DAVAO MEDICAL SCHOOL FOUNDATION

COLLEGE OF MEDICINE
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

Name of Student: ANKAM LAKSHMI SATYA SURYA PRIYANKA

Batch/Section: IMD 22 C
Date: July 30, 2022
Group No. / Preceptor: Dr. CLAIRE FRANCES MIYAKE

IDENTIFYING DATA:

NAME: Ms. M AGE/GENDER: 24 / FEMALE CIVIL STATUS: MARRIED

ADDRESS: MA-A, DAVAO CITY
OCCUPATION: HOUSE WIFE
RELIGION: ROMAN CATHOLIC
SOURCE OF HISTORY: PATIENT
RELIABILITY: 90%
DATE OF ADMISSION: 25th JULY 2022

LMP: 9 MAY 2022 EDD: 13 FEB 2023 AOG: 11 WEEKS

CHIEF COMPLAINT: VAGINAL BLEEDING

HISTORY OF PRESENT ILLNESS:

2 days prior to consultation, patient is having 1-2 drops light red vaginal bleeding
with heavy flow once which is associated with crampy abdominal pain in the hypogastric
region with a pain scale of 6/10 without any radiation. No medications were taken to relieve
the pain. No smell is noted during the vaginal bleeding. No other symptoms like dysuria or
burning sensation of urination.
On the day of consultation, patient noted the 2 teaspoons of on and off bright red
vaginal bleeding with blood clots and meaty tissues. This is associated with on and off
abdominal pain with a pain scale of 8/10 without any radiation and no medications were
taken to relieve the pain. Persistence of the symptoms prompted the patient to seek
consultation.
 PRESENT OBSTETRIC HISTORY:
 Patient had her first day of last menstrual period on May 9, 2022
 Confirmed her pregnancy with a pregnancy test.
 Date of pregnancy test: N/A
 Based on LMP, her AOG is 11 weeks and EDD is on FEB 13, 2022
PAST MEDICAL HISTORY:
 Patient had childhood illnesses like chickenpox at the age of 12.
 She doesn’t have diabetes, hypertension.
 No history of previous surgeries.
 She was admitted in hospital when she delivered and during the dilation and curettage
for the previous abortion in 2019.
IMMUNIZATION
 She was completed vaccinated against COVID 19 including booster dose
 She had her complete childhood immunizations.
She doesn’t have any psychiatric illness.
She denies allergies

FAMILY HISTORY:
 Both father and mother are hypertensive and are using antihypertensives.
 No history of cancers in any of the family members
 No history of genetically transmitted diseases.

PAST OBSTETRIC HISTORY:

Pregnancy Pregnancy year Gestation sex Birth Present Complications/

order outcome completed weight status abnormalities
G1 NSVD 2017 N/A MALE NORMAL N/A NONE
G2 NSVD 2018 N/A MALE NORMAL N/A NONE
G3 ABORTION 2019 6 TO 8 - - - DILATION
WKS AOG AND
CURETTAGE
G4 - - - - - - -

HER OB CODE: G4P2 (2-0-1-2)

MENSTRUAL HISTORY:
 She had her menarche at the age of 12
 Her menstrual cycle is regular and lasts for 4-5days and is associated with
dysmenorrhea.
 She uses 3-5 pads/ day
 She uses ibuprofen or mefenamic acid or OTC drugs to relieve the dysmenorrhea.
 She is having dysmenorrhea from the age of 12
 She doesn’t use any medicine if the pain is bearable.
  Her coitarche is 2017
 She doesn’t experience any dyspareunia.
 She used TRUST pills for contraception and now she is sexually active and is trying
to have a baby.
 No history of sexually transmitted diseases in her as well as in her partner.

PERSONAL AND SOCIAL HISTORY:

 She is housewife and lives in MA-A, Davao city.
 Her lifestyle is sedentary
 She follows Filipino diet
 She walks for 20 mins
 She does practice any yoga or meditation / alternative health practices
 She doesn’t smoke or drink
 She is interested in reading books and watching TV
 She is having support from her family members and her husband
 He copes up her stress by talking and enjoying outside
 She doesn’t have any other concerns or abuses
 She is strong by herself.

ANTENATAL HISTORY:
 No previous prenatal check-ups were done
 Transvaginal ultrasound: abnormal gestational sac with in cervical canal
 Now she is in 11 weeks AOG

REVIEW OF SYSTEMS:
General: (-) weight gain / loss, (-) fatigue
Skin: (-) itching, (-) rashes
Head: (-) headache; (-) lumps
Eyes: (-) redness, (-) vision loss
Ears: (-) hearing loss; (-) ear discharge
Nose: (-) nasal congestion, (-) sinus
Neck:(-) lymph gland enlargement; (-) stiffness
Throat: (-) tonsillitis, (-) dysphagia
Breast: (-) tenderness; (-) nipple discharge
Respiratory: (-) cough; (-) dyspnoea
CVS: (-) tachycardia, (-) arrhythmia
Gastrointestinal: (-) Diarrhoea, (+) HYPOGASTRIC PAIN
Genitourinary: (+) vaginal bleeding; (+) dysmenorrhea
Psychological:(-) behaviour changes; (-) stress
Musculoskeletal: (-) back pain; (-) joint pain.
Neurologic: (-) memory loss; (-) convulsions
Endocrine: (-) heat or cold intolerance, (-) thyroid insufficiency
PHYSICAL EXAMINATION:
Weight: Normal BMI
Vitals: BP: 124/84 mm/Hg HR: 83bpm without ectopy RR: 18 bpm Temp: 98.3F O2
sat: 100% on room air.
HEENT: normocephalic, anicteric sclera, pink palpebral conjunctivae, no cervical
lymphadenopathy.
BREAST: symmetric, no tenderness, no inflammatory ridges, no discrete nodules
CHEST AND LUNGS: Clear on auscultation in all fields
CARDIOVASCULAR: S1 and S2 were normal with no murmurs, gallops or rubs.
ABDOMEN: slightly distended and mild tenderness was present over lower pelvic area.
PELVIC: moderate active bleeding was noted in the vaginal vault with the cervical os open.
No cervical motion tenderness or adnexal tenderness was observed. Blood clots or tissue
were noted on a peri pad.
EXTREMITIES: no edema or varicosities.
MUSCULOSKELETAL: Normal gait, good posture

LABORATORY FINDINGS:
 WBCs: 10,000/uL (normal 4,500-11,000)
 Haemoglobin: 13.7 g/dL (normal 12.1-15.1)
 Haematocrit: 39.7% (normal 36%-44%).
 Chemistries and urinalysis were within normal limits.
 Blood type: B-positive.
 Beta-human chorionic gonadotropin (b-hCG) level was 9400.0 mlU/mL, which is
elevated and suggests a gestational age of three to four weeks, according to the lab
report.
 Transvaginal ultrasound: abnormal gestational sac with in cervical canal

PRIMARY IMPRESSION
G4P2 (2-0-1-2), pregnancy uterine, 11 weeks AOG, incomplete abortion
 TASK ANSWER REFERENCE

Enumerate the  24-year-old Case

salient features of
this case:
 Married
 1-2 drops of vaginal bleeding 2 days prior to consultation
which is light red in color
 associated with crampy pain in the hypogastric region with
pain scale of 6/10
 on the day of admission 2 teaspoons of vaginal bleeding
with Blood clots and passage of meaty tissues
 menstrual cycle is regular occurring for 4-5 days associated
with dysmenorrhea and consumes 3-5 pads/day
 dysmenorrhea since menarche at 12 years old.
 pregnancy test is positive.
 patient is pregnant now
 AOG – 11 weeks
 history of 1 abortion
 previous history of dilation and curettage for abortion
 both the parents are hypertensive
 no history of STD
 she goes for a 20 minutes’ walk
 all childhood immunizations including covid vaccination
were done
What is your G4P2(2-0-1-2), pregnancy uterine, 11 WEEKS AOG, Incomplete
primary
impression?
abortion

Justify your I had incomplete abortion as my primary impression because, the Case
answer why you
considered such
patient is pregnant, and she is presented with vaginal bleeding from
primary 2 days and on the day of consultation the patient is having clotting
impression. and meaty passage in her vaginal bleeding. She also had
ANSWER IN hypogastric discomfort.
SENTENCE FORM.

Enumerate what  Is there any abuse towards you by any of your family
other
specific/focused
members?
questions you  Do you take any medications in this period?
need to ask from  Number of prenatal check ups
this patient.  Maternal stress
FOCUSED
HISTORY. ANSWER  History of recent falls.
IN BULLET  Is there any recent sexual intercourse before symptoms
FORMAT. appear?

Enumerate what Pelvic Internal examination

other physical
examination
procedures you
will do focusing on
the patient’s case.
Be specific with
your answers.
 FOCUSED
PHYSICAL
EXAMINATION.
ANSWER IN
BULLET FORMAT.

Will you manage  I would like to admit this patient because of the patient’s William’s obstetrics
this patient in an
outpatient setting
condition. and gynecology 25th
OR admit in the  I will manage er with curettage/ expectant management or ed, page 349
hospital? Justify misoprostol after assessing the patient’s stability.
your answer.

Give FIVE DIFFERENTIAL DIAGNOSES and justify why you considered such diagnoses, and include a brief REFERENCE
discussion of the disease. STATE YOUR ANSWERS IN SENTENCE FORM WHEN STATING YOUR JUSTIFICATIONS
IN RULING-IN AND RULING-OUT. STATE YOUR ANSWERS IN BULLET FORMAT WHEN ANSWERING THE
ETIOLOGY, EPIDEMIOLOGY, RISK FACTORS UP TO THE PROGNOSIS.

1. ectopic pregnancy

Rule-in: Rule-out:

I will rule in this because the patient is Rule this out because there is no
having vaginal bleeding, 11 weeks AOG, radiation of abdominal pain to shoulder
crampy pain, gestation sac in cervical or back, no bladder or bowel
canal discomfort, tachycardia or hypotension
is absent
Etiology  Most common type happens when a fertilized egg gets struck on its William’s
way to the uterus, often because of fallopian tube is damaged by obstetrics, 25th
inflammation or is misshapen. edition Page no:
 Hormonal imbalances of the fertilized egg also might play a role. 371
Epidemiology Second leading cause of maternal mortality in the USA. William’s
obstetrics, 25th
edition Page no:
371
Risk Factors  Tubal corrective surgery William’s
 Tubal sterilization obstetrics, 25th
 Previous EP edition Page no:
 Intrauterine device 371,372
 Infertility
 Previous genital infection
 Multiple partners
 Smoking
 Douching
 Intercourse before 18 years.
Pathophysiology Transit of the fertilized ovum leads to the blocked burrows; blood vessels William’s
dilate leading to walls thinning out and ruptures the tubes. obstetrics, 25th
edition Page no:
371
History and PE  Vaginal bleeding William’s
Findings
 abdominal pain obstetrics, 25th
 amenorrhea edition Page no:
 cervical tenderness 371
 adnexal mass
 doughy uterus
Diagnostic tests  B hCG assay William’s
 Progesterone obstetrics, 25th
 Ultrasound edition Page no:
 Laparoscopy 373 - 376
 culdocentesis
Treatment  conservative surgery- salpingostomy, salpingotomy, segmental William’s
resection with or without reanastomosis obstetrics, 25th
 Radical management-salpingectomy, hysterectomy. edition Page no:
377
Prognosis  Patients with a relatively low beta hCG level will likely have a https://
better prognosis regarding treatment success with single-dose www.ncbi.nlm.ni
methotrexate. h.gov/books/
 The further the ectopic pregnancy has advanced, the less likely NBK539860/
single-dose methotrexate therapy will suffice.
 Prognosis will thus hinge on early recognition and timely
intervention

2. complete abortion

Rule-in: Rule-out: REFERENCE

I will rule in this because the patient is I will rule out because the gestational
having vaginal bleeding, crampy pain, sac should be unidentifiable in
passage of meaty tissues complete abortion
Etiology  Complete abortion may result from certain viruses most notably Williams
cytomegalovirus, herpesvirus, parvovirus, and rubella virus or from obstetrics, 25th
disorders that can cause recurrent pregnancy loss (eg, chromosomal edition Page no:
or mendelian abnormalities, luteal phase defects). 349
 Other causes include immunologic abnormalities, major trauma,
and uterine abnormalities (eg, fibroids, adhesions). Most often, the
cause is unknown.
Epidemiology  Increase with parity, maternal and paternal age William’s
 Women <20 years old 12% obstetrics, 25th
 12 % with men < 20 years old edition Page no:
 26% in women with > 40 years old 349
 20% in men with > 40 years old
Risk Factors  Advanced maternal age William’s
 Previous spontaneous abortion obstetrics, 25th
 Medicines and substances edition Page no:
 Alcohol and drug use 349
  Environmental exposure
 Structural uterine abnormalities
Pathophysiology Death is usually accompanied by hemorrhage in to the decidua basalis Williams
followed by the tissue necrosis adjacent to the bleeding that stimulates obstetrics, 25th
uterine contractions and expulsion. edition Page no:
349

History and PE  Cramping Williams

Findings
 passage of tissue obstetrics, 25th
 blood clots edition Page no:
 Cervical os subsequently closes 349
 heavy bleeding
 gestational sac is not identified
 Beta hCG levels drop quickly.
Diagnostic tests  Transvaginal sonography Williams
 Products of conceptions are seen grossly. obstetrics, 25th
 Serum hCG edition Page no:
349

Treatment No need for therapy, may need surgical or medical management for Williams
ongoing bleeding. obstetrics, 25th
edition Page no:
349

Prognosis Morbidity increases with infections and anemia. Williams

obstetrics, 25th
edition Page no:
349

3. cervicitis

Rule-in: Rule-out:

I will rule in this because the patient is I will rule this out because there is no
having, vaginal bleeding, crampy dyspareunia, dysuria, irritation in vulva,
abdominal pain abnormal vaginal discharges in patient
Etiology Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma Harrison’s
genitalium and anaerobes associated with BV. principles of
internal
medicine, 20th
edition Page no:
984

Epidemiology  High incidence among women aged 15 to 25 Harrison’s

  STI principles of
 More prevalent in HIV positive women than non-HIV internal
 High in developing countries and underserved communities. medicine, 20th
edition Page no:
984

Risk Factors  Age < 25 years Harrison’s

 History of STDs principles of
 Multiple sexual partners internal
 Sexual intercourse at an early age medicine, 20th
 Smoking edition Page no:
 Alcohol or drug use 984
 Unprotected sex
Pathophysiology  Mucopurulent cervicitis (MPC) refers to inflammation of the Harrison’s
columnar epithelium and sub epithelium of the endo cervix and of principles of
any contiguous columnar epithelium that lies exposed in an ectopic internal
position on the ectocervix. MPC in women represents the “silent medicine, 20th
partner” of urethritis in men, being equally common and often edition Page no:
caused by the same agents (N. gonorrhoeae, C. trachomatis, M. 984
genitalium)
 However, MPC is more difficult than urethritis to recognize, given
the nonspecific nature of symptoms (e.g., abnormal vaginal
discharge) and the need for visualization by pelvic examination.
 As the most common manifestation of these serious bacterial
infections in women, MPC can be a harbinger or sign of upper
genital tract infection, also known as pelvic inflammatory disease

History and PE  Yellow mucopurulent discharge Harrison’s

Findings
 Endo cervical bleeding upon genital swabbing principles of
 Dysuria internal
 Dyspareunia medicine, 20th
 Edematous cervical ectopy edition Page no:
984

Diagnostic tests  Gram stain Harrison’s

 Swab test principles of
 Pap smear internal
 Urinalysis medicine, 20th
edition Page no:
984
Treatment  Antibiotics active against C. trachomatis should be provided for Harrison’s
women at increased risk for common STI. principles of
 Concurrent therapy for gonorrhea is indicated if the prevalence of internal
thus infection is substantial in the relevant population. Plus medicine, 20th
treatment for chlamydia infection and single dose regimen effective edition Page no:
for gonorrhea for the treatment of urethritis. 984
 https://
According to the guidelines published by Institut national d’excellence en www.ncbi.nlm.ni
Sante et en services sociaux (INESSS), the empiric regimens are as follows: h.gov/books/
 1g single oral dose azithromycin PLUS either 800 mg cefixime in a NBK562193/
single oral dose or 250 mg intramuscular ceftriaxone in a single
dose
 100 mg oral doxycycline twice daily for 7 days PLUS either 800 mg
cefixime in a single oral dose or 250 mg intramuscular
ceftriaxone in a single dose
 For severe allergy to penicillins/cephalosporins: 2g oral
azithromycin in a single dose

Prognosis The overall prognosis of infectious causes cervicitis is good. Recovery is https://
within a week, or two and a test of cure is not required www.ncbi.nlm.ni
h.gov/books/
NBK562193/