/79 mmHg.
• Heart rate: 84 bpm
0
• Temp: 37.0 C
• Respiratory rate: 22 breaths/min
• SpO2: 99% in room air

SYSTEMIC EXAMINATION

PER ABDOMEN

Uniformly distended gravid abdomen moving with respiration with striae

gravidarum, no visible distended veins, no therapeutic or traditional marks
Soft non-tender abdomen, no palpable organ, dull on percussion, bowel
sounds not appreciable Fundal height 36cm

Leopold maneuver: Singleton fetus palpable, longitudinal lie, at the fundus

there are soft like mass palpated that are in consistency with fetal buttocks, a
firm uniform longitudinal that is consistent with fetal back palpated on the
left side of the mother, multiple digits in consistent with fetal hands and feet
palpated on the mother`s right side, a round hard that is ballotable and in
consistent with fetal head palpated at the hypogastrium. Fetal heart rate is
126 beats/min.

On pelvic examination: she had normal female pattern hair distribution,

normal external female genitalia, no any lesion.

Per vaginal examination

Cervix soft, central located with vertex presentation.

CARDIOVASCULAR SYSTEM:

• Radial pulse rate is 84 beats per minute regular rhythm and

synchronized
• Blood pressure is 140/80 mmHg
• Jugular venous pressure not elevated
• No precordial hyper activity
th
• Apex beat is located at 5 intercostal space left mid clavicular line.
• No heaves and thrills.
• S1 and S2 heard, no added sounds or murmurs.

RESPIRATORY SYSTEM:
• Respiratory rate is 22 breaths per minute
• Normal chest contour
• Bilaterally symmetrical chest movement
• Trachea is centrally located
• No tenderness and no palpable mass
• Bilateral symmetrical chest expansion
• Resonant note on percussion
• Vesicular breath sounds heard, no added sounds

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher centers: Conscious, oriented to time, place and person. Has normal
speech and intact long term and short-term memory.

Cranial nerve examination

 Cranial nerve I- She can smell well in both nostrils

 Cranial nerve II- She can read from a 6 meters distance, pupils
reactive to light and are bilateral equal in size, fundoscopy was not
done.
 Cranial nerve III, IV and VI- She can move eyes in all directions
 Cranial nerve V- Has intact facial sensations both to pinprick and fine
touch, can clench teeth, can close eyes against resistance.
 Cranial nerve VII- She has symmetrical facial smile, able to purse and
blow out her cheeks
 Cranial nerve VIII- She can hear in both ears
 Cranial nerve IX and X- uvula is centrally located.
 Cranial nerve XI- She can shrug shoulders and turn neck against
resistance.
 Cranial nerve XII- She can protrude tongue, No tongue deviation, No
fasciculation and No wasting.

Motor examination

 Normal Bulkiness in all groups of muscles both upper and lower

extremities.
 No Involuntary movements, no scars, no muscle wasting and no
tremors
 Normal Gait
  Normal muscle tone in both upper and lower extremities.
 Normal Power in all groups of muscles both upper and lower
extremities Grade 5.
 Both superficial and deep tendon reflexes are normal.

Coordination

 Normal finger-nose test and normal heel-shin test.

Sensation

 She has normal sensation both to pain, temperature, fine touch and
vibration.

SUMMARY II

J.S 25 years old primigravida at 36 GA weeks by date, came presenting with

chief complaints of headache for one day which was associated with blurry
vision, dizziness and lower limb edema. Had no history of fits or
convulsions, no difficulty in breathing when lying flat, no abdominal pain or
genitourinary symptoms.

On examination she was alert, afebrile with bilateral lower limb edema and
elevated blood pressure. She had a gravid abdomen and fetal heart sounds
were heard. The fundal height corresponded to the Gestational Age.

PROVISIONAL DIAGNOSIS

Term pregnancy not in labour with Pre-eclampsia

INVESTIGATIONS AND RESULTS

LABS

1.Full Blood Picture;

• Hb=12.9
• MCV=86.5
• MCH=28
• Platelets=121 (Low)
• WBC=7.9

2.Liver Function Test

• AST= 17
• ALT= 15
• Direct Bilirubin= 2.4,
• Total Bilirubin= 5.5

3.Renal Function Test

• Proteinuria= 3+ (Raised)
• Creatinine= 74.5
• BUN= 4.4

4. B/S for malaria; Negative

IMAGINGS
1.Obstetric USS:
• Showed single viable fetus seen in vertex presentation
• BPD (38 wks + 2 days), HC (37wks+ 4 days), AC (36wks + 4 days)
FL (36wks)
• Average 37+ 2 days weeks GA.
• No fetal anomaly with normal organs. Fundal placentation posterior
away from the os with adequate liquor volume. Normal maternal
kidneys, adnexa and cervix. Estimated fetal weight is 3.06 kg.

MANAGEMENT

 Tabs Methyldopa 500mg 8 hourly 2/52

 Tabs Nifedipine 20mg BD 2/52

 IV Fluids NS/RL 3Litres per 24hrs

 Inj. Dexamethasone 6mg BD for 2 days

 IV MgSO4 4g 4hourly for 24hrs

 Monitor Blood pressure and Urine output

PROGRESS IN THE WARD

  She had an admission BP of 150/90 which after management she got
down to around 108/70. Her proteinuria of 3+ on admission later
dropped to 2+ after initial management with Tabs Methydopa,
Nifedipine, MgSO4. She was also on inj. Dexamethasone for fetal
lung maturity. Obstetrics USS showed a single fetus with vertex
presentation and being a primigravida it was discussed to perform
Caesarian section after completion of dexamethasone.

 C/S after completion of the dexamethasone dose

INTRA OPERATIVE FINDINGS

A female baby weighing 3 kg was extracted score 9 in 1minute and 10 in

5minutes, cried immediately after delivery.

POST OP MANAGEMENT

• IV ringers lactate alternating with dextrose normal saline 2 litres 8hourly

for 24hours
• Pethidine 100mg IM 12hourly for 24hours
• Metronidazole 500mg IV 8hourly for 72hours
• Ceftriaxone 1g IV 12hourly for 72hours
• Monitor vitals 15minutes then 4hourly
• Monitor fluid input and output

1st day post op

Patient seen during ward rounds with complaint of pain at incision site,
wound was clean. The baby was fine as well. Plan was to continue with
medications

2nd day post op

Patient seen during ward rounds, and the baby was breastfeeding well.
Surgical wound was dry and clean. Stable vitals She passed flatus.
Encourage ambulation

3rd day post op

Patient was doing well, no complaints. Passed stool and flatus Stable vitals,
wound swab removed, wound was clean. Encourage ambulation and
breastfeeding. Planned for discharge with Iron sulphate 200mg 12hourly for
1 month and Folic acid 5mg once daily for 1 month and was instructed to
return after 10 days as an outpatient for stitch removal.

FOLLOW UP:

She underwent a C/S and she delivered a female baby with body weight of
3kg, Apgar score of 8 and 10 in the first and fifth minute respectively. Vitals
were within the normal range (BP=115/65, PR=85, RR=20, SpO2=100%),
had a normal abdominal contour with a well contracted uterus. She was
encouraged to feed on soft diet and early ambulation. The baby was doing
fine and breast-fed well.

CASE REPORT 2
NAME: AT
AGE: 22 years old

SEX: Female

OCCUPATION: Entrepreneur

RELIGION: Christian

MARITAL STATUS: Married

ADMITTED ON: 26/01/2021

PARITY: Primigravida

LNMP: 26/05/2020

EDD: 02/03/2019

GA: 35 weeks by date

MAIN COMPLAINT
Per vaginal leakage for 2/7

HISTORY OF PRESENTING ILLNESS:

The patient was apparently well until 2 days ago when she presented with
sudden gush of fluid through the vagina. The fluid was warm and clear and
non-smelling, which wet her underwear. The condition is progressive in
nature however the leakage is intermittent. No history of bleeding or blood
spotting through vagina and the condition was not preceded or being
accompanied by abdominal pain or cramping.
No history of painful urinating increased frequency, difficulty to hold urine
or loss of sense to urinate. She also denied history of fever.

Fetal movements were reported to be present.

REVIEW OF OTHER SYSTEM:

Cardiovascular systemNo history of awareness of heartbeats, difficulty on
lying flat or air hunger
Respiratory systemNo history of chest pain, difficulty in breathing or
cough.
Central nervous system
No history of headache or blurred vision
Musculoskeletal system
No history of limited joint movements or joint pain.

OBSTETRIC HISTORY
She is primigravida booked ANC clinic at 4 weeks GA at hospital and had a
total of 5 visits Generally, she received antimalarial drug, haematenics,
deworming drug, TT injection and screened for infections, she is PMTCT 2,
VDRL was non-reactive, normotensive in all visits and last visit hemoglobin
level was 12g/dl.

GYNECOLOGICAL HISTORY
Attained menarche at 16-year-old, menstrual cycle is regular with a cycle of
28 days and menstrual flow taking 3-4 days, she changes 2-3 pads per day
not soaked however reported history of pain during menses. She had no
history of using contraception No history of gynecological procedure and
cervical cancer screening.

PAST MEDICAL HISTORY

This is the first admission, no history of surgery, blood transfusion or known
history of allergy to food/drugs.
FAMILY AND SOCIAL HISTORY
She is the last born in family of 3 children all other children are healthy and
doing well. She has college education and housewife, married and lives with
her husband
No family history of chronic illness. Hospital and medical costs are not
covered by insurance payment; her husband is taking care of her and
provides the financial support.
She doesn’t drink alcohol or smoking cigarette

SUMMARY I
A.T 22-year-old female, primigravida, 35 weeks GA by dates, presented
with per vaginal leakage for 2/7, no per vaginal bleeding, no labor pain, no
features of infections, no urinary incontinence and fetal movements were
present.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
Conscious, GCS 15, not obese, not ill looking, not pale, not jaundiced, not
cyanotic, no darken lips and teeth, no bilateral lower limb edema.

Vital signs:
 BP= 103/72 mmHg,
 PR= 100 bpm,
 RR= 21 cpm (Tachypnea),
 T= 36.0 degree centigrade
 FHR=143bpm

PER ABDOMINAL EXAMINATION

Inspection: Symmetrical distended abdomen moves with respiration, no

surgical scar, no striae gravidarum, no distended veins, no tenderness.

Leopold maneuver: Cephalic presentation, longitudinal lie, not engaged,

symphysis fundal height 36/40 and fetal heart rate were heard

Per vaginal examination:

Normal external female genitalia, no whitish/greyish discharge, no blood.
Speculum examination: cervix was closed with pooling of watery fluid in
the posterior fornix.

CARDIOVASCULAR SYSTEM EXAMINATION

Radial pulse had strong volume with regular rhythm, non-collapsing, and
synchronized with peripheral pulses, no raised jugular venous pulse, no
precordial hyperactivity, S1 and S2 were heard, no heart murmur.

RESPIRATORY SYSTEM EXAMINATION

Normal chest contour, no surgical scars, trachea centrally located,
symmetrical chest expansion, resonant note, vesicular breath sound heard,
no crackles.

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher Centre: Oriented to place, person and time, short- and long-term
memory intact, no difficult in conversation

Cranial nerves: Can see, both eyes move in all direction, fine touch on face
is intact bilaterally, Can clinch teeth, symmetry facial expression, Can close
eyes against resistance, can puff out cheeks, Can hear whispered sound
bilaterally, Can swallow, uvula centrally located, Can turn head against
resistance, No tongue fasciculation or deviation on protrusion.

Motor examination: No muscle fasciculation or spasms, she has normal

muscle bulkiness to all muscle groups of upper and lower limbs bilaterally,
normal tone and power 5/5 to all muscle groups of all four limbs.
Coordination: Finger-nose test; Coordination was intact

Sensory examination: Fine touch sensation was intact Conclusion: Normal

central nervous system

SUMMARY II
S.B.A 22 year-old female, primigravida 35 GA by dates, presented with per
vaginal leakage for 2/7, no per vaginal bleeding, no labor pain, no features
of infections, no urinary incontinence and fetal movements were reported to
be present.
On examination: She is tachypneic not cyanotic, distended abdomen, non-
tender, on Leopold maneuver no pelvic engagement, symphysis fundal
height 36/40, fetal heart rate heard and on speculum, fluid leaking via
external OS, pooling of watery fluid also observed at posterior fornix of
cervix.

PROVISIONAL DIAGNOSIS:
Preterm premature rupture of membranes at 35 weeks GA by dates.

INVESTIGATIONS
1. B/S for malaria parasites
2. ABO blood grouping and Cross-matching
3. Full Blood Picture (Hb level, WBC and platelets)
4. Urinalysis (Nitrites, pus cells, cell casts, RBCs)-not done
5. Obstetric USS

Results:
 1) Obstetric USS: Singleton, viable fetus at 34+4 days GA, AFI was
8cm, no abnormal morphology of fetus.
2) B/S for MPS was Negative
3) FBP:
• Low Hb level 10.8g/dl,
• Low HCT (35.0%),
• Normal MCV (85.7 FL)
• Low MCH (26.4 pg.)
• Low MCHC (30.9 g/dl)
• Raised RDW (17.5)
• Other parameters (WBCs, neutrophils, RBCs, and platelets) were
within normal ranges.
Conclusion from FBP: Hypochromic normocytic anemia

MANAGEMENT
A. NON-PHARMACOLOGICAL TREATMENT
1. Encouraged to have bed rest
2. Mother was told about her condition; treatment options and
expected time of hospital stay.
3. Monitor vital signs for both mother and fetus

B. PHARMACOLOGICAL TREATMENT
On day of admission
 • IV Dexamethasone 6mg 12 hourly for 48 hours
• IV Erythromycin 250 mg 6 hourly for 48 hours, then to continue with
tabs erythromycin 250 mg 8 hourly per day for 3/7
• IV metronidazole 500mg TDS for 3/7
• IVF NS/RL 1 liter

2hrs in ward
Started to present with lower abdominal pain, gradual onset, on/off relieved
by paracetamol, no vomiting or diarrhea.Reported also history of increased
frequency however no blood in urine.Increased per vaginal watery
discharge. Fetal movement present.
Around 11 am she presented with heavy per vaginal leakage and emergency
USS was ordered and results showed severe oligohydramnios but the fetus
was viable.
Plan for emergency cesarean section was opted as mode of delivery.

INTRA OPERATIVE FINDINGS

At around 2pm cesarean section was done (LSCS) and a male baby
weighing 2.9 kg was extracted score 9 in 1minute and 10 in 5minutes, cried
immediately after delivery.

POST OPERATION MANAGEMENT

 IV ringers lactate alternating with dextrose normal saline 2 litres 8hourly
for 24hours
 Pethidine 100mg IM 12hourly for 24hours
 Metronidazole 500mg IV 8hourly for 72hours
 Ceftriaxone 1g IV 12hourly for 72hours
 Monitor vitals 15minutes then 4hourly
 Monitor fluid input and output

FOLLOW UP
1st day post op
Patient seen during ward rounds with complaint of pain at incision site,
wound was clean. The baby in P3 was fine as well. Plan was to continue
with medications.
2nd day post op
Patient seen during ward rounds, and the baby was breastfeeding well.
Surgical wound was dry and clean with table vitals, she passed flatus and
she was encouraged to ambulate
3rd day post op
Patient was doing well, no complaints. Passed stool and flatus with stable
vitals, wound swab removed, wound was clean. Encourage ambulation and
breastfeeding. Planned for discharge with Iron sulphate 200mg 12hourly for
1 month and Folic acid 5mg once daily for 1 month and was instructed to
return after 10days as an outpatient for stitch removal.

CASE REPORT 3
NAME: SP
AGE: 29 years
SEX: Female
OCCUPATION: Teacher
MARITAL STATUS: Married
RELIGION: Muslim
ADMITTED ON: 31/01/2021
PARITY: G2 P1 L1
LNMP: 19/05/2020
EDD: 17/02/2021
GA: 37 weeks + 4 days weeks by date

MAIN COMPLAINT: Labor like pain 5hours prior admission

The patient was apparently well until 5hours prior to admission when she
started to experience lower abdominal pain which was gradual in onset. The
pain was cramp like in nature and progressive, increasing in intensity,
frequency and duration associated with scanty vaginal discharge, thick and
sticky blood stain, not smelly. The pain was radiating to the lower back and
thighs, it came in every 10minutes and lasts for 30seconds, not associated
with leakage of water even on coughing. There is no history of fever,
headache, vomiting, diarrhea, painful micturition reported.
She booked at 20weeks gestation in this index pregnancy, had 4 visits,
received all necessary supplements during her visits, she was normotensive
throughout her visits, OMCT2 and VDRL non-reactive.

REVIEW OF SYSTEMS
Central nervous system: No history of fever, loss of consciousness,
headache, dizziness or blurred vision.
Cardiovascular system: No history of awareness of heartbeats, chest
tightness or shortness of breath.
Respiratory system: No history of difficulty in breathing, chest pain, or
cough.
Genitourinary system: No difficulty in urination, no pain during urination.
Musculoskeletal system: No history of joint pain or muscle pain

PAST GYNAECOLOGICAL HSTORY

She attained Menarche at 12 years, with 28 days cycle lasting for 4 days and
regular flow and she normally uses 3 pads per day. She reported to
experience mild pain during menses. No history of pain intercourse, history
of post coital bleeding, history of contraceptive use or history of STIs

PAST OBSTETRIC HISTORY

She got her first pregnancy in 2004, delivered by C/S due to poor progress of
labor, delivered a female baby weighing 3kg, cried immediately, no
complication.
2nd pregnancy was in 2007, delivered by C/S due to previous scar. Male baby
weighing 2.9kg cried immediately, no complication.

PAST MEDICAL AND SURGICAL HISTORY

 This is her third admission.
 No any other admission apart from obstetrics.
 No history of any other surgery.
 No known food and drug allergies.
 No history of chronic illnesses (Diabetes or hypertension)
FAMILY AND SOCIAL HISTORY
 She is the fifth born out of 7 children, her siblings are alive and well.
 Married to one husband and living together.
 She denied history of either smoking or alcohol throughout her life and
during her pregnancy.
 History of hypertension on maternal side.

PHYSICAL EXAMINATION
GENERAL EXAMINATION:
Conscious, oriented to people, place and time. Not pale, not jaundiced, no
lower limb edema, no lymphadenopathy. Height 161 cm, weight 68.5kg
Vitals:
BP=120/70mmHg,
PR=80bpm,
RR=16cycles/min,
T=36.4°C

SYSTEMIC EXAMINATION:
PER ABDOMEN
Distended abdomen, no surgical or traditional marks, visible linea nigra and
striae gravidarum. Umbilicus inverted and retracted. Fundal height 37/40,
Estimated fetal size was 3.8kg, fetal lie was longitudinal in cephalic
presentation. Fetal heart sounds present with fetoscope, FHR was 138bpm

Per vaginal examination: Cervix soft, central located with vertex

presentation. Level 3/5

CENTRAL NERVOUS SYSTEM

Patient was alert with GCS of 15/15. Normal mood, good memory, good
speech. Normal reflexes. All cranial nerves were intact. Motor and sensory
test was intact.

CARDIOVASCULAR SYSTEM
Normal chest contour, moves with respiration, no traditional or surgical
scars seen. No thrill no heaves, no precordium hyperactivity; apex beat
palpable on fifth intercostal space in mid-clavicular line. S1 and S2 were
heard with no added sounds.

RESPIRATORY SYSTEM
Chest moves with respiration and no visible veins. Trachea was centrally
located, normal chest expansion and normal vocal fremitus. No palpable
mass. Resonant note was heard. Normal vesicular breath sounds heard with
no added sounds.

PROVISIONAL DIAGNOSIS: Term pregnancy with two previous scars in

labor.

PLAN:
 Admit to OG1
 Prepare for emergency Caesarian section after being counseled about
the procedure
 FBP
 Grouping and X-match
 IV line
 Catheterization
 Sign consent form
 To inform the anesthesiologist
 Pre-operative medications were given; 1g Ceftriaxone IV and 500mg
Metronidazole stat.

INTRA OPERATIVE FINDINGS

A female baby weighing 3.6kg was extracted score 9 in 1minute and 10 in
5minutes, cried immediately after delivery. The baby was sent to P3.
POST OP MANAGEMENT
 IV ringers lactate alternating with dextrose normal saline 2 liters
8hourly for 24hours
 Pethidine 100mg IM 12hourly for 24hours
 Metronidazole 500mg IV 8hourly for 72hours
 Ceftriaxone 1g IV 12hourly for 72hours
 Monitor vitals 15minutes then 4hourly
 Monitor fluid input and output
1st day post op
Patient seen during ward rounds with complaint of pain at incision site,
wound was clean. And the baby in P3 was fine as well. Plan was to continue
with medications.

2nd day post op

 Patient seen during ward rounds, and the baby was breastfeeding well.
 Surgical wound was dry and clean.
 Stable vitals
 She passed flatus.
 Encourage ambulation

3rd day post op

 Patient was doing well, no complaints. Passed stool and flatus
 Stable vitals, wound swab removed, wound was clean.
  Encourage ambulation and breastfeeding.
 Planned for discharge with Iron sulphate 200mg 12hourly for 1 month
and Folic acid 5mg once daily for 1 month and was instructed to
return after 10days as an outpatient for stitch removal.

OG2
CASE REPORT 4
NAME: SZ
AGE: 17 years old

SEX: Female

OCCUPATION: Teacher

RELIGION: Christian

MARITAL STATUS: Single

ADMITTED ON: 24/02/2021

PARITY: Primigravida

LNMP: 13/11/2020

CHIEF COMPLAINTS
Per vaginal bleeding for 2 weeks
Abdominal pain for 3 days

HISTORY OF PRESENTING ILLNESS

A patient was apparently well until 2 weeks ago when she started
experiencing a gradual onset of per vaginal bleeding which initially was
spotting but it was increasing in severity with time, bleeding had no specific
periodicity but it was aggravated by activities like walking, it was not
associated with feeling of dizziness, headache or difficult breathing.
currently she reported bleeding is still spotting but its severity increases with
abdominal pain.
Also, she reported abdominal pain since past 3 days, pain is experienced
below umbilicus, radiating to the back along the waist, gradually increasing
in severity, cramping in nature, with non-specific period and non-aggravated
and since admission she is on injectable anti pain medications.
No history of awareness of heart beats, loss of consciousness, difficult
breathing, feeling of mass coming out of the vagina or passage of tissues
from the vagina.
She has not attended antenatal clinic and denies use any over the counter
medications during this pregnancy, not a known hypertensive, diabetic or
having any chronic illness. She has no history of fevers, foul smelling per
vagina discharge, painful urination or radiation exposure.

REVIEW OF OTHER SYSTEMS

CNS: No convulsion, loss of consciousness, blurred vision
RS: No difficulty breathing, chest pain, and cough.
MSS: No muscle pain, joint pain, limitation of movements.

GYNECOLOGICAL HISTORY
Attained menarche at 12 years, prior to per vaginal bleeding, she had normal
menstrual periods regular cycle of 28 days, with a maximum of 5 days of
bleeding, she used a maximum of 2 sanitary pads per day which are not fully
soaked, no pain during menstruation, no inter-menstrual bleeding, no history
of contraceptive use, no any gynecological surgery, first sexual debut at 18
years age.

PAST MEDICAL HISTORY

This is her index admission, no known drug allergy, no history of blood
transfusion, no history of any surgery.

FAMILY AND SOCIAL HISTORY

She is the third born in a family of 3 children; she is a college student, single
and living with her parents, no family history of chronic diseases such as
hypertension, diabetes or epilepsy.
She doesn’t smoke cigarette or alcohol.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
Fully conscious, adult female, GCS of 15, normal hair distribution, texture
and color, no conjunctiva paleness, sclera is not jaundiced, no angular
stomatitis or oral lesion, normal tongue architecture, no palpable peripheral
lymph nodes (sub mental, axillary, supraclavicular), Has cannula on the right
upper limb, no finger clubbing, no koilonychia and no lower limb edema.

Vital signs
• Blood pressure= 110/84 mmHg
• Pulse rate= 84 beats per minute
• Respiratory rate= 18 breath per minute
• Temperature= 37.1C
SYSTEMIC EXAMINATION

PER ABDOMEN
Obese abdomen, no surgical scars, no traditional marks, umbilicus is slightly
retracted and inverted. Soft abdomen, non-tender, no palpable organ,
tympanic percussion notes and normal bowel sounds heard
Pelvic examination
Has normal female pattern hair distribution, normal external female
genitalia, no any lesion is visible. Speculum was done and showed some
clots on the external cervical OS and no active bleeding from the cervix.

RESPIRATORY SYSTEM
Normal chest contour, symmetrical chest movement, no any visible scar or
skin lesion. Two breasts in their normal position, no discharge seen. No area
of tenderness, no palpable mass in the two breasts, normal tactile vocal
fremitus, symmetrical chest expansion and trachea is in normal position.
Resonant percussion notes, bilateral equal vesicular breath sounds.

CARDIOVASCULAR SYSTEM
Warm extremities, normal capillary refill (<2 sec), radial pulse of 84 b/min,
which is of strong volume, regular, synchronous with left radial pulse. And
the radial pulse is none collapsing. Blood pressure of 110/80 mmHg. No
distended jugular venous pressure (JVP). No precordial hyperactivity, no
precordial bulging, apex beat at 5th intercostal space along mid-clavicular
line. No thrills, S1 and S2 heard, no added sound.

CENTRAL NERVOUS SYSTEM

Higher Centers: Conscious, Oriented to time, place and person. Normal
speech, long and short- term memory intact
Cranial Nerve examination:
 CN I: Can smell normally
 CN II: Can see, both pupils present and equally reactive to light.
 CN III, IV & VI: Can move eyes in all directions, no strabismus or
diplopia
 CN V: Can feel the sensation (pin prick and cotton wool) at
ophthalmic, mandibular and maxillary area and can clench the
teeth.
 CN VII: Can form wrinkles, can close eyes against resistance,
symmetrical facial smile and can puff out cheeks
 CN VIII: able to hear with both whispering sound and vibration in
right and left ears
 CN IX & X: can swallow, no uvula deviation, has normal gag
reflex
 CN XI: Can shrug shoulders and turn the head against resistance
 CN XII: no tongue fasciculation, can protrude the tongue without
deviations
Sensory function
 Light touch, proprioception, vibration and pin prick sensation are
normal in both upper and lower limbs
Motor function.Upper and Lower Limbs
 Normal muscle bulkiness, no fasciculation or tremors, normal
muscle tone, power of 5/5 in all groups of muscles, normal deep
tendon reflexes and normal gait.
Co-ordination
 Normal heel-shin test, normal finger nose test.

SUMMARY
This is S.K 17-year-old female, Primegravida, LMNP was 13/11/2020,
Came with chief complaints of per vaginal spotting for 2 weeks and
cramping abdominal pain for 2 days. No history of passage of tissues per
vaginally, fevers, loss of consciousness, no convulsion.
On speculum examination there is some clots on the external cervical OS
and no active bleeding from the cervix.

PROVISIONAL DIAGNOSIS
• Incomplete abortion
DIFFERENTIALS
• Un raptured ectopic pregnancy

INVESTIGATIONS
• Full blood count- Hb, WBC and platelets
• Serum B-hCG
• Blood group and cross match
• Obstetric ultrasound
 • Serum electrolytes

RESULTS AND INTERPRETATION

Full blood picture
• WBC= 6.92 X 109/L- normal
• HGB= 13.1g/dl- normal
• HCT= 39.9- normal
• Platelets= 186 X 109/L - normal
• MCV= 85- normal
• MCH= 28- normal B-hCG= 750- elevated
Serum electrolytes
• K= 3.6- normal
• Na= 149- elevated
• Cl= 104- normal
• Ca= 2.18- normal Ultrasound results
TREATMENT

CASE REPORT 5

NAME: RM
AGE: 28 years old
SEX: Female

OCCUPATION: Teacher

RELIGION: Christian

MARITAL STATUS: Single

ADMITTED ON: 24/02/2021

PARITY: G2 P1 L1

LNMP: 15/11/2020
GA: 14 weeks + 3 days by dates

CHIEF COMPLAINTS
Persistent vomiting for 2 months

HISTORY OF PRSENTING ILLNESS

2 months ago, the patient started to experience nausea and vomiting after she
got pregnant. In the first few days she had few episodes of vomiting but the
frequency was increasing with time such that she had more than 8 episodes
of vomiting per day. The vomiting is not projectile in nature and she vomits
food particles and sometimes she has yellow vomitus. The vomiting is
aggravated by food intake and not relieved with any medication. The
vomiting is associated with heartburn and constipation the vomiting is
severe such that it interferes with her normal feeding behavior because she
has loss of appetite also feeding triggers vomiting episodes. Also, the
vomiting has impaired her other social and occupational functioning since
she cannot carry on her activities normally. The vomiting has impaired her
feeding such that she has lost 6 kg of body weight. The vomiting is
associated with general body weakness but there is no history of fever, no
history of headache, no history of loss of consciousness and no history of
abdominal pain.
This is the second admission at KCMC due to the severe vomiting, the last
admission was in January this year whereby the vomiting was controlled
after 5 days of admission and she was discharged uneventfully. There is no
history of severe nausea and vomiting in the previous pregnancy also there is
no history of severe vomiting during pregnancy in the family.
However, there is no history of bleeding per vagina, no history of passing
tissues or any abnormal discharge per vagina.

REVIEW OF OTHER SYSTEMS

RS- no history of difficulty in breathing, no history of chest pain, no history
of cough.

CVS-no history of awareness of heartbeat, no history of difficulty in

breathing on lying flat, no history of lower limb edema

GUS- no history of painful urination, no history of blood in urine

HISTORY OF INDEX PREGNANCY
The patient booked at antenatal clinic at gestational week of 8 weeks and has
affected two attendances so far. She was screened for malaria and HIV,
which were negative. Her BP was 125/70 and 130/80mmHg during the first
and last visit respectively with last hemoglobin level was 11.4 g/dl.

PAST OBSTETRIC HISTORY

She is G2P1L1, in 2016 first baby delivered by SVD 3.2 kg female with no
any complication.

PAST GYNECOLOGAL HISTORY

She had menarche at the age of 14 years her menstrual circle is normal
monthly circle and she was bleeding for 4-5 days. She changes 3 to 4 pads,
which are moderately soaked. She has no history of painful menstruation.
She has no history of contraceptive use, history of sexually transmitted
disease or history of gynecological surgery.

PAST MEDICAL HISTORY

 No history of blood transfusion
 No history of admission due to other illness apart from this one.
 No history of surgery
 No history of chronic illnesses such as diabetes, hypertension or
asthma.
 No known drug or food allergy.
FAMILY AND SOCIAL HISTORY.
She is 8th daughter out of 9 children married living with her husband and one
female child she is a teacher with degree graduate in bachelor of education.
Her husband is a Businessman.
She neither smokes nor takes alcohol-her medical expenses are being
covered by NHIF.

SUMMARY I
A 28-year-old female patient, G2P1L1, GA 14 weeks + 3 by dates presents
with intractable nausea and non-projectile vomiting. It is associated with
heartburn and constipation.no history of fever, no history of headache.

EXAMINATION FINDINGS
GENERAL EXAMINATION
Ill looking, lethargic, not dyspneic, not jaundiced, not pale, no sunken eyes,
not dehydrated (normal skin turgor).
Normal hair color, texture and distribution, no conjunctival pallor, no scleral
jaundice, no nasal or ear discharge, no oral lesions, no palpable lymph
nodes, no palmar pallor, no lower limb edema.
Vital signs:
BP = 118/77mmHg,
PR = 89bpm,
T = 36.8C,
RR = 18 cycles per minutes.

Per abdomen
Distended abdomen, moves with respiration, flat umbilicus, no distended
veins, no surgical scars, non-tender abdomen.

CARDIOVASCULAR SYSTEM
No splinter hemorrhage, no finger clubbing, capillary refill is less than 2
seconds, radial pulse is palpable with normal strength, regular, normal
volume, synchronized with other peripheral pulses. No precordial
hyperactivity, apex beat located at 5th intercostal space mid clavicular line,
no apical or parasternal heaves, normal S1, S2 heart sounds, no basal
crepitation.

RESPIRATORY SYSTEM
Symmetrical chest expansion, no surgical scars, no traditional marks, trachea
is centrally located, no tenderness, no palpable mass. Palpable tactile vocal
fremitus, resonant note on percussion, bilateral air entry,

PROVISIONAL DIAGNOSIS:
 Pre term Pregnancy with Hyperemesis gravidarum

INVESTIGATIONS AND RESULTS

1. RFT
 BUN = 2.0
 Creatinine= 54.5
 Potassium= 3.5
 Sodium= 135
 Chloride = 107
2. FBP
 WBC = 9.9
 Hb = 11.0 g/dl
 Platelets = 226
3. USS
Single viable fetus, no fetal anomaly,
Placentation- fundal anterior. Adequate liquor.
Cervix- normal length
CONCLUSION: -the electrolytes (potassium and sodium) are in lower
limits of normal range.
SUMMARY II
G.C.M, 28-year-old female, G2P0+1L0 at GA of 20+2 by date and 16+5 by
USS was admitted due to persistent vomiting and abnormal USS results
from antenatal clinic at KCMC. On examination, she was ill looking,
lethargic, not pale, not jaundiced, not dehydrated with a fundal height of
18cm. In the ward, the vomiting was controlled and she had cervical
cerclage on the 4th day of admission and was discharged after three days of
bed rest.

Definitive diagnoses
Hyperemesis gravidarum

MANAGEMENT
• Fluid Therapy: NS/RL 1.5L maintenance
• Antiemetic- ondansetron 4mg iv PRN
• Bed rest and frequent feeding of snacks

CASE REPORT 6
NAME: AM
AGE: 37 years old

SEX: Female

OCCUPATION: Teacher

RELIGION: Christian
MARITAL STATUS: Married

ADMITTED ON: 02/03/2021

PARITY: G4 P3 L3

LNMP: 14/09/2020
GA: 24 weeks + 1 days by dates

CHIEF COMPLAINT
Headache for 7 days.

HISTORY OF PRESENTING ILLNESS

The patient was apparently well until 7 days prior to the admission when she
started experiencing a sudden onset of headache, it was on and off throbbing
in nature, increasing in severity with time, more on the frontal part, no
periodicity, no aggravating factors stated but the patient tried to use
paracetamol with no relief. It was not associated with blurred vision,
convulsion, confusion and no history of fever.
The patient reported to have no history of difficulty in breathing, coughing
or chest tightness. She reports the history of epigastric pain but had no
nausea, vomiting, diarrhea or constipation. She reported to have normal
urine output, frequency, no froth urine, passing blood in urine, history of
painful urination micturition, but has history of lower limb swelling. She has
no history of vaginal bleeding or vaginal discharge. She had heartbeat
awareness, easy fatigability but no history of dizziness.
The patient reported to have history of raised blood pressure in the third
pregnancy (4 years ago), there is positive maternal family history of raised
blood pressure during pregnancy as her mother had the same condition, she
is not diabetic, no family history of diabetes mellitus, no history of head
trauma, and no history of cigarette smoking.

REVIEW OF OTHER SYSTEM

ENT- She has no history of abnormal discharge, pain or bleeding from ears
or nose and no difficult in swallowing.

OBSTETRIC HISTORY
Index pregnancy
This is her fourth pregnancy, she booked antennal clinic (ANC) at 14th
week, had 4 visits, she reported high blood pressure to be noted since her
first ANC visit but no medical intervention was instituted. Her blood
pressure trends were 150/90, 145/95 and 148/90. PMTCT 2 and VDRL
which were non-reactive, her last Hb was 11.9. She has received anti-
malarial, haematenics, and ant-helminthic.

Past obstetric history

In 2013, she delivered her first baby by spontaneous vaginal delivery (SVD)
a 3.6 kg at term and no complications encountered during labor and delivery
In 2008 and 2011 delivered 3.5 and 3.7kg respectively both by SVD and no
any complication encountered.

PAST GYNECOLOGICAL HISTORY

She attained menarche at 13 years old, regular; she has an average length of
28 days with 4 days of menstruation and reported to use 3 pads per day
which are partially soaked. She has no history of experiencing severe
menstrual pain or bleeding in between her cycle. She has no history of using
any contraceptive method and she has no history of abortion.

PAST MEDICAL HISTORY

She has history of previous admission due to pregnancy during deliveries.
No history of other chronic illness such as diabetes, asthma or epilepsy. She
has no history of surgery or history of blood transfusion and no known
history of drug or food allergies.

FAMILY AND SOCIAL HISTORY

She is married and living with her husband. She has 3 living children. She is
educated to collage level and she works a primary school teacher. Her
husband works as driver. There is no known history of hereditary diseases
other than hypertension such as diabetes, asthma or malignant conditions or
epilepsy in first-degree family members.
She doesn’t smoke or drink alcohol, she is insured by NHIF.

SUMMARY II
A.E.M, 37 years old female from Pasua, G4P3L3 at 24 weeks + 1 day GA, a
known hypertensive patient for 4 years on irregular medications presented
with headache for 7 days prior to the admission. She has history of epigastric
pain but no convulsion. There is positive previous history of pregnancy-
induced hypertension and in the family.
ON EXAMINATION

GENERAL EXAMINATION
She is conscious, well oriented, not ill looking, well nourished, normal hair
texture and distribution, not pale, not jaundiced, no abnormal discharge per
ears or nose, no angular stomatitis, no oral thrush, normal buccal cavity, no
palpable peripheral lymph nodes, no finger clubbing, no koilonychias, but
she has pre tibial lower limb edema.
Vital signs
 Blood pressure = 130/85 mmHg
 Pulse rate = 88 beats/min
 Respiratory rate = 17 breaths/min
 Temperature = 37.1 centigrade

PER ABDOMEN EXAMINATION

She has distended gravid abdomen, moves with respiration, has linear
gravidarum and striae gravidarum present, no surgical scar or skin lesion, no
area of tenderness, both kidneys are not ballotable, spleen and liver not
palpable, fundal height is 25 cm, singleton fetus palpable,

Leopold maneuver; the fetus is longitudinal lie, at the fundus there are soft
like mass palpated that are in consistency with fetal buttocks, a firm uniform
longitudinal that is consistent with fetal back palpated on the left side of the
mother, multiple digits in consistent with fetal hands and feet palpated on
the mother`s right side, a round hard that is ballotable and in consistent with
fetal head palpated at the hypogastrium. Fetal heart rate is 152 beats/min.

Pelvic examination
She has normal female pattern hair distribution, normal external female
genitalia and no any lesion. There is no vaginal bleeding or discharge.

RESPIRATORY EXAMINATION
She has normal chest contour, symmetrical chest movement, no any visible
scar or skin lesion. There is no area of tenderness, no palpable mass, normal
tactile vocal fremitus, symmetrical chest expansion and trachea is in normal
position. Resonant percussion notes, equal air entry bilaterally and vesicular
breath sounds heard.

CARDIOVASCULAR EXAMINATION
She has warm extremities with normal capillary refill, radial pulse of 88
beats/min, has good volume, regular, non-collapsing, synchronous with left
radial pulse. Blood pressure of 130/85 mmHg. No distended jugular venous
pressure (JVP). No precordial hyperactivity, no precordial bulging, apex
beat at 5th intercostal space along mid- clavicular line. No thrills, no heaves,
First and second heart sounds heard, no murmurs.

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher Centers: She is conscious with GCS of 15, Well oriented to time,
place and person. Has normal speech, and has intact long- and short-term
memory.
Cranial Nerve examination:
 CN I: Can smell normally.
 CN II: Can see, both pupils present and equally reactive to light.
 CN III, IV & VI: Can move eyes in all directions, no strabismus or
diplopia.
 CN V: Can feel the sensation (pin prick and cotton wool) at
ophthalmic, mandibular and maxillary area and can clench the teeth.
 CN VII: Can form wrinkles, can close eyes against resistance,
symmetrical facial smile and can puff out cheeks.
 CN VIII: able to hear with both whispering sound and vibration in
right and left ears.
 CN IX & X: can swallow, no uvula deviation, has normal gag reflex.
 CN XI: Can shrug shoulders and turn the head against resistance.
 CN XII: no tongue fasciculation can protrude the tongue without
deviations.
Sensory system
She can sense light touch, has intact proprioception, vibration and pin prick
sensation are normal in both upper and lower limbs

Motor system
Normal muscle bulkiness, no fasciculation or tremors, normal muscle tone,
power of 5/5 in all groups of muscles, normal deep tendon reflexes and
normal gait on both upper and lower limbs
Co-ordination system
Normal heel-shin test, normal finger nose test.

SUMMARY II
A.E.M 37 years old female from Pasua, G4P3L3 at 24 weeks + 1 day GA, a
known hypertensive patient for 4 years on irregular medications presented
with headache for 7 days prior to the admission. She has history of epigastric
pain but no convulsion. There is positive previous history of pregnancy-
induced hypertension and in the family. On examination, he is full
conscious, not pale, has bilateral pre tibial lower limb edema, FH- 25/40,
FHR- 152 beats/min and BP 130/80 mmHg.
PROVISIONAL DIAGNOSIS
1. Chronic hypertension with superimposed pre-eclampsia with severe
features.

INVESTIGATIONS AND RESULTS

1. Urine for protein= 2+
2. Full blood picture
 WBC = 9.71x109/L (Normal)
 Neutrophil = 7.09x109/L (Normal)
 Eosinophil = 0.225x109/L (Normal)
 Platelets = 336x103u/L (Normal)
 HGB = 11.2g/dl
3. Renal fuction tests
  BUN= 2.5
 Cr= 58.8
4. Liver function tests
 AST- 8 (N),
 ALT- 4 (N)
5. Serum electrolytes
 Ca- 1.95(L),
 K- 3.2 (L),
 Na – 140meq/L (N)
6. Serum uric acid- 0.2916 (N)
7. Blood slide for malaria parasite - Negative
8. Obstetric ultrasound
 It showed a singleton fetus with variable lie, fundal posterior far from
the OS, adequate liquor volume seen, Regular fetal heart rate
(160bpm). Gestation age of 25 weeks.
Conclusion:The patient has proteinuria, no features suggestive of HELLP,
has normal ultrasound scan, no oligohydramnios
FINAL DIAGNOSISChronic hypertension with superimposed pre-
eclampsia with severe features.

TREATMENT
• For blood pressure control
Tabs Nifedipine 20mg 12hourly for 2/52 • Tabs Methyldopa
500mg 8 hourly for 2/52
• For seizure prophylaxis •
IV MgSO4 1g hourly for 24 hours
 • Haematenics
Tabs Ferrotone 1tab daily for 1/12
• Other management (Non pharmacological)
Ensure bed rest
Aim to deliver the mother at least at 37 weeks of GA
Monitor daily fetal kicks count • Monitor blood pressure, urine
output
PROGRESS IN THE WARD;
The patient is doing well in the ward, the headache has now subsided, she
still feels the fetal movements, had ultrasound done that showed a single live
fetus. She is currently using nifedine, methyldopa, ferrotone and her blood
pressure is now well controlled as it is within the normal ranges.

OUTCOME
• The patient stayed in the ward for 15 days then discharged home as blood
pressure has already stabilized and symptoms subsided. The patient has been
instructed to attend her ANC as per schedule or return to hospital
immediately if the conditions worsens for both maternal and fetal conditions
like diminishing of fetal kicks.