Case Book Roderick Final

OBSTETRICS & GYNAECOL-
OGY
CASE BOOK
Bachelor of Medicine & Surgery
ANTHONY, RODERICK BASIL N. A.
10657862
Group D (Junior clerkship)

Group E (Senior Clerkship)
ANTHONY, RODERICK BASIL N. A 1

Table Of Contents
ELECTIVE MAJOR SURGERY 3

EMERGENCY LAPAROTOMY 20
MANUAL VACUUM ASPIRATION 32
INFERTILTY 42
FAMILY PLANNING 50
LABOUR CASE 1 60
LABOUR CASE 2 65
LABOUR CASE 3 70

ELECTIVE MAJOR SURGERY
ADMISSION NUMBER- AAV 0191
NAME - Madam D. A.
AGE - 53 years
PARITY - P 3+2
L.M.P - 10 years ago
DATE OF ADMISSION - 24th May, 2022
DATE OF DISCHARGE - 10th June, 2022
HISTORY
PRESENTING COMPLAINT - bleeding per vaginum - 6

months ago.
HISTORY OF PRESENTING COMPLAINT -
Patient was in her usual state of health until 6 months ago

when she experienced heavy vaginal bleeding after 10 years
of amenorrhoea. She became very concerned and informed
her daughter who is a pharmacist who advised her to do a
pelvic scan, which she did of which she was told it was a
small fibroid. She then sent the scan to a peripheral hospital
where upon evaluation, an endometrial biopsy was done.
Days following the biopsy, she began to loose appetite, began
feeling nauseous and was vomiting. The vomitus as clear, was
unable to quantify the vomitus despite various comparisons,

vomiting occurred at anytime throughout the day, was not
blood stained initially, however after some few days, the vom-
itus became blood stained. The vomiting was not related to
meals. In addition, there was still bleeding per vaginum which
had now become foul smelling. She then returned back to the
peripheral hospital, where she was admitted and managed ap-
propriately for a week. She was then referred to Korle-Bu
Teaching Hospital for further management. She has been
coming for reviews at the Gynae OPD, and a curettage was
done for her 2 weeks ago and was booked for an elective
surgery on the 25th of May, 2022.
ON DIRECT QUESTIONING -
The bleeding was heavy, had clots of about 50 pessewa coin,

she wore adult diapers which were heavily soaked, there was
a history of flooding. There was dizziness, palpitations, gen-
eral body weakness and easy fatiguability. There was no feel-
ing of a mass, no known family history of fibroid. Her menar-
che was at 14 years and her menopause was at 43 years. She’s
lost weight, there was no night sweats or abdominal bloating.
There is no history of estrogen replacement therapy. There is
no known family history of breast cancer, ovarian cancer, col-
orectal cancer or endometrial cancer She is not diabetic or
hypertensive.
SYSTEMIC ENQUIRY -
Cardiovascular system - There was no chest pain, no dyspnea,

no orthopnea or paroxysmal nocturnal dyspnea.
Respiratory system - She had no cough or wheezing.

Gastrointestinal system - She had no change in bowel
movements.
Genitourinary system - There was no dysuria, frequency or

hematuria.
Central nervous system - She had no headache or seizures.
Musculoskeletal system - She had no muscle ache or joint

pain.
PAST MEDICAL HISTORY -
She was admitted to Lekma hospital 3 months ago of which

she was there for a week. She was given IV fluids and 1 unit
of blood was transfused.
She has had no surgery.
DRUG HISTORY -
She takes 1 vial of Tot‘hema - twice a day
She takes vitamin C(1000mg) - once a day
GYNAECOLOGICAL HISTORY
Her menarche was at 14 years . She bled for 7 days. There

was secondary dysmenorrhea. She passed clots of about 5
pesewa coin. She had no intermenstrual bleeding

Her Coitarche was at 17 years. Her number of life time sexual
partners is 2. She has no post-coital bleeding or dyspareunia.
Contraceptive History - she has used secure oral con-

traceptive, however still got pregnant because she was not
compliant.
Her partner does not use condom.
Self breast examination - She doesn’t perform self breast

examination.
Pap smear - She has not done a Pap smear.
She has no history of sexually transmitted infection.
She’s had no past gynaecological surgery.
OBSTETRIC HISTORY ( She’s P3+2 )
Her first pregnancy was in 1989. The pregnancy was planned

and welcomed. She realized she might be pregnant when she
missed her period and the pregnancy was confirmed via an
ultrasound. She was a regular attendant at ANC which was
uneventful. She carried the pregnancy to term and delivered a
live baby girl via spontaneous vaginal delivery. She was not
sent to NICU. She did not breastfeed exclusively.
Currently, she is doing well and working as a pharmacist.
Her 2nd pregnancy was in 1991. The pregnancy was planned

missed her period and the pregnancy was confirmed via an ul-
trasound. She was a regular attendant at ANC. However, at 5

month of pregnancy, there was a miscarriage. The fetus was
dead in utero.
Her 3rd pregnancy was in 1994. The pregnancy was planned

trasound. She was a regular attendant at ANC which was un-
eventful. She carried the pregnancy to term and delivered a
live baby girl via spontaneous vaginal delivery. The baby was
not admitted to NICU. She was not exclusively breastfed. She
is currently doing well and 28 years of age.
Her 4th pregnancy was in 2007. The pregnancy was planned

trasound. She was a regular attendant at ANC which was un-
eventful. She carried the pregnancy to term and delivered a
live baby boy via spontaneous vaginal delivery. He was not
admitted to NICU. He was not exclusively breastfed. He was
fine until at age 10, died while swimming at a beach.
Her 5th pregnancy was unplanned and unwelcomed in 2014.

She had a medical termination at 8weeks of pregnancy. There
was no post-proceedure complication.
FAMILY HISTORY
Mother is a known hypertensive and alive.
SOCIAL HISTORY

Lives at Teshie with her first child. She completed Form 4.
She is a trader.
She is a widow. However, she has a partner now who is 60
years old and works as a driver at Tema port. She is Christian.
She is willing to accept blood transfusion if the need be. She
has an active National Health Insurance Scheme. She neither
smokes nor drink alcohol.
SUMMARY
I present Madam D. A, 53 year old P3+2, who is 10 years

postmenopausal who presented with bleeding per vaginum 6
months ago.
She was symptomatic of anemia. There was no feeling of an
abdominal mass, she lost weight, had bouts of vomiting and
had a curettage done 2 weeks ago.
PHYSICAL EXAMINATION
General examination - I examined an elderly woman who laid

comfortably in bed and was well looking. She was not in any
obvious respiratory distress. She was not jaundiced or pale.
She had no peripheral or central cyanosis. She had no anterior
neck swelling, lymphadenopathy or edema.
Her height was 153cm with weight of 89kg. Her body mass
index is 38.02kg/m2, which is obese.
Breast examination - Her breasts were symmetrical. Her nip-

ples were everted. Her breast had no ulcers, visible nodules or
differential warmth. Her breast was not tender and no masses
were palpable. There was no nipple discharge or axillary lym-
phadenopathy.

Cardiovascular system - Her pulse was 84 beats per minute,
regular and of good volume. Her blood pressure was 110/84 .
Her JVP was not raised. Her chest had no deformities and her
apex beat was at the left 5th intercostal space mid-clavicular
line. She had no heaves or thrills. She had heart sounds 1 and
2, which were normal and she had no added heart sounds or
murmurs.
Respiratory system - Her respiratory rate was 16 cycles per

minute. Her trachea was centrally placed. She had no area of
tenderness on the chest. Her chest movement was adequate
and bilaterally symmetrical. She had a normal tactile fremitus.
She had adequate air entry and breath sounds were vesicular.
She had no added breath sounds.
Abdominal examination - Her abdomen was full moved with

respiration. Her umbilicus was inverted. She had no scars or
scarification marks. She had female hair pattern distribution.
There was no tenderness or masses felt. The liver edge was
not palpable. The spleen was not palpable and both kidneys
were not bimanually ballotable. Bowel sounds were present
and of normal frequency.
I could not do a pelvic examination because patient did not al-

low me to.
Central Nervous System - She was conscious and alert. She

had adequate tone, normal reflexes and power 5/5 on all
limbs. She had a normal gait as well.
CLINICAL IMPRESSION
Endometrial Cancer likely Obesity being the risk factor

INVESTIGATIONS AND RESULTS
The curettage results which was done 2 weeks ago

(8/05/2022)
• The comment of the histopathology report is as follows -
Tissue or site - endometrium

Macroscopically - Multiple endometrial fragments with aver-
age length of 0.2cm
Microscopically - The specimen was adequate with diagnostic

lesion as neoplastic and neoplastic type as malignant with his-
tological grading as poorly differentiated evidenced by nu-
clear pleomorphism, mitosis and solid in morphology. How-
ever lymph node involvement were not identified
Diagnosis given was high grade carcinoma likely Carcinosar-

coma.
She had a full blood count, BUE & Cr and Chest X-Ray done.
Below are the results
• Full Blood Count (FBC) - 20/04/2022
Haemoglobin - 9.5 g/dl
White blood cells - 8.23 x 10^9/L
Platelets - 751 x 10^9/L
• BUE/ Cr

Creatine - 0.6g/dl
eGFR - 129 ml/min > 90 ml/min
Urea(SI) - 2.3 mmol/L
• Chest X ray - It was taken in the posterior-anterior position.

All lung zones had normal lung markings, trachea was cen-
tral, no rib fractures and there was a normal cardiac silhou-
ette.
DIAGNOSIS
Endometrial Cancer
PRE-OPERATIVE MANAGEMENT
Patient was counselled for a total abdominal hysterectomy +

bilateral salpingoophrectomy. She had anaesthesia review and
did the above investigations. She was admitted a day before
the surgery. A thorough history was taken and she was re- ex-
amined. Her blood was taken for Full Blood Count as well as
for grouping and cross matching against two units of blood.
She then signed a consent form.
Full Blood Count (24/05/2022)
Hemoglobin - 11.6g/dl
White blood cells - 4.84 x 10^9 /L

Platelets - 250 x 10^9 /L
The following medications and items were requested and

brought by the patient;
• Tab Midazolam 7.5mg nocte and 7.5mg mane
• IV Amoxiclav 1.2g bd × 24 hrs
• Tab Amoxiclav 625mg bd × 7 days
• IV Flagyl 500mg × 24 hrs
• Tab Flagyl 500mg tid × 7 days
• Suppository diclofenac 100mg bd × 5 days
• Tranaxemic acid
• Gelafusine
• Subcutaneous Clexane 40mg daily × 3 after 12 hrs
• IV Paracetamol 1g 6 hourly
• Tab Paracetamol 1g tid × 3 days
• IM Pethidine 50mg 6 hourly
• IV fluids 3L ( 2L dextrose normal saline , 1L ringers lactate)
in 24hrs
OPERATION FINDINGS AND PROCEDURE

Operation - Total Abdominal Hysterectomy + Bilateral Salp-
ingoophrectomy + Infracolic omentectomy + Right Ureteric
Re-implantation.
Indication - Endometrial Cancer
Surgeon - Dr. H.
Assistant - Dr. N
Findings - The uterus was about 10 weeks size with fundal

perforation which was patched by omentum. The tumor ex-
tended over the right pelvic side wall.
The tubes and ovaries appeared normal. No tumor seedings on
the bowel or liver as well.
Proceedure - Under General Anesthesia, patient was cleaned

and draped. Abdomen was entered via a midline incision. A
total hysterectomy was done. The tumor that had extended
over the right pelvic side wall was excised which accidentally
injured the ureters. A ureter re-implantation was then done.
Her abdomen was then closed in layers with nylon 2 to fascia,
vicryl 1 to subcutaneous membrane and nylon 0 to skin. A JJ
stent was placed intrabdominally to drain the kidneys.
POST- OPERATIVE MANAGEMENT
The vitals were monitored quarter-hourly while on the recov-

ery ward till full recovery from anaesthesia.
The following requirements were also given accordingly:

• IV fluids 3L ( 2L dextrose normal saline, 1L ringers lactate)
in 24hrs
• IV Paracetamol 1g 6 hrly x 24hrs
• IV Amoxiclav 1.2g b.d x 24hrs
• IV metronidazole 500mg tds x 24hrs
• IM Pethidine 100mg 8hrly x 24hrs
• Suppository diclofenac 100mg b.d for 5 days
• Started SC Clexane 40mg daily after 24 hours.
• Fluid input and output was monitored with a chart.
POST-OPERATIVE DAY 1
She complained of pain at the incision site. She was asympto-
matic of anemia. She had passed flatus.
On examination, she looked in pain, she was neither pale nor
jaundiced. Her vitals were normal. Chest was clinically clear.
Abdomen was full moved with respiration, there was tender-
ness at the incision site. Wound dressing was clean and dry.
Bowel sounds were present and normal. The wound drained
about 30mls which was bloody.

Plan
She was to start oral sips. The urethral catheter was to be left
until further notice. She was to take 1 gram of paracetamol
tablet three times daily for 5 days, suppository diclofenac
100mg bd for 5 days, oral metronidazole 400mg tds for 7
days, oral amoxiclav 1g bd for 5 days, subcutaneous clexane
40mg daily for 3 days and encouraged to ambulate. She was
to be on a strict urine input and output chart.
Patient complained of pain at the incision site, in addition
complained of finding it a bit challenging ambulating because
of the urethral catheter and wound drain in-situ. She was
asymptomatic of anemia. On examination, she generally
looked well, she was neither pale nor jaundiced. Her vitals
were normal. Chest was clinically clear. Abdomen was full
moved with respiration, there was tenderness at the incision
site. Wound dressing was clean and dry. Bowel sounds were
present and normal. The wound drained about 10mls which

was bloody. Her urine output as at that morning was 200mls.
A 24-hour urine output was not recorded.
Plan
To maintain wound drain and urethral catheter.
She was to be on a strict urine input and output chart.
Patient had no complaints. She was asymptomatic of anemia.
On examination, she generally looked well, she was neither
pale nor jaundiced. Her vitals were normal. Chest was clini-
cally clear. Abdomen was full moved with respiration, there
was tenderness at the incision site. Wound dressing was re-
moved and the non-absorbable stitches still in place. The
wound was clean and dry. Bowel sounds were present and
normal. Her urine output over 24 hours was about 2,048mls.
Plan
She was to do a full blood count. The wound drain and ure-
thral catheter was still to be maintained.

Patient was managed appropriately and accordingly through-
out her stay in the hospital with minimal complaints.
On post-operative day 15, the wound drain was removed after
there was zero milliliters drain over the past 24 hours. The
urethral catheter was also removed. Her wound was clean and
dry.
Plan
She was to be discharged and referred to radio-oncology and
booked for JJ stent removal at the genitourinary unit.
DISCHARGE SUMMARY
Madam D.A , a 53 year old P3+2, had a total abdominal hys-
terectomy on account of Endometrial cancer and Iatrogenic
right ureteric injury. She was discharged on her oral medica-
tions.
She was also counseled on compliance to medications. She
was to come to for review the following week (14/06/2022) at
the Gynae clinic. She was advised to have wound dressings on
alternate days at a nearby health facility. She was to start ra-

diotherapy at the radio-oncology unit and booked for ureteric
stent removal at the Genitourinary unit.
HISTOPATHOLOGY REPORT
Specimen Type: Uterus, tubes, ovaries and omentum.
Macroscopically : The dimension of the uterus was

6x5x4.3cm with cervix being 3x2.5x2.5cm, the left ovary was
2.5x1.2cm, the right ovary was 2.6x1.5cm, the left tube was
5cm and the right tube was 6cm.
There was a tumour in the endometrial cavity (6.2cm widest)
extending into the cervical canal. There were pale brown,
large necrotic areas, which appeared to have perforated the
uterine wall at the lower segment.
The omentum was grossly normal.
Microscopically : The specimen was adequately prepared. The

tumor type was Carcinosarcoma ( malignant mixed Mullerian
tumor), which was high grade with less than 1mm stromal in-
volvement, more than 50% myomertrial invasion with thick-
ness of 17mm. Lymph nodes were not sampled.
The provisional FIGO staging was II.
OUTCOME AND PROGNOSIS

From the histopathogy report, the prognosis appears to be bad
due to the histological grade and histological subtype.
The patient has a good potential to meet the expected outcome
of treatment after she was counseled on the need to be on ra-
diotherapy treatment and was willing to start.
CRITICAL APPRAISAL
The patient was well managed and was satisfied with a level
of care despite the intraoperative complication of damage to
the ureter. For subsequent similar operations, much care
should be taken when clearing tumor seedlings. She was well
counseled for radiotherapy following an early histopathology
report.

EMERGENCY LAPAROTOMY
ADMISSION ID - AAH2762
NAME - Madam P. M
AGE - 21
P0+1
LMP - 21st March 2022
Gestational Age - 8 weeks 1 day
DATE OF ADMISSION - 22nd May 2022
DATE OF DISCHARGE - 25th May 2022
HISTORY
PRESENTING COMPLAINT -
Severe lower abdominal pain for 10 hours
Patient was in her usual state of health until 10 hours ago

when she started experiencing severe lower abdominal pain,
which was constant, non-radiating, and severity of 8/10 while
on an errand for her mum.
This was unusual so reported to a peripheral hospital where a
pelvic scan was done with findings suggestive of
hemoperitoneum with left-sided ectopic pregnancy.

and then referred to Korle-Bu Teaching Hospital for further
management.
ON DIRECT QUESTIONING
She was amenorrheic for 2 months. There was spotting. She

was dizzy and had palpitations. There was feeling of
tiredness. There was no fever, chills or abnormal vaginal
discharge. She had done a urine pregnancy herself which was
was positive.
SYSTEMIC ENQUIRY
General - She had not lost weight or lost appetite.

Gastrointestinal system - There was no vomiting or change in

bowel movements.

hematuria.
Central nervous system - She had no headache or seizures.
Musculoskeletal system - She had no muscle ache or joint

pain.
PAST MEDICAL HISTORY

She did not have hypertension, diabetes, asthma or sickle cell
disease. She had not been admitted before. Neither had she
had any surgery before.
DRUG HISTORY
She was not on any medication.
Menstrual History
Menarche was at 10 years. She bleeds for 7 days with a
regular monthly cycle. She uses about 3 pads a day which are
lightly soaked. She has no dysmenorrhea. She doesn’t pass
clots and has no intermenstrual bleeding.
Sexual History
Coitarche was at 18 years . She has no post-coital bleed or
dyspareunia.
Contraceptive History -
She has not used any contraceptive method before. She
mentioned she has no reason why although aware of it.
Self Breast Examination - She does not perform self breast

examination.
Pap Smear - She had not done any Pap smear before because
she was not aware of such test and so was counseled on it.
She has had no sexually transmitted infection.

Past Gynaecological Surgery - She’s had no past
gynaecological surgery.
OBSTETRIC HISTORY (P0+1)
1st pregnancy ended in 2021. It was unplanned and

unwelcomed. There was a period of amenorrhea. She did a
urine pregnancy test which was positive and pregnancy was
confirmed via an ultrasound scan. She had a miscarriage at 6
weeks gestation and products of conception was removed via
manual vacuum aspiration. There were no post-abortal
complications.
FAMILY HISTORY
She has no family history of hypertension, diabetes, sickle cell

disease or asthma.
SOCIAL HISTORY
She lives at North Kaneshie with her mother. Her highest

level of education is senior high school. She does online
business. She is not married. She takes in alcohol
occasionally. She does not smoke. She does not have an active
National Health Insurance Scheme.
SUMMARY
A 21 year old, Madam P. M. P0+1, whose LMP was 21st of

March 2022 who was referred to Korle Bu Teaching Hospital
on account of ectopic pregnancy after she presented with a

history of amenorrhea for 2 months and a 10 hours history of
severe lower abdominal pain and spotting.
General examination - I saw a young woman who looked in

pain and uncomfortable in bed. She was not in any obvious
respiratory distress. She was afebrile (36.4 degree Celsius),
anicteric, severely pale and moderately dehydrated. She had
no neck masses or peripheral lymphadenopathy.
She had no bipedal oedema.
Breast examination - Her breasts were symmetrical with

everted nipples. She had no ulcers or nodules. There was no
differential warmth, neither were her breasts tender. She had
no palpable breast lump. There was no nipple discharge or ax-
illary lymphadenopathy.
Cardiovascular System - Her pulse rate was 97 beats per

minute , of good volume and regular rhythm. Her blood
pressure was 106/60 mmHg. There was no raised jugular
venous pressure. Her apex beat was at the left 5th intercostal
space midclavicular line. She had no heaves or thrills. On
auscultation, her heart sounds 1 and 2 were present and
normal. She had no murmurs or added sounds and she had no
bibasal lung crepitations.
Respiratory system - Her respiratory rate was 16 cycles per

minute, she had no chest wall deformity, her chest movement
was adequate and symmetrical. Her trachea was centrally
placed. There were no areas of tenderness on the chest. She

had normal tactile fremitus and percussion note was resonant.
On auscultation, there was adequate air entry bilaterally. Her
breath sounds were vesicular. There were no added sounds.
Abdominal examination - Her abdomen was full moved with

respiration. Her umbilicus was inverted. She had no scars or
scarification marks. She had female hair pattern distribution.
There was tenderness elicited over the suprapubic region,
however no masses were felt. The liver edge was not palpable.
The spleen was not palpable and both kidneys were not bi-
manually ballotable. There was no demonstrable fluid in the
abdomen on percussion. Bowel sounds were present but
distant and of normal frequency.
Bimanual pelvic examination - The vulva looked healthy. The

Bartholin glands were not palpable. There was no abnormal
vaginal discharge but some blood at the introitus.
There was cervical motion tenderness. No adnexal masses
were palpated.
Culdocentesis - There was about 2ml of non-clotting blood

drawn from the posterior fornix.
INVESTIGATIONS
1. The urinary pregnancy test was positive (22/05/2022)
2. The abdominopelvic ultrasound scan done at peripheral

hospital revealed a left adnexal mass of size 23.20 mm by
24.10 mm

3. Blood was taken for Full blood count, grouping and cross-
matching as well as blood urea, electrolytes and creatinine.
IMPRESSION/DIAGNOSIS
Ruptured ectopic pregnancy
PLAN
1. Blood was taken for grouping and crossmatching against 2

units of blood.
2. Patient was to sign consent form.
3. Patient was to get the following items as follows
• 2L Dextrose Normal Saline

• 2L Ringer‘s Lactate
• 2L Normal Saline
• IV Amoxiclav 1.2g bd × 24 hrs
• Tab Amoxiclav 625mg bd × 7 days
• IV Flagyl 500mg × 24 hrs
• Tab Flagyl 500mg tid × 7 days
• Supp diclofenac 100mg bd × 5 days
• Subcutaneous Clexane 40mg daily × 3 after 12 hrs
• IV Paracetamol 1g 6 hourly
• Tab Paracetamol 1g tid × 3 days
• IM Pethidine 50mg 6 hourly
OPERATION FINDINGS AND PROCEDURE
Operation - Laparotomy + left salpingectomy + left wedge

resection

Indication - Ruptured left interstitial gestation.
Surgeon - Dr. B.
Assistant - Dr. A.
Findings - Her uterus was about 10 weeks size. Both ovaries

were normal. There was a ruptured left interstitial gestation.
Her right tubes were normal. The estimated blood loss was 3L
Proceedure - The surgery was done under aseptic techniques

and the patient was put under general anaesthesia. She was
then scrubbed and draped. Her abdomen was entered via a
lower transverse incision. The findings were as stated above.
Her abdomen was cleared of blood. A left salpingectomy with
left wedge resection of the interstitial gestation was done and
haemostasis was secured. A peritoneal lavage was done. Ab-
domen was closed up in layers.
POST OPERATIVE MANAGEMENT
RECOVERY WARD
Patient was sent to the recovery ward in a fair state and

conscious. She had an IV cannula in the right dorsum of her
hand connected to 500mls of Ringer’s lactate. She was pale.
Her respiratory rate was 16 cycles per minute. She had a pulse
of 78 beats per minute and of good volume. Her blood
pressure was 106/65 mmHg. Her SpO2 was 100% on room
air.
She had mild pain over the incision site.

Patient‘s vitals were monitored quarterly till she was stable
and then was done 4 hourly. She was given 2 units of blood
and 2 units of Fresh Frozen Plasma (FFP). She was also given
the following
IM pethidine 75mg
IV Amoxiclav 1.2g
IV Flagyl 500mg
Suppository Diclofenac 100mg
SC clexane 40mg
IV calcium gluconate 1g
IV Metoclopramide 10mg
IV Lasix 20mg
She was put on a fluid input and output chart.
There was a blood transfusion reaction. She had pain at the

cannula site and she complained of feeling feverish. Her pulse
was 96 beats per minute with blood pressure of 85/42 mmHg.
The blood transfusion was stopped and the blood was sent
back to the blood bank. She was then given 200mg IV
hydrocortisone.
She became stable and was sent to Chenard Ward A for
further treatment and monitoring.
She had complained of slight abdominal pain at the incision

site. On direct questioning, she was asymptomatic of anemia,
she had passed out flatus, she had not vomited. On examina-
tion, Patient looked generally unwell. She was not pale, not
jaundiced, afebrile (36.0 ̊C), hydration was satisfactory.

Her Blood Pressure-106/65 mmHg, Pulse- 70 bpm which was
regular, of good volume and had a regular rhythm. Heart
sounds 1 and 2 were present and normal and there were no
murmurs. Her chest was clinically clear (there were no bibasal
lung crepitations). Her abdomen was was soft, moved with
respiration, there was mild tenderness over site of surgical
wound. The wound dressing was clean and dry. Bowel sounds
were present and normal.
PLAN FOR POST-OPERATIVE DAY 1

She was to start oral sips. Her urethral catheter removed and
ambulation encouraged. She was to be given 1g of IV
paracetamol and continue with antibiotics and SC clexane.
The patient was stable and had no complaints aside slight pain
at the site of incision.
She was feeding and ambulating well.
On examination, She looked generally well, she was not pale,
afebrile with temperature of 36.0 ̊C. Her hydration was satis-
factory. Her blood pressure was 130/82 mmHg. Her pulse was
81 bpm, of good volume and regular rhythm. 1st and 2nd
heart sounds were present and normal and there were no
murmurs.
Abdomen was full, soft, moved with respiration, mild tender-
ness at incision site. Wound dressing was clean and dry.
POST OPERATIVE DAY 3

Patient complained of mild pain at the incision site. She was
feeding and ambulating well. On examination, she looked
well, she was not pale and was afebrile, her hydration was sat-
isfactory. Chest was clinically clear. Her abdomen was full
and moved with respiration, there was mild tenderness at the
incision site. Wound was clean and dry. Her vitals were nor-
mal.
Patient was discharged home on oral medication and to con-
tinue wound dressing at the nearest clinic.
DISCHARGE SUMMARY
Madam P. M, a 21 year old P 0+1, had laparotomy with left
salpingectomy and left wedge resection on account of a rup-
tured left interstitial gestation. She was discharged on oral
medications.
Patient was counseled on the type of operation done and the
need to report immediately to the nearest hospital after miss-
ing her menses for assessment and the need to deliver by ce-
sarean section for her subsequent pregnancy because of a pos-
sibility of uterine rapture.
She was to come for review the following week(31st May
2022)
OUTCOME AND PROGNOSIS
There is a risk of recurrence and uterine rapture following the
cornual wedge resection.
CRITICAL APPRAISAL

The patient was well managed and she was satisfied with the
level of care offered. She was well counseled into detail
which was commendable. However, patient was not coun-
seled on a family planning method.
For subsequent cases, patients should be counseled on a fam-
ily planning method following discharge.

MANUAL VACUUM ASPIRATION
NAME: Madam E.Y.

AGE: 23
LAST MENSTRUAL PERIOD: 5th May, 2022
P0+1
GESTATIONAL AGE: 7 weeks 3 days
DATE OF ADMISSION: 10th June 2022.
DATE OF DISCHARGE: 10th June 2022.
HISTORY
Presenting Complaints:
Lower abdominal pain of 5 days duration
Monthly menses, 4 days late
History of Presenting Complaints:

Patient was well until 5 days prior to presentation she began
experiencing lower abdominal pain. She described it as sud-
den, non-radiating and was not relieved by paracetamol and
graded a 2 out of 10. She had no associated symptoms with
the pain.

Patient also having realized she was four days later than her
regular monthly cycle bleeding, she did a urine pregnancy test
which was positive. She reported then to the Family Planning
Unit at Korle-Bu Teaching Hospital for termination of un-
wanted pregnancy.
On direct questioning:
There was no fever or abnormal vaginal discharge or bleed-
ing. She admitted to having breast fullness.
Systemic enquiry:
General: She had no weight loss, no rigors and no malaise.
Cardiovascular System: She had no chest pain, no dyspnoea,
no orthopnoea, no paroxysmal nocturnal dyspnoea.
Respiratory System: She had no cough, no dyspnea, no

wheeze or running nose.
Gastrointestinal System: She had no nausea, no vomiting, no

change in bowel habits. She had good appetite.
Genitourinary System: She had no dysuria, no haematuria, no

urgency. She experienced polyuria.
Musculoskeletal System: She experienced no joint pain, no

weakness or no muscle pain.

Central nervous system: She had slight headache, no syncope,
no convulsions, no blurred vision and no hearing difficulties.
Gyanecological history:
Menstrual history
Her menarche was at 15 years. She has had a regular monthly
cycle in which she bleeds for 5 days averagely. She uses about
2 sanitary pads in a day; they do not get soaked and there are
no clots and she has never had flooding. It is not associated
with any pain. She has not had any abnormal vaginal dis-
charges.
Sexual history
Coitarche was at 18 years. She has 4 lifetime sexual partners.
She has never experienced any post coital bleeding or dys-
pareunia.
She has no known history of any sexually transmitted infec-
tion.
She does not use contraceptives because she does not want to
use though she is aware of it. Her partners occasionally use
male condom.
She examines her breasts herself and has gone to a health fa-
cility for it to be examined of which findings were normal.
She knows what Pap smear is and has never had a pap smear
done before.
She has no past gynaecological surgeries.

Past obstetric history:
Now P1+0
Index pregnancy. Pregnancy was unplanned and unwelcomed.
Termination of pregnancy done on the 10th of June at 7 weeks
3 day at Family Planning Unit in Korle-Bu Teaching Hospital.
She had no complications encountered during procedure.
Past medical and surgical history:

She has no hypertension, no diabetes mellitus, no asthma and
no sickle cell disease. She has no previous admissions or surg-
eries.
Drug history:
She is currently not on any medication and has no known drug
allergy. She does not take herbal medication.
Family history:
Both parents are alive. There is no known family history of
hypertension, diabetes mellitus, asthma or sickle cell disease.
Social history:
She stays with her father at Ayi Mensah. Her mother lives at
Koforidua. Parents live separately because of location of their
jobs. She is a student at University of Cape Coast. She does

not drink alcohol or smoke cigarette. She is a Catholic and ac-
cepts blood transfusion.
SUMMARY: Client is a 23 year old Madam E.Y., P0+1 with

last menstrual period of 5th May 2022 who presented with a 5
days duration of lower abdominal pain and 4 days delayed
monthly period and reported to Korle-Bu Family planning
unit for termination of pregnancy following a positive urine
pregnancy test.
General Examination:
Patient was well and not in respiratory distress. She was nei-
ther jaundiced nor pale. Her temperature was 36.2 degrees
Celsius. She had good oral hydration and normal skin turgor
with capillary refill time less than 2 seconds. She had no cen-
tral or peripheral cyanosis. She had no clubbing. She had no
palpable lymph nodes in the neck, axilla or groin. She had no
pedal oedema or varicosities.
Breast:
Her breasts were symmetrical with everted nipples. There
were no scars, superficial veins or ulcerations. There was no
breast tenderness. No lumps or masses were palpated. There
was no nipple discharge.

Cardiovascular System:
Her radial pulse rate was 74 beats per minute of good volume,
regular rhythm and non-collapsing. The arterial wall was not
palpable. Her blood pressure was 115/71mmHg. Her apex
beat was in the fifth left intercostal space mid-clavicular line.
The first and second hearts sounds were present and normal.
There were no murmurs or added sounds.
Respiratory System:
The respiratory rate was 14 cycles per minute. The chest wall
moved symmetrically with respiration. There were no surgical
scars, scarifications or chest deformities. There was no chest
tenderness and the trachea was central. There was normal tac-
tile fremitus in all lung zones. Percussion notes were resonant
in all lung zones. Vocal fremitus was normal in all lung zones.
On auscultation, air entry was adequate with vesicular breath
sounds in all lung zones. There were no added sounds or
crepitations.
Gastriointestinal System:
Her abdomen was flat and moved with respiration. The um-
bilicus was inverted. There were no surgical scars or scarifica-
tion marks. There was female pattern hair distribution. On
light palpation, there was slight lower abdominal tenderness
and no masses were felt. The liver, spleen and two kidneys
were not palpable and there was no demonstrable free fluid in

the abdomen. On auscultation bowel sounds were present and
of normal frequency.
Pelvic examination:
Normal vulvovaginal area on examination. There was no
bleeding or abnormal discharge.
Central Nervous System:

She was conscious and alert. She was well oriented in time,
place and person.
INVESTIGATIONS
I. Urine pregnancy test was repeated and was positive.
II. Abdominopelvic ultrasound scan done at family plan-
ning unit which showed a mass in the uterine cavity
indicating a 7 week 3 day old fetus. There was fetal
heart activity. There was no fluid in the pouch of Dou-
glas. The internal cervical os was closed. Her adnexae
were normal. Her urinary bladder wall was also nor-
mal.
IMPRESSION/DIAGNOSIS:
Live fetus in uterine cavity. Pregnancy confirmed.

PLAN
1. To do a manual vacuum aspiration.
2. To counsel patient about family planning and contracep-
tion.
PROCEDURE
Patient was counseled about procedure. Patient was posi-
tioned in the lithotomy position. The vulva was cleaned using
savlon and spirit. A sterile speculum was inserted and the
cervix inspected and cleaned. Paracervical block was done
with 10 milliliters of lidocaine. Size 5 and 6 dilators were
used to dilate the cervix. The MVA device (aspirator) was
then charged that is a negative pressure was created. The ante-
rior lip of the cervix was gripped with a pair of a tenaculum
and gently pulled forward. A size 8 cannula was then inserted
through the cervix and the aspirator connected to it. The valve
was then opened and the cannula rotated in 180 degrees in
both directions while doing a gentle in and out motion. This
was continued until grittiness was felt and air bubbles began
to appear in the cylinder. The valve was then closed and the
cannula withdrawn from the uterus; the cannula was discon-
nected from the aspirator. The contents of the cylinder were
inspected and discarded. The equipments used were then
placed in a chlorine solution afterwards.
.
FINDINGS

Removed products of contraception and estimated blood loss
was 50 mls
POST PROCEDURE MANAGEMENT

1. She was made to lie down for about 5 minutes
2. She was then put on the following medications;
a) Tab Amoxiclav 625 mg bd x 5 days
b) Tab Metronidazole 400mg tds x 5 days
c) Suppository Diclofenac 100mg bd x 3 days.
She was discharged about 30 minutes later.
DISCHARGE NOTES
She was discharged on the started medications above and was
asked to come for review in two weeks. She was counselled
on post abortal care. After counselling, she declined family
planning option on account of not being ready.
FOLLOW UP
Patient visited the clinic 12 days post procedure. She was do-
ing well and had experienced no post procedure complications
after discharge.

CRITICAL APPRAISAL
Patient was well managed. She was satisfied with the manage-
ment. The counseling on the need for a family planning
method was a very good part of the management as it would
help to prevent future unwanted pregnancies and subsequent
risks of unsafe abortions.

INFERTILTY
Case number:
Name: Madam E.M
Age: 40 years
Parity: P0+0
Last menstrual period: 1st May, 2022
HISTORY
PRESENTING COMPLAINT -
Inability to conceive of 3 years duration
Irregular menses of 3 years duration.

Patient missed her period a month after she got married 3
years ago and this lasted for three consecutive months, so she
reported to a peripheral facility. At the peripheral hospital,
laboratory tests were done and she was given some drugs
which included Primulut-N. That very month her period re-
sumed. She took the drug she was given for only that month.
The following month she did not see her menses and so re-
ported back to the facility, where she was placed on
Bromocryptin but still failed to see her menses. She later then
reported to Swedru hospital where she was diagnosed with
ovarian failure and placed on oral contraceptive pills for three
months, for each of those months she had her normal menses.
However, after these three months the periods stopped. This

was associated with lower abdominal pain which was some-
times localised to the right or left lower abdomen and at other
times the entire lower abdominal region including her lower
back. It was of gradual onset and was dull in character. It re-
solved without any medication and was exacerbated when she
bends down. It had a grade of 5/10. In November 2021, she
was referred to KBTH but reported in February this year. At
Korle-Bu she did some laboratory investigations and an ab-
dominal scan which had no significant findings. She was then
placed on secure oral contraceptives and haematinics. Her pe-
riods now come every month.
ON FURTHER QUESTIONING
Her menarche was at 14-15 years. She has an irregular cycle
with 5 days of bleeding. She sees no clots. She uses 2 sanitary
pads on each day of bleeding. She has dysmennorhea which
starts about a week before her period and stops 2-3 days after
the period ends. Occasionally she experiences mid cycle
lower abdominal pain and she does not experience breast ten-
derness. She does not experience heat intolerance, cold intol-
erance, or change in bowel habit. She has never experienced
abdominal pain associated with fever and malodourous vagi-
nal discharge of which required antibiotics or a visit to the
hospital. She has no complaint of acne, oily skin or abnormal
excess hair growth on her face or chest. She has not experi-
enced any weight gain. She does not experience headache,
tunnel vision or any type of breast discharge. She has no his-
tory of previous pelvic surgery or any gynaecological proce-
dure. She lives with her husband and has unprotected sexual
intercourse with her husband twice a week.
SYSTEMIC ENQUIRY

General - She has had no fever. She has had loss of apetite for
about 3 days. She also has a feeling of malaise about 4 days
ago.
Gastrointestinal system - She had no change in bowel

movements.

hematuria.
Central Nervous System: she experiences migraines ,no

blurred vision, no tunnel vision, no fainting episodes.
Musculoskeletal system: occasional pain in the sides ,occa-
sional knee pain
PAST MEDICAL HISTORY

She doesn’t have hypertension, diabetes milletus, asthma or
sickle cell disease. She has a previous admission on account
of malaria last month. She has no past surgeries and has not
been haemotransfused before.
DRUG HISTORY
She is currently not on any medication. She has no known
drug allergies. She took herbal preparations for the current
condition.

Her menarche was at 14-15 years. She has an irregular cycle
with 5 days of bleeding. She sees no clots. She uses 2 sanitary
pads on each day of bleeding. She has dysmennorhea which
starts about a week before her period and stops 2-3 days after
the period ends. Occasionally she experiences mid cycle
lower abdominal pain and she does not experience breast ten-
derness.
Her Coitarche was at 37 years. She has had 1 lifetime sexual
partner. She doesn’t experience dyspareunia or post coital
bleeding.
She has never used any method of contraception before be-
cause she wanted to conceive. Her partner doesn’t use any
contraception.
She does breast-self examination.
She has not done a pap smear before for no apparent reason.
OBSTETRIC HISTORY
She is para 0 + 0
FAMILY HISTORY:
She is the third of her parents’ five children. Both parents are
alive. There’s no family history of hypertension, diabetes
mellitus, asthma or sickle cell disease. There’s no family his-
tory of infertility.
SOCIAL HISTORY

She stays at Bewadze with her husband. She is a seamstress
and her highest level of education was junior high school. She
has a NHIS card which is active. She doesn’t smoke or take
alcohol. Her husband is a short distance driver. He doesn’t
smoke or take in alcohol. She is a Christian and does not ac-
cept blood transfusion.
SUMMARY: Madam E.M., Forty year old, Para 0+0 whose

last normal menstrual period was 05-01-2022 who presented
with an inability to conceive and irregular menses of 3 years
duration. She has been on primilut-N and bromocryptin and is
currently on oral contraceptives. Her menses have resumed
and regular, however she is still unable to conceive.
PHYSICAL EXAMINATION .
General Examination: I saw a young woman, who looked
well. She was not jaundiced or pale. She had adequate oral
hydration and normal skin turgor. There was no central or pe-
ripheral cyanosis, no clubbing, no peripheral
lymphadenopathy, nor pedal oedema. She had no anterior
neck swelling. She had no acne, or facial hair. Her weight was
58kg and her height was 154 cm. Her Body Mass Index was
24.5kg/m^2 which is within normal range.
Breast Examination: Her breasts were symmetrical with
everted nipples. She had no ulcers or nodules. There was no
differential warmth, neither were her breasts tender. She had
no palpable breast lump. There was no nipple discharge or ax-
illary lymphadenopathy.

Cardiovascular System: Her pulse rate was 72 beats per
minute, of good volume, regular rhythm and non-collapsing.
The arterial walls were not palpable. Her blood pressure was
120/78mmHg. Her apex beat was at the left 5th intercostal
space mid-clavicular line. She had no heaves or thrills. On
auscultation, Heart sounds I and II present and normal, no
murmurs, no added sounds.
Respiratory system: Her respiratory rate was 20 cycles per
minute. She had no area of tenderness on the chest. She had
normal tactile fremitus and percussion note was resonant. On
auscultation, there was adequate air entry bilaterally and
breath sounds were vesicular with no added sounds and no
crepitations at lung bases.
Abdominal examination: Her abdomen was full and moved
with respiration. The umbilicus was inverted and there were
no scars or scarification marks. There was no tenderness. The
liver and spleen was not palpable and both kidneys were not
bimanually ballotable. There were no masses arising out of
the pelvis.
Pelvic exam: Normal looking vulvovagina. No obvious lesion
in the cervix or vagina.. No adnexal tenderness. No cervical
motion tenderness.
IIMPRESSION/ DIAGNOSIS: Primary infertility due to:

a. Hormonal factor
PLAN: Patient was counseled on condition and asked to

come along with her husband. She was advised to do a CT

scan view of the pituitary gland, thyroid function tests and
prolactin hormone assay.
INVESTIGATIONS
Full Blood Count -
Haemoglobin - 13.1g/dl
Platelets - 263×10^9/L
White blood cells - 6.28×10^9/L
Abdominopelvic ultrasound
It showed a normal liver , gall bladder , pancreas and spleen.
Both kidneys are normal. The uterus, fallopian tubes and
ovaries were all of normal architecture.
Hormonal assay
Prolactin - 234.1 mIU/L, which was within normal.
Estradiol - 52.3 pmol/L, which was low.
FSH - 29.2 IU/L, which was high.
LH - 27.4 IU/L, which was high.
Papanicolaou smear
Negative for cervical intraepithelial lesion or malignancy
PLAN
To counsel patient on findings and other fertility options.
CRITICAL APPRAISAL

The approach to the case was commendable. The patient was
counseled on what was going on and other options of fertility
such as surrogacy and adoption and the cost involved as well
which was well done.

FAMILY PLANNING
A CASE OF FAMILY PLANNING

Name: Madam D.P
Registration No.: 604/22
Age: 49
Last Menstrual Period: 25/05/2022
Parity: P3+2
Date: 09/06/2022
HISTORY:
Presenting Complaint: There was no complaint. Patient
came in for removal and insertion of an intrauterine device
(IUD). IUD has been in place for 11yrs.
On Direct Questioning: There was dysmenorrhoea, heavy
menstrual bleeding of 4yrs duration. There was palpitations,
no dizziness or headaches. There was no malodorous vaginal
discharge but had increased vaginal discharge for about 4days
which was clear and slightly stretchy in consistency.
She was happy with the method she chose. She is in a sexual
relation.
She does not have any history of liver disease. There is a fam-
ily history of breast cancer. There was no calf pain. She has
no reproductive wishes.
Systemic Enquiry:
General: She had no weight loss, no rigors and no malaise.

Cardiovascular System: She had no chest pain, no dyspnoea,
no orthopnoea, no paroxysmal nocturnal dyspnoea.
Respiratory System: She had no cough, no dyspnea, no

wheeze or running nose.
Gastrointestinal System: She had no nausea, no vomiting, no

change in bowel habits. She had good appetite.
Genitourinary System: She had no dysuria, no haematuria, no

urgency. She experienced polyuria.
Musculoskeletal System: She experienced no joint pain, no

weakness or no muscle pain.
Past Medical and Surgical History:

She has been admitted on account of malaria for an average of
two days at a peripheral hospital but does not recall the num-
ber of times.
She does not have hypertension, diabetes mellitus, sickle cell
disease or asthma.
She has not had any surgical procedures neither has she re-
ceived any blood transfusion.
Drug History:
She currently takes multivitamins and other food supplements.
She has no known food or drug allergy.
She has not taken any herbal medications.
Gynecological History

Her Menarche was at 16 years. She bleeds for 3 days and has
a regular monthly cycle. For the past 4 years she uses 2 adult
pampers, previously she used 2 sanitary towels a day. She has
dysmenorrhoea for the first 2days and sometimes continues
after the menstrual cycle. No clots has been seen. No vaginal
discharge. There is no flooding or intermenstrual bleed.
Her coitarche was at 17years. She has two life time sexual
partners. There is no dyspareunia or post-coital bleeding.
There is no history of sexually transmitted infection
Contraceptive History:
The client opted for Depo-Provera 15yrs ago. However, after
the 3months time elapsed she did not go for another injection
because she had a one-sided headache which started 2weeks
after the injection. She associated the headache to the Depo-
Provera. 4yrs later, she chose the copper intrauterine device,
used it for 11years and had no complaints. Partner does not
use condoms
Self breast examination - She performs it at least once a

month.
Pap smear - She has had a pap smear done which was 3years
ago and the results were normal.
Obstetric History
She is P3+2
Her first pregnancy ended in 1992. Pregnancy was not
planned but welcome. It was confirmed with an ultrasound
scan at 2months after a period of amenorrhoea and a positive

urine pregnancy test. Booking visit was at 2months. She was a
regular antenatal care attendant at Mamprobi Polyclinic. Preg-
nancy was uneventful. She delivered via spontaneous vaginal
delivery at 9months gestational age at Mamprobi Polyclinic to
a live female baby whose birth weight she could not remem-
ber. Baby cried at birth and was not sent to Neonatal Intensive
Care Unit (NICU). There were no postpartum complications.
Chid is now 30years old, alive and doing well.
Her second pregnancy ended in 1993. Pregnancy was un-

planned and unwelcome. After a period of amenorrhoea, gen-
eral feeling of malaise and a positive urine pregnancy test she
visited a peripheral hospital. At the peripheral hospital, she
had the pregnancy terminated because she felt she had just
given birth and was not ready for another child. She could not
recall the gestational age at termination. A manual vacuum as-
piration was done. She had minimal lower abdominal pain she
graded a 3 out of 10 after the procedure and there were no
other complications after the procedure. She was counseled on
family planning methods however she was not ready.
Her third pregnancy ended in 1996. It was planned and wel-

comed. It was confirmed with an ultrasound scan at 3months
after a period of amenorrhoea and a positive urine pregnancy
test.Booking visit was at 3months. She was a regular antenatal
care attendant at Mamprobi Polyclinic. Pregnancy was un-
eventful. She delivered via spontaneous vaginal delivery at
Mamprobi Polyclinic at 9months gestational age to a live
male baby. She could not remember baby’s birth weight.
Baby cried at birth and was not admitted to Neonatal Intensive
Care Unit (NICU). There was no postpartum complication.
Child 26years old now, alive and doing well.

Her fourth pregnancy ended in 2000. It was planned and wel-
comed. It was confirmed with an ultrasound scan at 2months
after a period of amenorrhoea and a positive urine pregnancy
test. Booking visit was at 2months. She was a regular antena-
tal care attendant at Mamprobi Polyclinic. Pregnancy was un-
eventful. She was referred to Korle-bu Teaching Hospital on
account of prolonged pregnancy. Induction of labour was
done and delivery was via vaginal delivery at 9months
3weeks gestational age at Korle-bu Teaching Hospital to a
live female baby. She could not remember baby’s birth weight
who cried at birth and was not admitted to Neonatal Intensive
Care Unit (NICU) admissions. There was no postpartum com-
plication. Currently child is 22years old, alive and doing well.
Her fifth pregnancy ended in 2007. It was unplanned and un-

welcome. She visited the family planning unit at Korle-bu
Teaching Hospital for termination of unwanted pregnancy be-
cause she was did not desire to have more children. A manual
vacuum aspiration was done at six weeks gestational age.
There were no complications after the procedure. She was
counseled on family planning methods, after which she opted
for Depo-Provera
Family History: She is the second of three children. Both

parents are deceased, mother passed on account of a sickle
cell crisis but the cause of death of her father is unknown. Her
step-sister on her father’s side passed from breast cancer.
Aside sickle cell disease and breast cancer, there is no other
known chronic illness such as hypertension, diabetes mellitus
or asthma in their family.
Social History: Client stays at Mamprobi with her husband

and her two youngest children. She trades in clothes and bags
as her occupation and her highest level of education is Senior
Secondary School. She drinks a glass of red wine every other
day and does not smoke. She is Christian and accepts blood
transfusion. She is on the National Health Insurance Scheme
but it’s not active.
Her husband is 54years old automobile mechanic who has vo-
cational training school as his highest form of education.
The father of her child is a 22year old unemployed senior high
school graduate, he doesn’t smoke or drink. She does not
smoke cigarette or drink alcohol. He drinks alcohol occasion-
ally and does not smoke.
Summary
This is a case of Madam D.P, 49years old Para 3+2, who at-
tended the family planning unit to have an 11-year Copper
IUD removed and insert a new Copper IUD with a past his-
tory of Depo Provera use. She was counseled and she is happy
with the method she chose.
General examination: I examined a middle-aged woman

who laid comfortably in bed. She looked well and was not in
any form of respiratory distress. She was afebrile. She was not
pale or jaundiced. She had no central or peripheral cyanosis.
She had no digital clubbing. Her capillary refill was less than
2 seconds. There was no anterior neck swelling. She had no
peripheral lymphadenopathy. There was no pedal oedema.
Her weight was 94kg and her height was 180cm. Her BMI is
29.01kg/m2, thus she is overweight .
Cardiovascular System: Her pulse was 84bpm, of good vol-

ume, regular rhythm and non-collapsing with arterial wall not
palpable. Blood pressure was 149/98 mmHg which was high.
Her apex beat was palpable at the fifth left intercostal space,
mid-clavicular line. There were no heaves or thrills. Heart
sounds I and II were present and normal and no murmurs
were heard.
Respiratory System: Her respiratory rate was 16 cycles per
minute. Trachea was central, tactile fremitus was normal, per-
cussion note was resonant on all lung zones. On auscultation,
her air entry was adequate bilaterally with vesicular breath
sounds and no added sounds. Her chest was clinically clear.
Abdomen: Her abdomen was full, moved with respiration,
umbilicus was flat. She had no scars or scarification marks.
She had female pattern hair distribution. There was no tender-
ness or masses felt on light palpation. The spleen and liver
were not palpable and the kidneys were not bimanually bal-
lotable. Bowel sounds were present and of normal frequency.
Pelvic examination - Vulva looked clean and dry. There was

no scars or abnormal growth on the vulva. There was no ten-
derness elicited on palpation of the accessory glands of the
vulva.
Central Nervous System - She was conscious and alert. She

had adequate tone, normal reflexes and power 5/5 on all
limbs. She had a normal gait as well
COUNSELLING: Client was counseled briefly about the

contraception she chose. She was asked if she had any issues
with the previous IUD insertion of which she said she did not.
She was then re-educated on how CuT380A IUD works. She

was told the advantages, disadvantages and expected side ef-
fects were emphasized. She was further advised to return any-
time she experienced any of the side effects mentioned.
CONTRACEPTIVE CHOSEN: CuT380A Intrauterine de-
vice (IUD)
PROCEDURE:
Removal
The client was informed of the procedure and consent ob-
tained. The equipment and materials needed were set.
Patient was positioned in a lithotomy position and appropri-
ately exposed.
Under aseptic conditions and a good light source, a sterile
speculum was passed to see the cervix and IUD strings.
The cervix and vagina was cleaned.
The patient was asked to cough and using narrow forceps, the
IUD strings were pulled slowly and gently until the IUD came
out completely..
The IUD was shown to the client and disposed off.
Insertion
A tenaculum was passed through the speculum unto the exter-
nal os of the cervix to provide a gentle traction on the cervix.
A uterine sound was passed through the cervix to determine
the depth and position of the uterus.
The IUD was loaded into the insertion tube in the sterile pack-
age. The IUD was adjusted to the depth which was deter-
mined by the uterine sound.
The new IUD was shown to the client.
The IUD was then gently placed into the uterus with the
strings neatly tucked at the posterior end. She was allowed to
dress up and counselled.

POST PROCEDURE COUNSELLING: -
1.She was asked to come for review in 6wks. However if she
had any concerns before then she was at liberty to return.
2.She was advised that if she does not experience her men-
strual period for about a year she can report back and after
consideration, the intrauterine device will be removed.
3.She must check for the attached string after each menstrua-
tion to ensure the device is still in place.
4.She should however report for yearly review even if she has
no complaints.
CRITICAL APPRAISAL:
The procedure was done in a conducive environment of which
privacy and confidentiality was assured. The client was satis-
fied with the care she received. However, the client was not
counseled on the use of barrier methods for protection against
sexually transmitted infections. In subsequent cases, client’s
should be told on the importance of barrier contraceptive use
in protecting against sexual transmitted infections.

OBSTETRICS

LABOUR CASE 1
NAME - Madam K.N.A.A
AGE - 35
G6 P4+1
LAST MENSTRUAL PERIOD - ?/05/2021
EDD (9 WEEKS)- 18/03/2022
GESTATIONAL AGE - 38 weeks 6 days
ADMISSION NUMBER - AAS 6966
DATE OF ADMISSION - 15/01/2022
ANTENATAL INFORMATION
Patient was a regular attendant at the Korle Bu - ANC clinic.

The pregnancy was planned and welcomed. She started her
ANC at 9 weeks of gestation. Blood, urine and stool were
taken for laboratory investigations. The results showed mod-
erate anemia and UTI of which she was treated for.
Quickening was at 20 weeks of gestation. She had 3 tetanus

toxoid and 2 sulphadoxine-pyremethamine doses.
She received antenatal education on the dangers of pregnancy,

birth preparedness and how to breastfeed.

She was admitted to maternity ward 2 on account of pneumo-
nia in pregnancy. While she was on admission she was
managed appropriately.
LABOUR
Patient was admitted to labour ward 1 on the 10th of March

2022 for c/s on account of oligohydraminos at 38 weeks 6
days gestation.
However, at time of admission to the labor ward, cervix was
favorable for vaginal delivery.
On general examination, she looked well and not pale. She

was afebrile, temperature was 37 degrees Celsius. Her hydra-
tion was satisfactory. Her pulse was 100 beats per minute,
regular and of good volume, arterial wall was not palpable.
Her blood pressure measured 105/74 mmHg.
On examination of the abdomen, her abdomen was uniformly

enlarged, moved with respiration, her umbilicus was everted,
there was a prominent linea nigra extending from the
suprapubic region to the epigastric region. There was straie
gravidarum. On light palpation, there was tenderness elicited
at the suprabubic region. The liver and spleen were not palpa-
ble. Both kidneys were not bimanually palpable. The symphi-
siofundal height was 35 cm which was below the expected
age of gestation of 38 weeks 6 days.
The lie was longitudinal and position was to the maternal
right. The presentation was cephalic and descent was 4/5th.
The fetal heart rate was 138 beats per minute.
DETAILS OF LABOUR

1ST STAGE -
She was admitted to labour ward 1 at 5:50pm on the 10th of

March 2022. She was 4cm dilated. The presentation of the
fetus was cephalic, descent was 4/5th and the membranes
were intact. Her membranes were artificially raptured at
6:05pm and liquour color was clear. She was put on 5 IU of
oxytocin in 500mls of normal saline at a rate of 15 drops per
minute.
She was managed as per partograph as attached.
At about 8:23pm, she was 8cm dilated and descent was 1/5th.
2ND STAGE -
Patient complained of bearing down sensation and vaginal ex-

amination confirmed full dilatation of cervix. The descent was
0/5. A live male baby was delivered at 8:47pm. The birth
weight was 3.165kg with Apgar scores of 8/10 and 9/10 at 1
minute and 5 minute respectively. The estimated blood loss
was about 300mls.
3RD STAGE -
Uterus was palpated and 10 international units of syntocinon

was injected into the patients left thigh intramuscularly.
A few minutes was allowed to pass and the placenta was de-
livered by controlled cord traction with counterpressure on the
uterus.
The placenta was delivered at 8:52 pm.
20 international units of syntocinon in 500mls of Ringer’s lac-
tate was set up.
The placenta membranes and lobes were intact.

IMMEDIATE POSTPARTUM PERIOD -
Mother aided by the midwife to tidy up and was made com-

fortable in bed. There was no perineal trauma. She was neither
pale nor jaundiced. Her hydration was satisfactory. Her tem-
perature was 37 degrees Celsius.
Her pulse was 88 beats per minute of good volume and regu-
lar rhythm. Her blood pressure measured 98/64 mmHg.
The uterus was well contracted.
She was then sent back to the maternity ward 2. She had no
complaint about herself nor the baby as well while on the
ward. She was discharged on the 13th of March 2022.

LABOUR CASE 2

NAME - Madam F. A

AGE - 37

G6 P4+1

LAST MENSTRUAL PERIOD - ?/09/2021

EDD (2 MONTHS 2WEEKS)- 5/06/2022

GESTATIONAL AGE - 38 weeks 4 days

ADMISSION NUMBER - AAG 6080



ANC at about 8 weeks of gestation. Blood, urine and stool
were taken for laboratory investigations. The results were
normal. However at 22 weeks of gestation, she was diagnosed
with gestational hypertension and gestational diabetes and
was given the appropriate treatment. She was compliant.

Quickening was at 20 weeks of gestation. She had 3 tetanus
toxoid and 2 sulphadoxine-pyremethamine doses.



She was admitted to maternity ward 5 for glucose monitoring
and control as well as induction of labor.
LABOUR
Patient was admitted to labour ward 1 on the 25th of May

2022 for induction of labour at 38 weeks 4 days gestation.

was afebrile, temperature was 36.9 degrees Celsius. Her hy-
dration was satisfactory. Her pulse was 92 beats per minute,

gravidarum. On light palpation, there was no tenderness
elicited at the suprabubic region. The liver and spleen were
not palpable. Both kidneys were not bimanually palpable. The
symphisiofundal height was 38 cm which was consistent with
the expected age gestation of 38 weeks 4 days.
The lie of the fetus was longitudinal and fetal position was to
the maternal right. The presentation was cephalic and descent
was 3/5th. The fetal heart rate was 146 beats per minute.
DETAILS OF LABOUR
1ST STAGE -

May 2022. She was then put on the partograph at 9:05pm at
4cm dilated. The presentation of the fetus was cephalic,
descent was 3/5th and the membranes were intact. Her
membranes were artificially ruptured at 9:30pm and liquour
color was clear. She was put on 5 IU of oxytocin in 500mls at
a rate of 15 drops per minute.
At about 1am she was 8cm dilated and descent was 2/5th.
2ND STAGE -
Patient complained of bearing down sensation and vaginal ex-

amination confirmed full dilatation of cervix. The descent was
0/5.
A live female baby was delivered at 2:21am and placed onto
the mother’s abdomen and the sex of the baby was shown to
the mother.
The birth weight was 3.225kg with Apgar scores of 8/10 and
9/10 at 1 minute and 5 minute respectively. The liquor had an
offensive smell and child was sent to NICU. The estimated
blood loss was about 200ml.
3RD STAGE -

A few minutes was allowed to pass and the placenta was de-
livered by controlled cord traction with counterpressure on the
uterus.

The placenta was delivered at 2:31am.
20 international units of syntocinon in 500mls of Normal
saline was set up.
The placenta membranes and lobes were intact. The placenta
weighed 0.624kg.
She was given 600mcg of cytotech sublingually. Uterus was
contracted and mother was taught and encourage to massage
the uterus.
Mother was aided by the midwife to tidy up and was made

comfortable in bed. There was no perineal trauma. She was
neither pale nor jaundiced. Her hydration was satisfactory.
Her temperature was 37 degrees Celsius.
lar rhythm. Her blood pressure measured 132/84 mmHg. Her
respiratory rate was 22 cycles per minute.
complaint about herself . Her child was brought to her on the
ward the next day and the child was doing well as well.
She had a full blood count done and result were normal
She was discharged on the 31st of May 2022.

LABOUR CASE 3
NAME - Madam T. O

AGE - 26
G5 P2+2
LAST MENSTRUAL PERIOD - ?
EDD (3 Months)- 19/05/2022
GESTATIONAL AGE - 41 weeks
ADMISSION NUMBER - AAU 3605

ANC at 3 months of gestation. Blood, urine and stool were
taken for laboratory investigations. At about 4 months gesta-
tion, she had a UTI of which she was appropriately treated
for.
Quickening was at about 4 months of gestation. She had 1

tetanus toxoid and 4 sulphadoxine-pyremethamine doses.

She was admitted to maternity ward 2 on account of post-date

for induction of labour.

LABOUR
Patient was admitted to labour ward 1 on the 30th of May

2022 for induction of labour. The induction of labour started
at 4:30pm.
was afebrile, temperature was 36.3 degrees Celsius. Her hy-
dration was satisfactory. Her pulse was 92 beats per minute,

gravidarum. On light palpation, there was tenderness elicited
at the suprabubic region. The liver and spleen were not palpa-
ble. Both kidneys were not bimanually palpable. The symphi-
siofundal height was 40 cm which was compatible with the
gestational age of 41 weeks. The lie was longitudinal and po-
sition was to the maternal right. The presentation was cephalic
and descent was 4/5th. The fetal heart rate was 136 beats per
minute.
DETAILS OF LABOUR
1ST STAGE -

May 2022. She was 4cm dilated. The presentation of the fetus
was cephalic, descent was 4/5th and the membranes were in-
tact. Her membranes were artificially raptured at 10:35pm and
liqour color was clear.

At about 12:30pm, she was already fully dilated with fetal
descent of 0/5th.
2ND STAGE -
A live male baby was delivered at 12:34am. The birth weight

was 3.330kg with Apgar scores of 8/10 and 9/10 at 1 minute
and 5 minute respectively. Cord was clamped and cut. The
baby was placed onto the mother’s abdomen and the sex of
the baby was shown to the mother. The estimated blood loss
was about 400ml.
3RD STAGE -

A few minutes was allowed to pass to deliver the placenta by
controlled cord traction however there was some resistance
and so a urethral catheter was passed to empty the bladder. At
about 1:20am, the placenta was still not out. The team was
then informed. Dr. A. arrived and a manual removal of the
placenta was done at 1:35am. The uterus was then massaged
to expel clots. 1g of IV tranexamic acid was given as well as
40 international units of syntocinon in 1L of Ringer’s lactate
was set up.
The placenta membranes and lobes were intact.
Mother aided by the midwife to tidy up and was made com-

fortable in bed. There was no perineal trauma. She was neither

pale nor jaundiced. Her hydration was satisfactory. Her tem-
perature was 37 degrees Celsius.
lar rhythm. Her blood pressure measured 128/76 mmHg.
Breastfeeding was initiated.
complaint about herself nor the baby as well while on the
ward. She was discharged on the 3rd of June 2022.

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OBSTETRICS & GYNAECOL-

Group D (Junior clerkship)

ANTHONY, RODERICK BASIL N. A 1

ELECTIVE MAJOR SURGERY 3

ANTHONY, RODERICK BASIL N. A 2

ADMISSION NUMBER- AAV 0191

L.M.P - 10 years ago

DATE OF ADMISSION - 24th May, 2022

DATE OF DISCHARGE - 10th June, 2022

PRESENTING COMPLAINT - bleeding per vaginum - 6

HISTORY OF PRESENTING COMPLAINT -

Patient was in her usual state of health until 6 months ago

ANTHONY, RODERICK BASIL N. A 3

The bleeding was heavy, had clots of about 50 pessewa coin,

Cardiovascular system - There was no chest pain, no dyspnea,

Respiratory system - She had no cough or wheezing.

ANTHONY, RODERICK BASIL N. A 4

Genitourinary system - There was no dysuria, frequency or

Central nervous system - She had no headache or seizures.

Musculoskeletal system - She had no muscle ache or joint

PAST MEDICAL HISTORY -

She was admitted to Lekma hospital 3 months ago of which

She has had no surgery.

She takes 1 vial of Tot‘hema - twice a day

She takes vitamin C(1000mg) - once a day

Her menarche was at 14 years . She bled for 7 days. There

ANTHONY, RODERICK BASIL N. A 5

Contraceptive History - she has used secure oral con-

Self breast examination - She doesn’t perform self breast

Pap smear - She has not done a Pap smear.

She has no history of sexually transmitted infection.

She’s had no past gynaecological surgery.

OBSTETRIC HISTORY ( She’s P3+2 )

Her first pregnancy was in 1989. The pregnancy was planned

Her 2nd pregnancy was in 1991. The pregnancy was planned

ANTHONY, RODERICK BASIL N. A 6

Her 3rd pregnancy was in 1994. The pregnancy was planned

Her 4th pregnancy was in 2007. The pregnancy was planned

Her 5th pregnancy was unplanned and unwelcomed in 2014.

Mother is a known hypertensive and alive.

ANTHONY, RODERICK BASIL N. A 7

I present Madam D. A, 53 year old P3+2, who is 10 years

General examination - I examined an elderly woman who laid

Breast examination - Her breasts were symmetrical. Her nip-

ANTHONY, RODERICK BASIL N. A 8

Respiratory system - Her respiratory rate was 16 cycles per

Abdominal examination - Her abdomen was full moved with

I could not do a pelvic examination because patient did not al-

Central Nervous System - She was conscious and alert. She

Endometrial Cancer likely Obesity being the risk factor

ANTHONY, RODERICK BASIL N. A 9

The curettage results which was done 2 weeks ago

• The comment of the histopathology report is as follows -

Tissue or site - endometrium

Microscopically - The specimen was adequate with diagnostic

Diagnosis given was high grade carcinoma likely Carcinosar-

• Full Blood Count (FBC) - 20/04/2022

Haemoglobin - 9.5 g/dl

White blood cells - 8.23 x 10^9/L

Platelets - 751 x 10^9/L

ANTHONY, RODERICK BASIL N. A 10

eGFR - 129 ml/min > 90 ml/min

Urea(SI) - 2.3 mmol/L