Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

Trainee’s Name: ID No.:

Module Specialty: Date:

Mentor / Instructor:

1. A 21-year-old patient 23 weeks of gestation was admitted due to excessive vomiting.

Principal Diagnosis O21.2

Additional Diagnosis O09.3

2. A patient of her 6 weeks of pregnancy has had a complete spontaneous miscarriage, without
complication.
Principal Diagnosis O03.9
Additional Diagnosis O09.1

3. Laceration of cervix following abortion performed two days ago at another hospital.

Principal Diagnosis O08.6

4. Incomplete abortion complicated by air embolism.

Principal Diagnosis O06.2

Additional Diagnosis O08.2
Additional Diagnosis O09.9

5. A patient has been admitted due to an ectopic (fallopian) pregnancy. She is 6 weeks pregnant
and the pregnancy must be terminated. 

Principal Diagnosis O00.1

O08.9
Additional Diagnosis O09.1

FATEN F. KEHAIL 1
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

6. Patient admitted for suction D&E (GA ASA 2) for termination of pregnancy at 15 weeks due to
chromosomal abnormality in fetus.

Principal Diagnosis O04.9

Additional Diagnosis O09.2
Additional Diagnosis O35.1
Principal Intervention 35643-03[1265]
Additional Intervention 92514-29[1910]

7. Patient admitted for termination of pregnancy at 19 weeks due to fetal anencephaly.

Principal Diagnosis O04.9

Additional Diagnosis O09.2
Additional Diagnosis O35.0

8. Patient admitted for hemorrhage in early pregnancy.

Principal Diagnosis: O20.9

9. Patient admitted at 25 weeks’ gestation with diagnosis of fetal death in utero (FDIU). Medical
and surgical induction of labor.

Principal Diagnosis O36.4

O04.9
O80
Additional Diagnosis O60.3
Additional Diagnosis O09.3

FATEN F. KEHAIL 2
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

Additional Diagnosis Z37.1

90465-05[1334]

10. Patient with 6 weeks of gestation admitted with anembryonic pregnancy, patient diagnosed
with blighted ovum.

Principal Diagnosis O02.0

Additional Diagnosis O08.8
O09.1

11. A 36 weeks of gestation patient was admitted for irregular uterine tightening, patient diagnosed
for false labor.

Principal Diagnosis O47.0

Additional Diagnosis O09.5

12. Ruptured tubal pregnancy at 8 weeks with salpingitis.

Principal Diagnosis O00.1

Additional Diagnosis O08.0
Additional Diagnosis O09.1

13. A patient was admitted for an elective lower segment CS at 39 weeks due to breech
presentation. A low vaginal swab was taken and was positive for streptococcal group B.
Patient was commenced on prophylactic antibiotics. A healthy live male infant was delivered.

Principal diagnosis O82

Additional diagnosis  O64.1
Additional diagnosis  Z22.3
Additional diagnosis Z29.2
Z37.0

FATEN F. KEHAIL 3
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

16520-02[1340]

14. Thrombophlebitis of legs in pregnancy.

Principal diagnosis O22.9

I80.3

15. Ruptured tubal with 4 weeks’ pregnancy.

Principal Diagnosis O00.1

O08.6
Additional Diagnosis O09.0

Discharge Summary 1

Significant Physical and Other Findings:

A 30-year-old G5P4 woman at 36 weeks’ gestation complains of significant bright red vaginal
bleeding. She denies uterine contractions, leakage of fluid, or trauma. She experienced some vaginal
spotting since 4 weeks. Patient diagnosed with placenta Previa, delivered by emergency lower
segment cesarean section under GA ASA 3E.

Examination:
Blood pressure is 110/60 mm Hg,
Heart rate (HR) is 80 beats per minute (bpm), and
Temperature is 99°F (37.2°C).
The heart and lung examinations are normal. The abdomen is soft and uterus nontender. Fetal
heart tones are in the range of 140 to 150 bpm.

Hospital Course: LSCS.

Patient's Condition at the time of Discharge:
Stable.

Follow-Up instructions:

FATEN F. KEHAIL 4
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

OPD Dra. Randa as planned.

Sick Leave:
No.

Principal / Additional Code(s)

Principal Code O44.1
Additional Code O82
Additional Code O60.3
Additional Code O09.5
Z37.0
Principal Intervention 16520-03[1340]
92514-30[1910]

Discharge Summary 2

Significant Physical and Other Findings:

Patient admitted for termination of pregnancy at 28 weeks due to anencephaly. Outcome

Single stillborn.

Diagnosis: anencephaly.
Patient's Condition at the time of Discharge:
Stable.

Follow-Up instructions:
OPD Dr. Ashraf as planned.

Sick Leave:
No.

Principal / Additional Code(s)

Principal Code O35.0

Additional Code O04.9

Additional Code O80

FATEN F. KEHAIL 5
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
King Abdullah Medical City ‫مدينة الملك عبد هللا الطبية‬
Health Training Administration ‫إدارة التدريب الصحي‬

Additional Code O60.3

Additional Code O09.4

Z37.1

FATEN F. KEHAIL 6