wh written case gynaecology

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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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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wh written case gynaecology

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