Download - WH Written Case Gynaecology
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7/26/2019 WH Written Case Gynaecology
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GO JIA YEEWH Written Case Gynaecology
History Taking
Venue: Hospital Sultan Ismail Ward 4B (gynaecology ward)
Date: 1!"!#$1%
&atient's identication: #% years old *+inese insurance agent, w+o is &ara $-1+ad an uncomplicated termination o. ectopic pregnancy at /t+wee0 o. gestation andcurrently under postoperati2e care3
Presenting complaint
+is is a postoperati2e case o. ectopic pregnancy w+ere salpingectomy +as 5eendone laparoscopically to remo2e t+e gestation sac in t+e le.t 6allopian tu5e3
History of Presenting Complaint
&atient is a 0nown case o. ectopic pregnancy prior to t+e admission3 S+e waspresented wit+ mild 2aginal 5leeding wit+out any symptoms o. +ypo2olemic s+oc0and se2ere a5dominal pain w+ic+ indicates t+e possi5ility o. ruptured ectopicpregnancy3 7n admission, 2ital signs +ad 5een assessed and 2aginal e8aminationwas done3 trans2aginal ultrasound scan was per.ormed to conrm t+e location o.ectopic pregnancy3 S+e +ad a discussion wit+ t+e consultant a5out t+e managementplan3 Salpingectomy was o9ered and s+e agreed wit+ it3
History of pregnancy (ectopic pregnancy)
+is une8pected pregnancy was conrmed 5y urinary pregnancy test at t+e #ndwee0 o. gestation a.ter s+e +ad missed period .or " days3 S+e went to a pri2ateclinic to reconrm t+e pregnancy immediately3 Howe2er, no .etus was detected int+e uterus3 +e serum +*; le2el was ##3 +e ne8t 2isit was arranged in t+ene8t # wee0s3 t t+e 4t+wee0 o. gestation, t+ere was still a5sence o. .etus in t+euterus and t+e serum +*; reading was 4$$ I=!>3 S+e was suspected wit+ ectopicpregnancy and it was conrmed 5y trans2aginal ultrasound scan3 It was a tu5alectopic pregnancy in t+e le.t 6allopian tu5e3 +e si?e o. t+e gestation sac wasgreater t+an "3cm wit+ t+e 2isuali?ation o. .etal +eart3 re.erral letter to HospitalSultan mina+ was gi2en to +er3
Past gynaecological history
@enarc+e: 1# years old
=sual menstrual cycle:
occasionally
&atient +as no complaints o. intermenstrual 5leeding and postcoital 5leeding
Had an episode o. uncomplicated =I in t+e past % years w+ic+ +as 5eentreated 5y one course o. anti5iotics
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Inecta5le contraception was used .or a mont+
S+e ne2er +ad a cer2ical smear
Co +istory o. se8ually transmitted disease3
Co +istory o. gynaecological surgery and su5.ertility pro5lem
Past medical history
Co signicant past medical +istory
13 5sence o. any c+ronic medical conditions (dia5etes, +ypertension,cardiac disease)
#3 Co pre2ious admission to +ospital
"3 Co +istory o. 5lood trans.usion
Drug history S+e was ta0ing some traditional medicine w+ic+ is 5elie2ed good .or women
+ealt+ 5e.ore t+is pregnancy
Co allergy to drug or .ood
Social history
S+e li2es wit+ +er 5oy.riend and t+ey are +a2ing a sta5le relations+ip
Co nancial pro5lem
Cot smo0ing!alco+ol!drug a5user
Family history
Bot+ parents are t and well Co +istory o. dia5etes, gestational dia5etes, +ypertension and pregnancy
induced +ypertension 5sence o. multiple pregnancy and Down's syndrome
System review
Co .e2er
Co S7B Co c+est pain
Co =I symptoms
Co =I symptoms
Co a5dominal pain
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ICE
IdeasS+e t+in0s t+at t+is ectopic pregnancy mig+t 5e related to t+e traditional +er5 w+ic+s+e +as 5een ta0ing .or se2eral mont+s3
ConcernsS+e worried t+at t+e salpingectomy mig+t reduce t+e c+ances o. getting pregnantin .uture3
ExpectationsS+e needs ad2ices on contraception as s+e does not want to get pregnant in t+e.ollowing # years3
Physical examination
eneral e!amination
lert In postoperati2e mild pain
@edical aduncts: IV assess on le.t +and (Cormal saline)
emperature "%3/E*
&ulse %/ 5pm
*apillary rell time F#s
Blood pressure 1#!
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GO JIA YEEWH Written Case Gynaecology
Co organomegaly
AuscultationBowel sounds are present
Lower limb inspection&ulse o. preti5ial and dorsalis pedis are .elt
Co leg oedema
Co cal. tenderness
Co 2aricose 2ein
Management
@onitor 2ital signs (pulse, 5lood pressure, capillary rell time, temperature andrespiratory rate)
outinely c+ec0 .or a5dominal tenderness*+ec0 +aemoglo5in le2el (prescri5e iron supplement or 5lood trans.usion i.necessary)
*ontinue IVI o. normal saline
ssess appetite, Guid tolerance, 5owel and urinary +a5it
&rescri5e CSIDS .or t+e pain
Wound care (signs o. inGammation and 5leeding)
@easure serum +*; le2el (e8pect dropping in its le2el)
5dominal ultrasound (c+ec0 .or retained o. product o. pregnancy)
Ancourage early mo5ili?ation and maintain good +ydration status
In.orm t+e patient a5out ris0 o. ectopic pregnancy in t+e .uture
Discuss t+e contraception plan
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