Faculties:

Dr.AnnammaThomas
Dr.ManjulaS.K.
Dr.JayashreeKanavi
Dr.ShobhaG
Dr.Kavitha
Dr.Shivani
Dr.Deepa

St.JohnsMedicalCollegeHospital,Bangalore560034

DepartmentofObstetricsandGynecology
UNITIII
DISCHARGESUMMARY
NAME
IP.NO
OPNO.

RINKUAGARWAL
1192431
3407817

WARD
AGE
SEX

OBGIII
24Yrs
F

DOA
DOD

30/9/15
3/10/15

Final Diagnosis:24yearoldprimiat6+3wksofGAwithhypothyroidism/threatenedabortion
History of presenting complaints:H/opainabdomenonandoffx10daysandassociatedwith
constipation, not associated with nausea, vomiting or bleeding PV. Pain subsides on its own but
sinceyesterdaypainpersistsandincreasinginintensity.Noh/odysuria/fever
H/oWDPV,moderateamount,nonfoulsmelling,notassociatedwithitchingorpainfullesionover
vulvalregion.Noh/otrauma,heavyweightlifting,climbingupstaircase.Constipationrelieved
withsyp.Duphalaconandoff

Menstrual History:PMC5/30,regular,normalflow,LMP15/8/15,EDD21/5/16,
OB H:ML1year,NCM
G1:Presentpregnancy,spont.conception
Past History:K/c/ohypothyroidismontreatmentLT4100mcgx8months
Noh/oDM/HTN/allergy/asthma/TB/cardiacdisease/seizuredisorder
Family History:Noh/oDM,HTN,thyroiddiseaseorcardiacdisease.
Personal History:Sleep/appetitenormal.Bowel/bladderregular
O/E: Pulse:80/min,BP:120/70mmHg,RR16/mt,TempAfebrile
Nopallor/icterus/cyanosis/lymphadenopathy/oedema
Breast/Thyroidnormal

CVS/RSNAD
P/A:Soft,nontender,
P/S:Profusewhitishdischarge+
P/V:Uterus6wksmobile,NT,Nocervicalmotiontenderness

Investigations:BloodgpBpositive,HIV/HBsAgnegative,VDRLNR
21/4/15TSH0.448,FT41.28,AntiTPO>1300
23/9/15TSH0.629
30/9/15Hb12.6
UrineR/MSug/Albnil,RBC1,WBC5,Bact158
1/10/15FBS66
30/9/15Cervicalswabc/snogrowth
SCAN
30/9/15(6+3)
SLIUFAT6+1Wk,nosubchorionicbleednoted,FHR132,InternalosclosedEDD24/5/16,.

Discussion:24yearoldprimiat6+3wksofGAwiththreatenedabortion/hypothyroidismwas
admitted with above mentioned complaints. All necessary investigations done, managed
conservativelywithInj.ProlutondepotfollowedbyT.Susten.OnP/Sfoundtohaveprofusewhite
discharge.PatientwastreatedwithCandidV3.Patientwasimprovedsymptomatically,currentlypt
isstableandfitfordischarge.
Advice on Discharge:
T.Thyronorm100mcg100Xtocontinue
T.Folicacid5mg101Xtocontinue
T.Susten200mg101Xtocontinue
Syp.Duphalac2tspBDX1week

Review after 2 week in OBG III OPD on Wed/Sat

Plan: NT scan at 12 weeks