OBSTETRIC CASE

GENERAL DATA
PATIENT: A. A.
AGE: 23 years old
CIVIL STATUS: Married
OB SCORE: G2P1 (1001)
AOG: 16 weeks
RELIGION: Baptist
OCCUPATION: Accounting Tech
ADDRESS: Hillside Bajada, Davao City
RELIABILITY: 95%
CHIEF COMPLAINT

ABDOMINAL PAIN
 HISTORY OF PRESENT ILLNESS
● Patient had sudden onset of right lower
quadrant abdominal pain noted to be on and off
described as sharp, non-radiating with a pain
6 scale of 6/10.

HOURS ● This was followed by 2 episodes of vomiting

PRIOR TO
ADMISSION
about 400ml consisting of previously ingested
food.

● No associated symptoms were noted such as

fever, loss of appetite, diarrhea, and
constipation. No medications were taken.
 HISTORY OF PRESENT ILLNESS
● Persistence of symptoms with increased
severity noted with a pain scale 10/10.

1 ● Aggravated when the patient sits and

alleviated when lying down.
HOUR
PRIOR TO
ADMISSION ● This was associated with body malaise and
mild cramps at hypogastric area.

● Due to persistence of symptoms patient was

advised for admission.
OB-GYNE HISTORY
● LMP: November 3, 2019
● MENARCHE: 11 years old
● COITARCHE: 20 years old - 1 sexual partner

Menstrual pattern:
● INTERVAL/CYCLE LENGTH: 27 days
● DURATION OF FLOW: 3 days
● AMOUNT OF FLOW: 3-4 moderately soaked pads per day
● ASSOCIATED PAIN: (-) Dysmenorrhea
Method of Contraception: None
OB-GYNE HISTORY
G2P1 (1-0-0-1)
LMP November 3, 2019

AOG 16 weeks 6 days

EDD August 10, 2020

1ST ULTRASOUND: DECEMBER 2019

AOG 16 weeks 4 days

EDD August 9, 2020

OB-GYNE HISTORY

GRAVIDA YEAR OUTCOME SEX PROCEDURE COMPLICATION

G1 2018 TERM M NSVD NONE

G2 Present Pregnancy
ANTENATAL HISTORY
1st TRIMESTER:
5 weeks:
■ Pregnancy test: “POSITIVE”
■ 1st prenatal check-up
■ TVS (+) Fetal cardiac activity
(+) 5 cm right ovarian cyst
■ PAP Smear - unremarkable
■ 5mg Folic acid daily
ANTENATAL HISTORY

8 weeks:
■ 2nd prenatal check-up
■ TVS (+) Fetal cardiac activity
■ Screening tests: CBC & U/A
● CBC results - unremarkable
● UTI - unrecalled medication
ANTENATAL HISTORY

12 weeks:
■ 3rd prenatal check-up
■ TVS (+) Fetal cardiac activity
■ Calcium, Iron, DHA, Vit. C supplement
PAST MEDICAL HISTORY
● Non-Hypertensive
● Non-Asthmatic
● Non-Diabetic
● No history of previous surgeries
● No allergies to any food or medication

UTI (2018 & 2019)

● Unrecalled medication
FAMILY HISTORY

MATERNAL: PATERNAL:
● (+) Hypertension ● Aunt - (+) Breast
● (+) Diabetes Cancer
PERSONAL AND SOCIAL HISTORY

● Non-smoker DIET:
● Non-alcoholic beverage
● Typical Filipino diet
drinker
(rice, fish, chicken,
● Works as an Accounting Tech
vegetables)
● Living in a concrete house
together with her husband’s EXERCISE:
family
● Walking
● Exposed to secondhand
smoking
REVIEW OF SYSTEMS

(-) fever (-) chills (+)fatigue

GENERAL (-) weight change

(-) lumps (-) pigmentation (-)

SKIN lesions (-) rashes

(-) headache (-) dizziness

HEAD
REVIEW OF SYSTEMS

EYES (-) blurring of vision (-) eye pain

(-) hearing loss (-) discharge (-)

EARS ear pain

NOSE (-) nasal discharge (-)epistaxis

MOUTH/THROAT/NECK (-) sore throat (-) dysphagia

REVIEW OF SYSTEMS

CARDIOVASCULAR (-) chest pain (-) palpitations

(-) cough (-) dyspnea (-)

RESPIRATORY wheezing

(+) abdominal pain (+)nausea (+)

GIT vomiting (-) diarrhea (-)
constipation
REVIEW OF SYSTEMS
(-) dysuria (-) frequency
GENITOURINARY (-) urgency (-) hematuria
(-) flank pain

MUSCULOSKELET (-) joint pain (-) edema (-)

AL muscle pain

(-) dizziness (-) seizures (-)

NEUROLOGIC
numbness
REVIEW OF SYSTEMS

HEMATOLOGIC (-) easy bruising

(-) heat/cold intolerance (-)

ENDOCRINE polydipsia (-)
polyuria
 PHYSICAL EXAMINATION

GENERAL OBSERVATION:
Patient was awake, afebrile, slightly weak but
responsive and not in respiratory distress.
 PHYSICAL EXAMINATION

VITAL SIGNS ANTHROPOMETRICS

● Blood pressure:115/70 ● Height: 4’10’’
mmHg ● Weight
● Heart rate:72 bpm ○ Pre-pregnancy: 42kg
● Respiratory rate:17 bpm ● BMI: 19.33 (Normal)
● Temperature:36.7°C
 PHYSICAL EXAMINATION

● SKIN:
○ Good skin turgor
○ No rashes
○ Nails without clubbing or cyanosis

● HEAD:
○ Normocephalic
○ Black, even hair distribution
○ Scalp without lesions, infections or any infestation
 PHYSICAL EXAMINATION
● EYES:
○ Symmetrical in size
○ No redness or dryness
○ Anicteric sclera
○ No inflammation
○ Pink palpebral mucosa

● EARS:
○ Bilaterally symmetrical auricles
○ No discharges and foreign bodies
 PHYSICAL EXAMINATION
● NOSE:
○ Nasal septum midline,
○ No alar flaring, no congestion

● THROAT/MOUTH:
○ Lips are moist & pink mucosa
○ Tongue at midline
○ No ulceration or bleeding of gums
○ No tonsillar exudates
○ No lumps or masses palpated
 PHYSICAL EXAMINATION

● BREAST:
○ Not performed
 PHYSICAL EXAMINATION

● RESPIRATORY:
○ Inspection:
■ Symmetrical, no abnormal retractions, no accessory
muscles used
○ Palpation:
■ Symmetric tactile fremitus, equal lung expansion
○ Percussion:
■ Equal resonance on both lung fields
○ Auscultation:
■ Normal breath sounds, no wheezing or crackles
 PHYSICAL EXAMINATION

● CARDIOVASCULAR:
○ Inspection:
■ Adynamic precordium
■ No scars or lesions noted
○ Palpation:
■ PMI between 4th & 5th intercostal space left midclavicular
midline
■ No heaves or thrills noted
○ Auscultation:
■ Normal S1 & S2
■ No murmurs or abnormal heart sounds
 PHYSICAL EXAMINATION

● MUSCULOSKELETAL:
○ No atrophy or fasciculation
○ Good range of motion

● GENITOURINARY:
○ Negative kidney punch
 PHYSICAL EXAMINATION

● ABDOMEN:
○ The uterus was palpated at the hypogastric area with a
fundic height of 15 cm with striae gravidarum. FHT of
138 bpm was heard at the left lower abdomen.
○ No tenderness, guarding, rebound tenderness noted
upon palpation.
 PHYSICAL EXAMINATION

● GENITALIA:

○ Speculum Exam:
■ Minimal whitish, non-foul smelling discharge
■ No lesions on cervix
PHYSICAL EXAMINATION

○ Internal Exam:
■ I: inserts 2 fingers with ease
■ C: smooth cervix, closed. Negative wriggling
tenderness
■ U: enlarged to 16-18 weeks size
■ A: 4 x 5 cm mass, movable mass with tenderness at
right adnexa.
Negative mass and tenderness on left adnexa
■ D: none
 PHYSICAL EXAMINATION

● NEUROLOGIC
○ Mental status: Patient is alert, coherent, well-
groomed. Speech is fluent and words are clear.
Thought processes are coherent, insight is good. She
is oriented to person, place and time.
 PHYSICAL EXAMINATION

● NEUROLOGIC
○ Cranial nerve
■ I – patent nostrils with intact sense of smell
■ II – pupils reactive to light
■ III, IV , VI – normal extraocular movements
with perfect peripheral vision
■ V – can open mouth against resistance, clench
teeth, and feel sensations in entire face.
 PHYSICAL EXAMINATION

● NEUROLOGIC
○ Cranial nerve
■ VII - no asymmetry noted; no involuntary
movements; puffs cheeks
■ VIII – responds to sound well
■ IX – able to swallow without pain
■ X – positive gag reflexes
■ XI – able to shrug shoulders against resistance
■ XII – tongue symmetrical and at midline
 PHYSICAL EXAMINATION

● NEUROLOGIC
○ Motor: 5/5 in both upper and lower extremities
○ Deep tendon reflexes: Normal
○ Sensory: pinprick, light touch, position and vibration
intact
○ Cerebellar: not performed
○ Pathologic reflexes: not performed
 SALIENT
FEATURES
 PERTINENT POSITIVES
● Age of patient: 23 y.o.
● Pregnancy 16 weeks 6 days age of gestation
● G2P1 (1001)
● Mild cramps at hypogastric area
● Nausea
● Vomiting
● Body malaise
● Sharp right lower quadrant abdominal pain
● Right ovarian cyst measuring 5cm
● Previous history of UTI
● Fatigue
● Tenderness on right adnexa
● Closed cervix
● (+) FHT
 PERTINENT NEGATIVES
● No anorexia
● No fever
● No history of vaginal bleeding
● No passage of meaty tissue
● No tenderness at left adnexa
● No direct rebound tenderness
● Negative kidney punch sign
 Initial Impression:

G2P1 (1001)
Pregnancy uterine 16 weeks and 6 days age of gestation;
Ovarian New Growth to consider Torsion
 ENTIA
DIFFER L
DIAG NOSIS
 NON OBSTETRIC
RULE IN RULE OUT
● Right Lower ● No anorexia
Quadrant ● No direct and
Abdominal Pain rebound
● Vomiting tenderness
ACUTE ● Nausea ● Cannot be
APPENDICITIS completely ruled
out, request for
CBC &
abdominal USD

References: P.3832 Williams obstetrics 25th edition; P.1256 Schwartz Principles of Surgery
 NON OBSTETRIC

RULE IN RULE OUT

● Nausea
● No fever and
● Vomiting
chills
● Right lower
ACUTE ● Negative kidney
quadrant
PYELONEPHRITI punch sign
abdominal pain
S ● Request for
● Previous history
urinalysis
of UTI
● Pregnancy

References: P.3740-3747. Williams obstetrics 25th edition;

 GYNECOLOGIC

RULE IN RULE OUT

● Right Lower ● Cannot be completely
Quadrant Abdominal ruled out, needs
Pain further patient
● Vomiting evaluation for
● Nausea progress of pain
● 23 years old
OVARIAN ● Pregnancy 16weeks 6
TORSION/CYST days AOG
● History of Right
ovarian cyst

Reference p.418 comprehensive gynecology by lobo

 OBSTETRIC
RULE IN RULE OUT

● No history of vaginal
bleeding
INCOMPLETE ● Mild cramps at
● No meaty show
ABORTION hypogastric area
● Closed cervix
● (+) FHT

● No vaginal bleeding
MISSED ● No passage of tissue
ABORTION ● Closed cervix ● (+) FHT

References: P.1250-1253 Williams obstetrics 25th edition;

 OBSTETRIC

RULE IN RULE OUT

● Mild cramps at ● No history of
hypogastric vaginal
area bleeding
THREATENED
● (+) FHT ● Cannot be
ABORTION
● Closed cervix completely
ruled out

References: P.1248-1249 Williams obstetrics 25th edition;

 Final Impression:

G2P1 (1001)
Threatened Abortion 16 weeks and 6 days age of gestation; Acute
appendicitis Vs Ovarian New Growth