09/08/2021  

First name: Dike Last name: Obiora-Eze course 6 group 35

Passport Data
Name:- Annie Leonhart
Age:- 32 years old

History
Patient arrives at hospital because of complaint(vaginal
spotting). She’s pregnant with 30 weeks of gestational
age. This is currently her 2nd pregnancy.
At 12years of age, menarche happened and it’s cycle is
about 20-29days with 5 days of flow.
The pregnancy doesn’t have any complications.

Physical Examination
- Normal uterine tonus
- Head presentation, anterior variety, 2nd position was
revealed during Leopold’s maneuver
- Pelvic size measurements
o Distance spinarum- 25cm
o Distance cristarium- 28cm
o Distance trochanterica- 32cm
o Lateral conjugate- 15cm
o Oblique conjugate- 21cm

Plan of investigation
- CBC- normal.
- Biochemical blood analysis- normal.
- Abdominal ultrasound- revealed that placenta is
localized in the anterior wall of the
uterus.
- Speculum examination reveals polyp of cervical canal.

Diagnosis
30 weeks of gestation, cervical presentation, anterior
variety, second position, polyps of cervical canal.

Treatment
- Using polyp forceps to gently twist and remove the
polyp tissue
- Rp .: "Ibuprofen" 400 mg 
D.td No. 20 in tabl. 
S. 1 tablet 2 times a day 
- Rp: "Acetaminophen" 500 mg
D.t.d. №500 in tab.
S. 1 table. 2 times a day