OB-GYN NEW CASE

CONFERENCE

CASE I

HISTORY
Case female 56 yr
Chief Complaint: 1
Present illness:
7

1 Lt>Rt

N/V

HISTORY
OB-GYN history
P2002, Menopause 7 yr
Last SI 7 days ago
Last PAP smear Jan,2015 normal
Past illness
No U/D, No allergy
Personal history
No alcohol drinking, No smoking

Family history
No history of malignancy in family

PHYSICAL EXAMINATION
General appearance: A middle-aged woman with normal
consciousness
V/S: T 38.9 C, PR 88/min, RR 18/min, BP 99/65 mmHg
HEENT: no pale conjunctivae, no icteric sclerae
Lungs: clear, equal breath sound both lungs
Heart: regular, normal S1S2, no murmur
Abdomen: normal contour, active bowel sound, soft,
marked tenderness without guarding at suprapubic & LLQ,
rebound tenderness negative, no palpable mass

PHYSICAL EXAMINATION
Extremities: no edema, CRT<2 sec, pulse full
PV:
IUB: normal
Vg: mucopurulent discharge
Cx: no gross lesion, mucopurulent discharge per os,
cervical motion tenderness postive
Ut: Normal size, moderated tenderness
Adx: moderated tenderness Lt>Rt, no mass

CASE I
Impression: Acute PID

Plan:
Admit for IV antibiotic
Supportive treatment

MANAGEMENT
Order for one day
Admit Gyne
CBC
BUN,Cr,elyte
H/C II specimens
Cervical discharge G/S,
C/S

Order for continuous

Soft diet
Record V/S
Med
Clindamycin 900 mg IV q
8hr
Gentamicin 240 mg IV
OD
Paracetamol(500) 1 tab
oral prn fever q 6 hr

CASE II

HISTORY
Case female 22 yr
Time of Admission 6 PM
Chief Complaint: 3
Present illness:
Case G2P0010 GA 39+4 wk/US
3

HISTORY
OB-GYN history
G2P0010 abort due to molar pregnancy last 2 yr, GA
39+4 wk/US
First ANC at GA 12 wk/LMP
At GA 26 wk/LMP size<date US GA 24+3 wk/US
F/U GA by US
Lab I,II normal
Thalassemia screening: no risk( MCV 88, DCIP neg)
BP 95-110/55-70 mmHg, urine albumin/sugar negative
Prepregnancy BMI 18.75, TWG 12 kg(4860 kg)
Total ANC 8

HISTORY
Past illness
No U/D, No allergy, No history of surgery
Personal history
No alcohol drinking, No smoking

PHYSICAL EXAMINATION
General appearance: A young woman with normal
consciousness
V/S: T 36 C, PR 80/min, RR 18/min, BP 100/70 mmHg
HEENT: no pale conjunctivae, no icteric sclerae
Lungs: clear, equal breath sound both lungs
Heart: regular, normal S1S2, no murmur
Abdomen: FH 37 cm, Vertex, ROA
160/min
Extremities: no edema, CRT<2 sec

PHYSICAL EXAMINATION
PV: 1 cm, 25%, -1, MI
UC: duration 1/10 , interval 30 , mild intensity

CASE II
Impression:
G2P0010 GA 39+4 wk/US with mucous bloody show in
latent phase of labour
Plan:
Go on labour