THE STATE UNIVERSITY OF ZANZIBAR

SCHOOL OF HEALTH AND MEDICAL SCIECES - MBWENI

OBSTETRIC AND GYNAECOLOGY CASES

PREPARED BY CLINICAL MEDICINE STUDENTS CLASS 2019-2022

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Contents
CASE 01: Urinary Tract Infection (UTI) in Pregnancy
CASE 02: Post MVA secondary to incomplete abortion
CASE 03: Dysmenorrhea

CASE 04: Pre term pre-labour ruptured of membrane (PPROM)

CASE 05: Acute Pelvic Inflammatory Disease

CASE 06: Pre-viable rupture of Membrane

CASE 07: Pre-term pre labour Rupture of Membrane

CASE 08: Post ceasarean section

CASE 09: Anaemia in Pregnancy

CASE 10:Term pregnancy not in labour & Gestational diabetes in term of pregnancy

CASE 11: Molar Pregnancy

CASE 12: Inevitable Abortion

CASE 13: False labour with 2 previous scar

CASE 14: Post C-Section 2° malpresentation of the fetus

CASE 15: [Link] in Pregnancy 2° poor diet

CASE 16: [Link] in Pregnancy 2° poor diet

CASE 17: [Link] in Pregnancy 2° poor diet

CASE 18: [Link] 2° PPH & Maternal Puerperal Sepsis

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 CASE 01: Urinary Tract Infection (UTI) in Pregnancy

NAME: XXX XXX XXX

AGE: 18 years.

SEX: FEMALE.

RELIGION: MUSLIM.

OCCUPATION: WEAVER.

ADDRESS: MUAMBE, PEMBA, ZANZIBAR.

MARITAL STATUS: MARRIED.

DATE OF ADMISSION: 19TH MAY, 2022.

TIME OF ADMISSION: 10:30 AM.

DATE OF CLERKSHIP: 19TH MAY, 2022.

TIME OF CLERKSHIP: 10:30 AM.

LNMP: 19TH APRIL, 2022.

NULL PARITY.

CHIEF COMPLAIN.

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 Amenorrhea for 3 weeks.

Low Abdominal Pain for 3 Days.

Low Grade Fever for 3 Days.

Painful urination for 2 days.

HISTORY OF PRESENTING ILLNESS.

The patient came with history of amenorrhea for 3 weeks, of gradual onset, progressive as time
went on. No aggravating factors, no relieving factors and no associating factors. No history of
use of contraceptives and no history of sexual abstinence. She also came with history of painful
urination for 2 days, of acute onset, progressive as time went on. No aggravating factors, no
relieving factors but associated with frequent urination. No history of passing blood in stool, no
history of abnormal vaginal discharge.

The patient also came with history of low grade fever for 3 days, of acute onset, on and off and
progressive as time went on. No aggravating factors, no relieving factors but associated with
mild headache which is persistent. No history of convulsions, no history of confusion, no history
of loss of consciousness and no history of blurred vision.

Also the patient came with history of low abdominal pain for 3 days, of acute onset, progressive
as time went one and cramping in nature. No aggravating factors, no relieving factors but
associated with loss of appetite, nausea and non – projectile vomiting. No history of painful
defecation, no history of passing loose stool, no history of passing blood in stool, no history of
difficulty in passing stool, and no history of inability to pass stool.

REVIEW OF OTHER SYSTEMS.

RESPIRATORY SYSTEM – No history of cough, no history of difficulty in breathing, no

history of running nose, no history of whistling sounds heard on breathing, no history of chest
tightness, no history of chest pain and no history of foul smelling breath.

CARDIOVASCULAR SYSTEM – No history of shortness of breath, no history of heart

palpitations, no history of lower limb swelling.

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MUSCULOSKELETAL SYSTEM – No history of joint pain, no history of inability to utilize
joints, no history of joint swelling, no history of muscle ache, no history of painful limb swelling
and no history of inability to utilize limbs.

PAST MEDICAL HISTORY.

No history of admission, no history of blood transfusion, no history of surgical intervention, no

history of food and drug allergy. No history of tuberculosis, no history of asthma, no history of
sickle cell disease, no history of diabetes mellitus and no history of hypertension.

GYNAECOLOGICAL HISTORY.

She started her menarche when she was 15 years old and her menstrual cycle is of 28 days with a
period of 5 days. During her period she uses three pieces of khanga for the first day which are
not fully soaked and she also uses 2 pieces of khanga from day 2 to day 4 of her period days and
one piece of khanga on her 5th period day. No history of any gynecological medical condition
and no history of use of contraceptives.

OBSTETRIC HISTORY.

No history of previous pregnancies, and possibly this is her first pregnancy and she hasn’t started
Ante – Natal Care (ANC) Clinic yet.

FAMILY AND SOCIAL HISTORY.

She is a weaver while her husband is a fisher. Together they live in the same house and they have
no any child. No history of asthma, hypertension, diabetes mellitus in the family. No history of
cigarette smoking and alcoholism.

SUMMARY 1.

18 years old female from Muambe, null parity, whose LNMP was in 19 th APRIL, 2022. She
came with chief complain of amenorrhea for 3 weeks, painful urination associated with increased
frequency of urination for 3 days, low abdominal pain associated with nausea, loss of appetite

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and vomiting for 3 days and low grade fever and mild headache for 2 days. No history of use of
contraceptives and no history of sexual abstinence.

GENERAL EXAMINATION.

The patient was conscious, oriented to people, place and time, afebrile on touch, not dyspnic
with blackish hair that was good in texture and well distributed all over the head. Not jaundiced,
not pale, not cyanotic. No eye, ear and nasal discharge. No eye, ear and nasal abnormality. No
angular stomatitis, no finger clubbing, no enlarged lymph nodes. No lower limb edema.

VITAL SIGNS.

Temperature was 36.7 degrees of Celsius.

Respiratory rate was 16 breaths per minute.

Pulse rate was 72 beats per minute, regular irregular with strong volume.

Blood pressure was 110/72 mmHg

PER ABDOMEN EXAMINATION.

On Inspection; the abdomen was flat, moves with respiration with the umbilicus inverted. No
visible swelling, no visible therapeutic mark(s) and/or surgical scar(s).

On Superficial Palpation; no tenderness and no palpable mass.

On Deep Palpation; no organomegaly of the liver, spleen and kidney.

On Percussion; tympanic note was heard.

On Auscultation; 3 bowel sounds per minute were heard.

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CARDIOVASCULAR SYSTEM EXAMINATION.

On Inspection; the hands were warm with capillary refill within 2 seconds. Pulse rate was 72
beats per minute, regular – regular with strong volume and blood pressure was 110/72 mmHg
taken on the left arm in sitting position. No jugular venous distension. No precordial
hyperactivity and no precordial bulging.

On Palpation; the apical beat was palpable at 5th Intercostal space along the left mid – clavicular
line.

On Auscultation; sound 1 and sound 2 were heard but with irregular rhythm and an added
sound in between.

RESPIRATORY SYSTEM EXAMINATION.

On Inspection; the chest was flat, symmetrical in shape and moves with respiration, with
respiratory rate of 16 breaths per minute. No visible swelling, no visible therapeutic mark(s)
and/or surgical scar(s).

On Palpation; trachea was centrally located with normal tactile vocal fremitus and symmetrical
chest expansion. No palpable tenderness.

On Percussion; resonant note was heard.

On Auscultation; vesicular breathing sounds were heard.

CENTRAL NERVOUS SYSTEM EXAMINATION.

The patient was conscious with Glasgow Coma Scale of 15/15 (Eye 4/Verbal 5/Motor 6), well
oriented to people, place and time.

Language, speech, both long and short term memory and thought were all intact. All cranial
nerves were intact.

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SUMMARY 2.

18 years old female from Muambe, null parity, whose LNMP was in 19 th APRIL, 2022. She
came with chief complain of amenorrhea for 3 weeks, painful urination associated with increased
frequency of urination for 3 days, low abdominal pain associated with nausea, loss of appetite
and vomiting for 3 days and low grade fever and mild headache for 2 days. No history of use of
contraceptives and no history of sexual abstinence.

On general examination, all vital signs were normal.

PROVISIONAL DIAGNOSES

Pregnancy.

Urinary Tract Infection (UTI) in Pregnancy.

DIFFERENTIAL DIAGNOSES.

Emesis Gravidurum

Malaria In Pregnancy.

INVESTIGATIONS.

Urine Pregnancy Test (UPT)), which was found to be positive.

Abdominal Pelvic Ultrasound.

Urinalysis.

MRDT.

Serum Electrolyte.

DIAGNOSIS: Urinary Tract Infection (UTI) in Pregnancy

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 Because the patient was found to be pregnant, so she is Prime Gravida with the Gestation
Age of 4 weeks and 2 days according to Last Normal Menstrual Period (LNMP) of 19th
April, 2022 with the Expected Date of Delivery (EDD) of 26th January, 2023, my diagnosis
is Urinary Tract Infection (UTI) in Pregnancy.

MANAGEMENT.

Tablet Erythromycin 500mg TDS for 5 Days.

Tablet Paracetamol 1g TDS for 3 Days.

HEALTH EDUCATION.

Adequate fluid intake.

Attending ANC clinic.

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 CASE 02: Post MVA secondary to incomplete abortion

NAME: XXXX XXXX XXX

AGE:22 YEARS
SEX: FEMALE
ADDRESS: MWAMBWE
DOA: 01-6-2022
TOA: 01:30
LNMP:10-3-2022
EDD: 17-12-2022
GA: 11 weeks +1 day
G3 P2 L2 A1
CHIEF COMPLAIN: Lower abdominal pain 1∕7
PV bleeding
HPI: Mother complain of lower abdominal pain for 1 day of gradual onset cramping in nature
which progress as time goes on, no aggravating factor, no relieving factor, associated by
vomiting 3 times which was projectile in nature, contain fluid particles no constipation, no
diarrhea, no blood in the feces.
Also, mother complain history of PV bleeding for 1 day of gradual onset which progress as time
goes on, heavy in nature with clots, no aggravating factor, no relieving factor, associated with
dizziness and headache, no history of fever, convulsion, confusion, loss of consciousness.
REVIEW OF OTHER SYSTEM

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Genital urinary system: -No history of frequent urination
-No history of pain during urination
Respiratory system: -No history of chest pain
-No history of cough
Cardiovascular System: - No history of awareness of heartbeat
- No history of lower limb edema
Muscle skeletal system: - No history of joint pain
-No history of muscle pain
PAST MEDICAL HISTORY: -Has history of admission
-No history of blood transfusion
-No history of surgery
-No history of food/ drug allergy

GYNAECOLOGICAL HISTORY: She started menarche since she was 16 years old, she was
having regular menstrual bleeding associated with slightly abdominal cramps, she changed pads
2 times per day, and the blood was in normal amount, she gets menstruation for 7 days in each
month, no history of using family planning methods, no history of pain during sexual
intercourse, no history of sexual transmitted diseases.
OBSTETRIC HISTORY: -She has two children.
The first child delivered at ABDALLA MZEE HOSPITAL via spontaneously vaginal delivery
with birth weight of 2.6kg, and no any complication after birth.
And second child was born at the home through spontaneously vaginal delivery with birth weight
of 2kg and no further complication get during and after birth.

FAMILY AND SOCIAL HISTORY: She is married with 2 children and live with her family, she
is housewife and her husband a business man, no history of using alcohol & cigar rete smoking
in a family, no history of chronic diseases in the family like HTN, DM, Asthma.
GENERAL EXAMINATION: The patient was alert, full conscious, well oriented with people,
place and time, with GCS 15/15, afebrile, she was pale, she has angular stomatitis to both sides
of the mouth, no jaundice, no cyanosis, not dyspnea, no lower limb edema.
VITAL SIGNS: Blood Pressure =110/70mmHg, Pulse Rate =98b/min, Respiration Rate
=23b/min, Temperature =36.5oc

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SYSTEMIC EXAMINATION
GASTROINTESTINAL SYSTEM: -The abdomen is flat with normal contour and move with
respiration, umbilical is inverted have striae on lower part of abdomen, no scar and no mark,
tympanic percussion note heard, spleen, liver and kidney not palpable, bowel sound heard 3 per
minute on auscultation.
RESPIRATORY SYSTEM: -The chest was symmetrical, move with respiration, tracheal is
centrally located, normal chest expansion, no scar and no surgical mark, no mass no deformity
palpable, resonance percussion note heard, normal vesicular breathing sound heard on
auscultation.

CARDIOVASCULAR SYSTEM: - The patient hands were warm, no cyanosis, normal capillary
refill within three seconds, no finger clubbing, normal pulse rate which was regular and normal
volume, non-collapse and synchronal, no jugular vein distention and precordium area not bulged,
apex beat was felt in 5th intercostal space left mid clavicular line, S1 and S2 were heard and no
added sound.
CENTRAL NERVOUS SYSTEM: - patient was alert, full conscious, with an intact memory
both short and long-time memory, well oriented with people, place, and time, cranial nerves were
assessed and were intact, normal muscle tone and power, no meningeal sign detected.

SUMMARY: 22 years old Female from MWAMBWE 1 day in the ward with GA 11 weeks and
1 day came with complain of lower abdominal pain which was cramping in nature associated
with projectile vomiting and she vomited 3 times a day, also came with the complain of PV
bleeding which was heavy with clots associated with dizziness and headache. No any physical
finding on general and systemic examination.
IMPRESSION DIAGNOSIS: Post MVA secondary to incomplete abortion
DIFFERENTIAL DIAGNOSIS: Ectopic pregnancy
Complete Abortion
INVESTIGATION
• FBP (Full blood picture).
• Abdominal pelvic ultrasound
Blood for grouping and X-matching
Serum electrolyte
TREATMENT
Cap. Amoxycillin 500mg tds 5/7

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 Tab. PCM 1g tds 3/7
• Tab FEFO OD for one months
• Tab metronidazole 400mg TDS 5/7
• Counseling on family planning.

COMPLICATIONS
Early
Hemorrhage -anemia-shock-renal failure
Sepsis
Late
Pelvic Inflammatory Disease, which may lead to infertility
Chronic pelvic pain
Emotional disturbance: Depression-marital disharmony
PREVENTION
Avoid heavy activity during pregnancy

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 CASE 3: Dysmenorrhea

Name: XXX XXX XXX

18 years old,

Frmale,

Kipangani,

5 hours in the ward.

Chief complain

Lower abdominal pain for 1 hr

History of presenting illness

The patient complain lower abdominal pain for 1 hr which was sudden onset increase as time
goes on which was cramps in nature, the pain migrate to thigh aggravating when walking no
relieving factor but it was associated with vomiting 1 times which contain food particles and was
yellowish in colour. No history of per vagina discharge and bleeding, no history of painful
urination, fever, headache and diarrhea.

Review of other systems

Respiratory system: No history of coughing, difficulty in breathing and chest pain.

Cardiovascular system: No history of heartbeat awareness, chest tightness and lower limb
swelling.

Past medical and surgical history

No history of admission

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No history of blood transfusion

No history of surgery.

No history of food and drug allergy.

No history of alcohol use and cigarette smoking.

No history of chronic diseases such as hypertension, diabetic mellitus, asthma and sickle cell
diseases.

Gynecological history

She started menarche when she was 15 years old. She was having irregular menstrual cycle
which some days took 2 month or having 2 times per month. She took 3 to 5 days, and changes 2
pads per day which was partially socked and it was associated with abdominal pain.

Family and social history

Third born out of 6 children live with her parents. Her level of education is secondary level.

No history of alcohol use and cigarette smoking in her family.

There is history of chronic diseases in her family which is Asthma but no history of hypertension,
diabetic mellitus and sickle cell disease.

General examination

The patient is well oriented with people, place and time with GCS of 15/15, hair are well
distributed with blackish colour and normal texture not pale not jaundice no discharge in eyes,
ears and nose. No palpable peripheral lympnode no lower limb edema.

Vital signs

Blood Pressure=115/74mmHg

Respiratory Rate= 16bpm

Pulse Rate= 68bpm

Temperature=36°C

SYSTEMIC EXAMINATION

Per abdomen examination

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On inspection: The abdomen is flat move with respiration and umbilical is inverted.

On superficial palpation: There is tenderness

On deep palpation: There is no any palpable organ such as liver, spleen and kidney.

On percussion: Tympanic sound heard

On auscultation: 4 bowel sounds heard per minute.

Cardiovascular system

On inspection: No bulging of precordium area, no jugular venous distention.

On palpation: Hands were warm, capillary refill is less than 2 seconds radio pulse was 68bpm
with strong volume regular regular which synchronized with left radio pulse and blood pressure
was 115/74mmHg at sitting position. Apex beat was felt at left 5 th intercostals space middle
clavicular line.

On auscultation: Sound1 and sound 2 were heard.

Respiratory system

On inspection: The chest is flat move with respiration symmetrically, respiratory rate was
16bpm.

On palpation: Trachea was central located, chest expansion was symmetrically, tactile vocal
fremitus was felt.

On percussion: Resonance sound heard.

On auscultation: Vesicular breathing sound heard.

Central nervous system

The GCS was 15/15 the long term memory and short term memory were intact. The language,
speech and thought were intact. All cranial nerve were intact as follow:

Cranial nerve I was intact because patient can see 5 meter away from him.

Cranial nerve II was intact because patient can smell

Cranial nerve III, IV and VI were intact because patient can move eye in all directions.

Cranial nerve V was intact because patient can close and blow mouth.

Cranial nerve VII was intact because patient can do facial expressions like smiling, angry.

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Cranial nerve VIII was intact because patient can stand while his eyes are closed.

Cranial nerve IX and XII were intact because patient can taste.

Cranial nerve X was intact because gag reflux was positive.

Cranial nerve XI was intact because patient can rise his shoulder with and without resistance.

Summary

18 years old female from Kipangani 5 hrs in the ward came with the complain of lower
abdominal pain for 1hr which was sudden onset increase as time goes on cramps in nature, the
pain migrate to the thigh aggravating when walking no relieving factor but it was associated with
vomiting. No history of per vagina discharge and bleeding, no history of painful urination, fever,
headache and diarrhea. On examination there is tenderness on superficial palpation.

Provisional diagnosis is Dysmenorrhea

Differential diagnosis

Chronic Urinary tract infections

Pelvic inflammatory disease

Fibroids

Abortion

Investigation

Hormonal profile

Pelvic Ultra sound

Full blood picture

Treatment

Injection hyocine 100mg start

Tab ibuprofen 400mg tds for 3 days

IV fluid Ringer Lactate 500mls for resuscitation.

Prevention

Exercise may ease the pain of menstrual

Heat: put heat water bottle on your lower abdomen may ease the pain

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Avoiding alcohol and cigarette can make menstrual worse

Complications

Fertilized problem due to endometriosis

Ectopic pregnancy due to pelvic inflammatory disease

Prognosis;

The prognosis of patient was good

CASE 04: Pre term pre-labour ruptured of membrane (PPROM)

Name: XXX XXX XXX

Address: Matemwe

Age: 24yrs

Date of admission: 7/6/2022

PRIME GRAVIDA. GA 29weeks

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Main complaint: per vaginal watery discharge 1/12

HISTORY OF PRESENTING ILLNESS

Her main complaint was per vaginal watery discharge mix with blood for one month gradually
onset increase their leakage as days goes on and more leakage during night no aggravating and
relieving factor but associated with lower abdominal pain denying history of vomiting diarrhea,
painful urination or blood in urine.

ROS

Central nervous system: no history of headache, no history of convulsion and loss of

consciousness

Respiratory system: no cough, no difficult in breathing, no chest tightness.

Cardiovascular system: no heart beat awareness, no lower limb edema, no chest pain.

Musculoskeletal system: no history of skin rashes, no history of joint pain, no history of muscle
pain and muscle cramp.

PAST MEDICLE HISTORY

No history of admission, no history of chronic illness like diabetes, hypertension and asthma. No
history of food and drug allergy.

OBSESTRIC HISTORY

This is the first pregnancy, she started antenatal clinic at 4 months of pregnant and visited two
times. Last hb was 12g/dl, all investigation done and was negative like HIV and syphilis, She
was receive two TT vaccine to this pregnant and No history of UTI and any other disease during
pregnancy.

GYNACOLOGICAL HISTORY

She started to get menses on std 7, her menstrual cycle is 29/4, she 2-piece pf kanga per day not
being socked. No history of Pelvic inflammatory disease (PID), no history of contraceptive
device used and no history of gynecological surgery.

FAMILY AND SOCIAL HISTORY

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Married leave with her husband, she is a housewife and her husband is famer, no history of
abortion and premature baby, no history of chronic illness to her family like hypertension,
diabetes and asthma.

GENERAL EXAMINATION

Patient was conscious, oriented time people and place, the hair was black normal texture and
well distributed. Not pale, not jaundice, not cyanosed, no discharge around the eye, ear and nose.
Not dyspneic, no palpable lymph node, and no lower limb edema.

Vitals: BP = 108/66, PR = 115 b/min, Temp = 36.5 and RR = 17b/min, SpO2 = 95% on RA

PER ABDOMEN

Inspection: abdomen was distended, have linear nigral and move with respiration. No surgical
and therapeutic mark and the umbilical was inverted.

Palpation: no tenderness, no mass, no organomegaly

The fundal height occupied by the buttocks, the baby lies longitudinal and the back of the baby
feels at the right side of the mother also presenting part was cephalic.

Fundal Height = 29cm and Fetal Heart Rate = 141b/min.

On speculum examination: cervix was closed. There is a colorless fluid with slightly blood
oozing from orifice with no smell.

RESPIRATORY SYSTEM

Inspection: chest was flat, move with respiration no surgical and therapeutic mark.

Palpation: trachea was located centrally, no tenderness, no surgical and therapeutic mark.
Symmetrically chest expansion and tactile vocal fremitus was normal.

Percussion: resonance sound heard

Auscultation: normal breathing sound heard

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CARDIOVASCULAR SYSTEM

Inspection: No pericardial bulging, no pericardial hyperactivity.

Palpation: Hand was warm, capillary refill revealed within 2 sec, pulse was regular regular with
normal volume, synchronized with right redial artery and femoral artery, no rising of jugular
venous pressure, the apex beat was located at fifth left intercostal space midclavicular line.

Auscultation: Sound 1 and sound 2 heard.

MUSCULOSKELETAL SYSTEM

Inspection: normal appearance of the limbs with no scar, no mark, no swelling.

Palpation: normal sensation, tone, power, no edema and no tenderness.

Percussion: patella reflex was normal.

CENTRAL NERVOUS SYSTEM

Patient was conscious oriented time people and place, with GCS 15/15, long term memory and
short-term memory were intact.

Power was 5/5 bilateral upper and lower limbs.

And all cranial nerve was intact and tested as

CNⅠ: patient can detect smell of an object

CNⅡ: patient can see far to the 6meter away and near clearly.

CNⅢ,Ⅳ,Ⅵ: patient can rotate the eyeball at all direction.

CNⅤ: Patient can blow and chewing normally

CNⅦ: Patient can wrinkle, smile, and blink the face.

CNⅧ: Patient can hear well and stand properly even closed the eyes.

CNⅨ,Ⅻ: Patient can feel sweet, salt, sour and better also can move the tongue at all direction.

CNⅩ: Gag reflex was present.

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CNⅪ: Patient can rotate their neck

SUMMARY

Female from matemwe 24 years 1 day in the ward. She came with complain of pv watery
discharge with some blood for one month gradually onset associated with lower abdominal pain
with no vomiting, diarrhea and painful urination. On examination not pale, afebrile, abdomen
was distended and have watery discharge with blood oozing and cervix was intact during
speculum examination. Vitals were stable.

Provision diagnosis: Pre term pre-labour ruptured of membrane (PPROM).

Differential diagnosis

Hydronium gravidarum

Urinary tract infection

Pelvic inflammatory disease

INVESTIGATION

Full blood picture

Urinalysis + culture and sensitivity

High vaginal swab (gram staining and culture and sensitivity)

Obstetrics ultrasound

TREATMENT

Complete bed rest

IV ringer’s lactate 1000mls start

Tab erythromycin 500mg tds 5/7

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Tab bascopen 10mg 3/7.

Tab fefol 1*1

PREVENTION

Avoid heavy work

Use of folic acid drug

Attend clinic regularly.

When feel danger sign quickly return to hospital.

PROGNOSIS

The patient was doing well when keep in complete bed rest.

COMPLICATION

Preterm labour and premature babe.

Chorioamnionitis.

Cord prolapses.

Dry labour.

CASE 05: Acute Pelvic Inflammatory Disease

NAME: XXX XXX XXX

AGE: 34 years

SEX: FEMALE

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ADRESS: MZURI

DATE: 2/6/2022

T . O . A : 12:20Pm

LAST NORMAL MENSTRAL PERIOD: 28/05/2022

PARA 5, LIVING 5, ABORTION 0

CHIEF COMPLAIN: Lower abdominal pain 6/7

Vaginal discharge 5/7

Fever 5/7

HISTORY OF PRESSENTING ILLNESS:

Patient complain about lower abdominal pain 6 days ago prior to admission which was gradual onset
increase in severity when times goes on colic in nature , the pain radiating to the back with no
aggravating , reliving factors but associated with nausea and loss of appetite dinied history of
diarrhea ,no history of vomiting no ,no history of constipation, no history of difficult in swallowing no
blood in stool no difficult in passing urine no pain during urination.

Also patient complain about acute onset of per vaginal discharge watery like fluid, yellowish in color and
painfully during sexual intercouse with bleeding after sexually intercouse no smell no itching.

As well as patient come with complain of fever which was acute onset increase in severity whentimes
goes on ,the fever was come on and off, no aggravated factor but relived by tabparacetamol ,with no
associated factor, denied history of convulsion, No history of loss of conscious,No history of confusion

REVIEW OF OTHER SYSTEM

Respiratory System: - No history of cough, No history of chest pain ,No history of chest tightness No
difficult in breathing,

Cardiovascular System: - No history of awareness of heart beat , No history of lower limb swelling

Muscle Skeletal System: - No history of muscle pain, - No history of joint pain.

Central nerve system:- no headache, -no dizziness ,no blurred vision

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PAST MEDICAL HISTORY: - No history of admission ,No history of food and drug allergy

No history of blood transfusion, No history of surgery.

GYNECOLOGICAL HISTORY: She started menarche since 14years, she was having regular menstrual
bleeding which was associated with slightly abdominal cramps, she changed pads three times a day and
the blood was in normal amount, and she get menstruation for 7 days in each month. Has history of
using family planning methods such as IUCD, haS history of pain during sexual intercourse, no history of
sexual transmitted diseases, no history of gynecological problems, nohistory of any gynecological
procedure.

FAMILY AND SOCIAL HISTORY: - She is married woman with four children and live with her family, but
her one child passed away since he was in seven month ,She is a house wife and her husband is a
business man, No history of using alcohol and cigarette smoking in a family, No history of chronic
diseases in his family.

GENERAL EXAMINATION : The patient was alert, full conscious ,well oriented with,people ,place and
time , with GCS 15/15 , afebrile, she was pale , she has angular stomatitis to both sides of the mouth, no
jaundice, no cyanosis , not dyspnea, no lower limb edema.

VITAL SIGN: Blood Pressure =100/70mmHg,

Pulse Rate =85b/min Respiration Rate 23b/min, Temperature =37.2c

SYSTEMIC EXAMINATION.

GASTROINTESTINAL SYSTEM: -

The abdomen is flat with normal contour and move with respiration, umbilical is inverted, no scar and
no mark, no tenderness on superficial palpation no mass, on deep palpation no organomegaly, tympanic
percussion note heard, Bowel sound heard 4 per minute on auscultation.

CENTRAL NERVOUS SYSTEM :

- patient was ,full conscious , with an intact memory both short and long time memory , well oriented
with people, place, and time, Cranial nerves were assessed and were intact normal muscle tone and
power,No meningeal sign detected.

RESPIRATORY SYSTEM: -

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The chest was symmetrical, move with respiration, normal chest expansion, no scar and no surgical
mark ,no mass no deformity palpable , tracheal is central located, tactile vocal fremitus is normal
resonance percussion note heard,normal vesicular breathing sound heard on auscultation.

CARDIOVASCULAR SYSTEM : -

The patient hands were warm , no cyanosis ,normal capillary refill within three seconds, no finger
clubbing , normal pulse rate which was regular and normal volume ,non-collapse and synchronal, no
jugular vein distention and precordium area not bulged,Apex beat was felt in 5th intercostal space left
mid clavicular line,S1 and S2 were heard and no added sound.

MUSCULOSKELETAL SYSTEM:

Normal appearance of the limbs with no scar no marks no deformity no swelling, normal sensation, tone
and power,On palpation no edema and no tenderness,On percussion patella is normal.

SUMMARY: 34 old female from Jambiani come with chief complain of lower abdominal pain 6 days ago
the pain radiating to the back colic in nature no aggravating ana reliving factor but associate with loss
appetite, also complain watery pv discharge yellowish in color and painfully during coitus with bleeding
after coitus no smell no itching in addition of low grade fever and has history of using family planning
method such as IUCD ,On examination the vital sign are normal and on examination all are normal.

Impression diagnosis: - acute pelvic inflammatory disease

Differential diagnosis :-acute appendicitis , complicated UTI

ectopic pregnancy

torsion of ovarian cyst

INVESTIGATION:-

pelvic ultrasound scan

culture and sensitivity

25
urinalysis

UPT test

TREATMENT

inj ceftriaxone intravenous 1gm startplus doxycyline

tab metronidozone 400mg tds for twor weeks

tab azithromycin 500mg tds for two weeks

tab doxycyline 100mg tds for two weeks

PREVENTIION

Primary prevention.

Safe sex , avoid multiple sexual pertness , avoid excessive douching

Secondary prevention.

Early diagnosis and prompt treatment

Health care providers and relatives should ensure that the patient take medicine at accurate time and
correctly.

Tertiary prevention.

Health care providers should manage complications effectively in order to prevent death.

COMPLICATIONS

Septicemia

Ectopic pregnancy

Infertility

Peritonitis

PROGNOSIS :-Prognosis is good if the give the correct management and adhere on it.

26
FOLLOW UP.

The patient should return the hospital after two week of treatment to be assessed if the treatment is
valid or not.

CASE 06: Pre-viable rupture of Membrane

XXX XXX XXX

FROM MATEMWE

36 YEARS OLD

ADMITTED ON 19 MAY 2022 IN GYNA WORD

1 DAY IN THE WARD

LNMP 11/12/2021

EDD 18/09/2022

27
GA 23W

G6POLOA5

Chief complain per vagina watery discharge /1day

HISTORY OF PRESENTING ILLNESS

Patient came with chief complain of PV watery discharge for 1 day ,the fluid was clear in color , not
blood ,not smelling which was gradually onset ,increased in severity of leakage as time goes on ,no
aggregating factor ,no relieving factor , associated with back pain,

Denied history of pain during urination, blood in urine and had normal urine in amount and color

She has amenorrhea for six months

She is group O-ve and has never received ANT D injection in any pregnancy

REVIEW OF OTHER SYSTEM

Respiratory System: - No history of cough, No history of chest pain, No history of chest

Tightness No difficulty in breathing

Cardiovascular System: - No history of awareness of heart beat, - No history of lower limb edema.

Muscle Skeletal System: - No history of muscle pain, - No history of joint pain.

Central nerve system:- no headache, -no dizziness ,no blurred vision

PAST MEDICAL HISTORY: - Has history of admission at kivunge hospital, No history of food and drug
allergy No history of blood transfusion, No history of surgery.

GYNECOLOGICAL HISTORY: She started menarche since 13years, she was having regular menstrual
bleeding which was associated with slightly abdominal cramps, she changed pads three times a day and
the blood was in normal amount, and she get menstruation for 5 days in each month. No history of
using family planning methods, have history of pain during sexual intercourse, no history of sexual
transmitted diseases, has history of gynecological problems, no history of any gynecological procedure.

28
OBSTRETIC HISTORY: have history Of 5 abortions all occurring around six months of pregnancy

FAMILY AND SOCIAL HISTORY: - She is married woman with no children and live with her family.

-She is a waitress and her husband is a business man.

No history of using alcohol and cigarette smoking in a family.

No history of chronic diseases in his family

GENERAL EXAMINATION:

The patient was alert, full conscious, well oriented with people, place and time, with GCS 15/15,
afebrile, she was pale, no angular stomatitis, not jaundice, no cyanosis , not dyspnea, no lower limb
edema.

VITAL SIGN:

Blood Pressure =110/70mmHg, Pulse Rate =80b/min, Respiration Rate

=23b/min, Temperature =37.4c

SYSTEMIC EXAMINATION.

GASTROINTESTINAL SYSTEM: -

The abdomen is distended, umbilical is inverted, has linear naira , no tenderness on palpation , the
fundus is occupied by the buttocks, babies lie is longitudinal , back of the baby is on left side of the
mother with cephalic presentation ,FHR present

CENTRAL NERVOUS SYSTEM: - patient was, full conscious, with an intact memory both short and long
time memory, well oriented with people, place, and time.

29
-Cranial nerves were tested and were intact.

-Normal muscle tone and power.

-No meningeal sign detected.

RESPIRATORY SYSTEM: -The chest was symmetrical, move with respiration,, normal chest expansion, no
surgical mark or surgical scar .

-No mass no tenderness on palpable, tracheal is central located, tactile vocal

flemitus were heard

-Resonance percussion note heard on percussion.

-Normal vesicular breathing sound heard on auscultation.

CARDIOVASCULAR SYSTEM: - The patient hands were warm, no cyanosis, and normal

Capillary refill within three seconds, no finger clubbing, normal pulse rate which was regular and normal
volume, no jugular vein distention and precordium area not bulged.

-Apex beat was located at 5th intercostal space in the left mid clavicle line.

-S1 and S2 were heard and no added sound.

MUSCULOSKELETAL SYSTEM: Normal appearance of the limbs with no scar no marks no

Deformity no swelling.

-Normal sensation, tone and power.

-On palpation no edema and no tenderness.

-On percussion patella is normal.

30
SUMMARY: 36 years old female from matemwe , with GA of 23 W with P6A5 came with chief complain
of PV watery discharge for 1 day ,the discharge was not blood ,not smelling , it was for 1 day which was
sudden onset , progressive as time goes on and relieved on rest ,associated with back pain ,she is
amenorrhea for 6 months and rhesus negative group O , Has never received ant D

On examination the vital sign are normal and other examination are normal

Provisional diagnosis: - pre viable rupture of membrane

Differential diagnosis; inevitaible abortion

Pre matured rupture of membrene

INVESTIGATIONS

Obstretic ultrasound to check amount of amniotic fluid and fetal monitoring

Blood group and cross matching

FBP

Sterile speculum examination to check if the cervix is open

TREATMENT

Bed rest

IV fluids RL 2L for 24 hrs

tab arythromycin 500mg TDS for 5 days

tab PCM 1g TDS for 3 days

incase abortion occurs ,inject ANT D within 72 hrs of abortion

Prevention

avoid doing heavy activities

injection of ANT D prior to pregnancy

COMPLICATION

31
complete abortion

recurrent abortion

mycosis

dried labor

septicemia

PROGNOSIS :-

my patient received un expected abdominal pain and gave birth herself in the toilet ,the child was alive
in first few mins after and suddenly died ,the mother continued treatment in the hospital

she received ANT D injection within 72 hrs and was discharged

also received ant pain after discharge

FOLLOW UP

The mother should attend clinic soon after getting pregnant

She should come back in third trimester to receive another ANT D injection

She should come back incase she feels any abnormal situatuion

CASE 07: Pre-term pre labour Rupture of Membrane

32
NAME: XXX XXX XXX

AGE: 24 years

SEX: FEMALE

RESIDENCE: DONGE

OCCUPATION: HOUSEWIFE

DATE OF ADDMISSION: 6 June 2022

CLERKED ON: 06 June2022

LAST NORMAL MENSTRUAL PERIOD (LNMP) 17/11/2021

EXPECTED DATE OF DELIVERY 24/08/2022

GESTATION AGE: 28 WEEKS 5 DAYS

PARITY: GRAVIDA 2 PARA 1 LIVING 1 (G2P1L1)

Chief complain: watery discharge per vagina 2/7

HISTORY OF PRESENTING ILLNESS

The patient was well until 2 days ago when she presented with an acute onset of abnormal
vaginal watery discharge, not stained or mixed with blood, non foul smelling, it started as a gush
of clear fluid and as time went on she reports that it trickles along the thigh up to the legs.
Currently she reports changing up to 3pads per day not fully soaked, aggravated by standing and
walking and relived by rest.

There is no history of abdominal pain prior to the onset of the discharge.

There are no history of fever prior to the onset of discharge. She has no history of increased
frequency of voiding, painful voiding or passage of urine mixed with pus. No history of
abnormal foul smelling discharge per vagina prior to this.

No history of previous pregnancy losses or similar history in the previous pregnancy. There is no
history of trauma. The mother reports the fetal kicks are present and have not been reduced since
the onset of the illness

33
REVIEW OF OTHER SYSTEMS

RESPIRATORY SYSTEM- no history of difficulty in breathing, chest pain or cough.

CARDIOVASCULAR SYSTEM- no history of awareness of heart beats, syncope or chest pain

CNS- no history of headache, loss of consciousness or seizure.

GYNAECOLOGICAL HISTORY

Attained menarche at 14 years of age, she has a cycle of 28days and period of 3-4 days. She
changes the pad thrice once in her periods, not fully soaked. No pain during menstrual period
that could interfere her daily activities.

OBSTETRIC HISTORY

Historyofindexpregnancy

She booked clinic at 24 weeks o f gestation age and she made two visits and she has received
hematenics, folic acid, 1dose of TT, mebendazole, malaria prophylaxis. VDRL was non reactive,
HIV negative. Her last hemoglobin was 12mmol/L.

Her previous delivery she delivered by caesarian section due to cord prolapsed, it was at term
and the baby weighed 3.8kg. it was 2020. This is her second pregnancy.

PAST MEDICAL HISTORY

This is the second admission, the first was in 2020 due to caesarian section. No history of blood
transfusion. No known allergy to food or drugs. No history of chronic illness such as
hypertension or diabetes.

FAMILY AND SOCIAL HISTORY

She is married with 1 child, lives with the husband in their house. She is a housewife and the
husband is a bus farmer. She doesn’t smoke or take alcohol. No family history of chronic illness
like hypertension or diabetes.

34
SUMMARY

24 years old female, admitted on 6 June 2022, she is G2P1L1, the gestation age of 28weeks
5days,, came with complains of a gush of watery discharge per vagina for 2days. No prior
history of fever, pregnancy loss or preterm delivery.

PHYSICAL EXAMINATION GENERAL EXAMINATION

Conscious, afebrile, not pale, not jaundiced, no palpable peripheral lymphadenopathy and has no
lower limb edema.

VITAL SIGNS

BP=110/70mmhg, PR=84beats/min and RR=17breaths/min T= 37.2C

SYSTEMIC EXAMINATION

PER ABDOMEN

Gravida abdomen, niformly distended, moves with respiration and there is a surgical scar
(pfannesteil incisional scar), presence of striae, but no visible distended veins. Not tender on both
superficial and deep palpation. No palpable organ, dull on percussion and bowel sounds not
appreciable. Fundal height-34 cm= 34 weeks gestation age. Leopold manuvre- on fundal grip it’s
the buttocks that occupy, the lie is longitudinal, cephalic presentation, not yet engaged and the
fetal heart rate is 150beats/min. Speculum examination- fluid leaking from cervix, cervix was
mid positioned, firm, cervical os closed and there is clear fluid pooling at posterior fornices.
Detection of PH using litmus was not done.

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM

35
Patient was alert ,full conscious , with an intact memory both short and long time memory ,

well oriented with people, place, and time .

- Cranial Nerves

Olfactory - The patient can smell

Optic – The patient can see
Oculomotor, Trochlear, Abducens - The patient can move eyes on both direction like to move
eyes upward, downward, medially and laterally.
Trigeminal, Facial – Symmetrical face and the patient can blow cheeks and able to show
wrinkles,
Vestibularcochlear – The patient can hear
Glossopharyngeal, Vagus – Normal Gag reflex, Uvula centrally located
Accessory - The patient can moves his shoulder upward against resistance, able to shrug
shoulders. hypoglossal – The patient can move tongue out and on both direction

RESPIRATORY EXAMINATION

Inspection: The chest was flat, symmetry move with respiration with respiratory rate of 17b/min,
no surgical mark, no tradition mark no visible mases.

Palpation: The tracheal was central located, tactile vocal fremitus was normal, the apex beat felt
at 6th left intercostal space mid clavicular line, the chest expansion was symmetry.

Percussion: Normal resin ounce sound were noted.

Auscultation: vesicular breathing sound was heard.

CARDIOVASCULAR SYSTEM

Inspection: The chest was flat, symmetry move with respiration, no pericardial hyperactivity, no
bulging of pericardial area, no tradition no therapeutic mark no scar. There is no rising of jugular
vein.

36
Palpation: The palms was warm, capillary refills retain within 2 min, pulse rate was 84 b/min,
regular-regular synchronised with right redial artery, the apex beat located at 6th left intercostal
space mid clavicular line, the blood pressure was 110/70 mmHg.

Auscultation: S1 and S2 were heard

SUMMARY 2

24 years old female from Donge, 1 days post admission, at gestation age of 28weeks 5days, with
lnmp on 17 November 2021, G2P1L1 presented with a gush of watery discharge per vagina
which begun two days ago. On speculum there is pooling of fluid at the posterior fornices.

PROVISIONAL DIAGNOSIS: Preterm pre labor rupture of membranes.

INVESTIGATION

Full Blood Picture

Urinalysis

Obstetric Ultrasound

TREATMENT

Antibiotics: Oral Erythromycin 250mg 6hourlly 10/7

Inj dexamethasone 12.5mg 12 hours 2 days

Complete bed rest

Monitor the patient, Induce the labor at 37weeks gestation

OOMPLICATION

Dry Labor

37
Cord prolapse

Infection (Chorioamnionitis)

Abruptio Placenta

Neonatal Sepsis

CASE 08: Post ceasarean section due to big baby.

38
NAME: XXX XXX XXX

AGE: 29 years old

SEX: FEMALE

ADDRESS: PAJE

DATE OF ADMISSION: 08th of June 2022, 2 days in the ward

TIME OF ADMISSION: 06:00 am

TIME OF CLERK: 07:45 am

PARITY: PARA 2 LIVING 2

2 days post ceaserean section

CHIEF COMPLAIN: Lower abdominal pain for 5 hours

HISTORY OF PRESENTING ILLNESS.

The patient was apparently well till 5 hours ago prior to admission when she started
experiencing lower abdominal pain of sudden onset, on and off in nature, progresses into severity
as time goes on, no associating factor relieved when lying down , aggravated when walking. The
patient denied history of vomiting, diarrhea, pain during urination, frequent urination, blood in
urine.

The patient is 2 days post ceasarean section due to big baby, the baby was extracted with 4.2kg
and cried immediately after delivery.

Today patient has no new complain and she is still in medication using ceftriaxone intravenous
1g od for 5 days, tab metronidazole 400mg tds for 5 days and tab diclofenac 50mg tds for 3 days.

Today’s hemoglobin level is 11.2g|dl.

REVIEW OF OTHER SYSTEMS.

Central nervous system: no history of loss of consciousness, no history of convulsions

Respiratory system: no history of cough, no history of difficult in breathing, no history of chest

tightness.

39
Cardiovascular system: no history of heartbeat awareness, no history of lowerlimb swelling.

OBSTRETIC HISTORY

P2 L2

First child was male, born in 2021 at makunduchi hospital, through ceasarean section due to
cephalopelvic disproportion with a birthweight of 3.1kg with no any complication after birth.

The second child was male, born in 2022 at makunduchi hospital through ceasarean section due
to big baby with a weight of 4.2kg.

GYNAECOLOGICAL HISTORY

She started menarche at the age of 14years, a cycle of 28 days, period length is 4 days each
month, changes pads three times a day not fully soaked. No history of family planning methods,
no history of pain during sexual intercourse, no history of sexual transmitted disease, no history
of gynaecological problems.

PAST MEDICAL HISTORY

No history of previous admission

No history of surgery

No history of drug and food allergy

No history of blood transfusion

FAMILY AND SOCIAL HISTORY

She is a married woman living with her husband and 1 child.

She is a housewife with a form four graduate certificate whereas the husband is a farmer. No
history of alcohol use and ciggarrette smoking, no history of chronic illnesses in their family like
hypertension and diabetic mellitus.

GENERAL EXAMINATION

The patient was conscious, well oriented to people place and time, afebrile, not dyspnoeic with
normal hair distributed all over the head with normal texture, not pale, not jaundiced, not

40
cyanotic, no abnormal discharge of the ear, no abnormal discharge of the nose, no nasal polyps,
no angular stomatitis, no chelitis on the lips, no any palpable lymph node, no lower limb oedema.

VITAL SIGNS

MOTHER

Blood pressure: 118|76 mmHg

Pulse rate: 82beats per minute

Respiratory rate: 17breaths per minute

Temperature: 36.2 Celsius.

SPO2: 98%

All of which were normal

BABY

Pulse rate: 138 beats per minute

Respiratory rate: 42 breath per minute

Temperature: 36.8 celsius

SPO2: 98%

All of which were normal

SYSTEMIC EXAMINATION

PER ABDOMEN EXAMINATION

Inspection:

41
The abdomen is slightly distended, symmetrically moves with respiration, the umbilicus is
inverted, there is pfanential incision 2cm above the pubic symphisis, wound is clean with stitches
and no discharge

Palpation:

No tenderness on the lower abdomen

Percussion:

Tympanic note sound was heard.

Auscultation:

3 bowel sounds were heard per minute.

CENTRAL NERVOUS SYSTEM

The patient is conscious well oriented to people, place and time, Glasgow coma was
15|15 with normal thoughts and an intact memory both short term and long term.

All cranial nerves were intact

No meningeal sign detected

RESPIRATORY SYSTEM EXAMINATION

Inspection:

Chest is flat, symmetrically moves with respiration with a respiratory rate of 17 breath per
minute, no surgical scars, no traditional marks.

Palpation:

Trachea is centrally located , symmetrically chest expansion, auxiliary lymph nodenot psalpable.

Percussion:

Reasonant note sound was heard

Auscultation:

Vesicular breath sounds were heard

CARDIOVASCULAR SYSTEM

42
 Inspection:

No surgical scars, no traditional marks on the precordium area, no hyperactivity on the

precordium area, no bulging on the precordium area.

Palpation:

The hands were warm, no finger clubbing, capillary refill was less than three seconds, pulse rate
was 82 beats per minute, regular-regular with strong volume synchronized with brachial artery,
blood pressure was 118|76 mmHg measured on the left arm while on sitting position, apex beat
was at 5th left intercoastal space mid clavicular line.

Auscultation:

Sound 1 and sound 2 were heard.

SUMMARY

A 29 years old female from Paje, P2 L2, 2 days post ceasarean section came with a complain of
lower abdominal pain for 5 hours of sudden onset, on and off in nature, progresses into severity
as time goes on, no associating factor relieved when lying down , aggravated when walking. The
patient denied history of vomiting, diarrhea, pain during urination, frequent urination, blood in
urine. She is 2 days post ceasarean section due to big baby, the baby was extracted with 4.2kg
and cried immediately after [Link] patient has no new complain and she is still in
medication using ceftriaxone intravenous 1g od for 5 days, tab metronidazole 400mg tds for 5
days and tab diclofenac 50mg tds for 3 [Link]’s hemoglobin level is 11.2g|dl. Review of
other system was unremarkable, 1 previous scar due to cephalpopelvic disproportion, no positive
findings in gynaecological history, family and social history. On examination ther is pfanential
incision 2cm above the pubic symphisis with no discharge. Other system examination were
unremarkable.

PROVISIONAL DIAGNOSIS:

Post ceasarean section due to big baby.

Due to:

Fundal height measured was 45 cm where as the gestation age of the mother was
38weeks

43
DIFFERENTIAL DIAGNOSIS:

Cephalopelvic disproportion

INVESTIGATIONS:

Full blood picture:

To check for leukocytosis and hemogoblin level

Urinalysis:

To check for white blood cells in the urine

MANAGEMENT

Prevent infection by giving:

>Ceftriaxone injection(Intravenous) 1g od stat

>Metronidazole tablets 400mg tds for 5 days

Proper dressing with normal saline

Antipain: diclofenac tablets 50mg tds

HEALTH EDUCATION

Maintain good personal hygiene for her and the baby

Appropiate family planning method

Exclusive breastfeeding of the baby

Wound dressing as required so she should attend nearest clinic

Proper diet as required

Stich removal is after 10 days so she should go to the nearest clinic

44
COMPLICATION

Anaemia

Urinary tract infection due to cathetirization

Septicemia

Endometritis

Paralytic ileus

PROGNOSIS:

Prognosis of the patient is good since the wound has no discharge and is healing properly with
no signs of sepsis.

CASE 09: Anaemia in Pregnancy

Name: XXX XXX XXX

45
Age: 42 years.

Sex: Female.

Address: limbani

Date of visit: 10/05/2022

Amenorrhea for 2 months.

LNMP: 21/02/2022

EDD: 28th November 2022

GA: 11 weeks by date.

Gravid 2 para 1 living 1 abortion 0

Chief complain

Headache 4/7.

History of present illness

Patient came with the chief complain of headache which was sudden onset progress as time goes
on, the pain occurs more at frontal part with no aggravating factor reported , it was associated
with dizziness and heartbeat awareness but no history of convulsion, fever, numbness, loss of
conscious, confusion, dry cough and difficulty in breathing on exertion and at rest, bleeding
through vagina, rectum no relieving factor reported.

Review of other system

Respiratory system

No history of coughing, difficulty in breathing, chest pain and chest tightness.

Gastrointestinal tract

No history of abdominal pain, diarrhoea, vomiting, constipation, blood in stool, nausea and loss
of appetite.

Genito urinary system

No history of painful urination, frequency urination and blood in urine.

46
Muscular skeletal system No history of joint pain, muscle pain, muscle swelling, skin itching
and skin rashes.

Past medical history

No history of admission.

No history of blood transfusion.

No history of food and drug allergy

No history of surgical intervention

Past obstetric history

Her first pregnancy was 2019, she delivered full term a male baby by spontaneous vaginal
delivery of 2.5 kg at wete government hospital, no any complication occur during pregnancy and
after delivery.

Index pregnancy

She has not started to visit ANC.

Gynaecological history

She started menarche when she was 13years. No pain during menses, she uses three pieces of
kanga per day which is partially soaked, her menarche circle was 28 and duration is 5 days. Age
of coetus is 26 years, no pain during coetus and no any abnormal discharge during and after
coetus. No history of any gynaecological procedures. No history of Sexual transmitted infection,
No history of family planning.

Family and social history

She is married living with her husband and her child. Her level of education is form four. Her
husband level of education is standard 7. She is housewife. Her husband is a shopkeeper. No
history of any chronic diseases in their family. No history of smoking and alcohol intake in their
family.

Dietary history:

At morning she eats tea with bread. Afternoon she eats rice with mchuzi. At night she eats tea
with bread or some day’s rice with mchuzi. The food is inadequate interm of quantity and quality

General examination

47
She is conscious oriented with people, place and time of GCS 15/15, afebrile, she is pale on the
conjuctiva, no jaundice, not cyanotic, no lymphadenopathy, no finger clubbing,, no lower limb
oedema.

VITAL SIGNS

BP: 124/80mmHg PR: 80b/min RR: 17b/min T: 36.5°C Hb: 6.2g/dl

SUMMARY:

42 years from limbani, amenorrhea for 2 months came with the chief complain of headache for 3
days which was associated with dizziness and heartbeat awareness but no history of convulsion,
loss of conscious, fever and difficulty in breathing on exertion and at rest. But during
examination the patient is pale on the conjuctiva with Hb of 6.2g/dl.

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

The hand is cold, the capillary refill last within seconds 2seconds the pulse rate was 80 beat per
minute regular irregular with strong volume synchronized with femoral artery, the blood pressure
was 124/80mmhg taken at the left arm on sitting position, no jugular vein raised

On Inspection;

No palpitation, no pericardium bulging, no jugular vein distention.

On Palpation;

Apex beat is palpable at 5th intercostal space along mid clavicle line.

On Auscultation;

S1 and S2 heard so it was normal.

CENTRAL NERVOUS SYSTEM EXAMINATION

She is conscious oriented with people, place and time of GCS 15/15, Normal speech and
thought, the long term and short term memory were intact. All groups of cranial nerves are
intact.

PER ABDOMINAL EXAMINATION

On Inspection;

48
 Gravida abdomen move normally with respiration, umbilical is inverted, no surgical mark
and therapeutic mark

On Palpation;

On superficial no tenderness and on deep no organomegally and there is palpable mass.

On Percussion;

Tympanic noted.

On Auscultation;

3 Bowel sound heard for one minute.

RESPIRATORY SYSTEM

On Inspection;

The chest is flat in shape, move symmetrically with respiration, no scar, no deformity.

On Palpation;

Trachea is centrally located, chest expand symmetrically, normal tactile vocal fremitus.

On Percussion;

Resonance noted.

On Auscultation;

Vesicular breathing sound heard.

PROVISIONAL DIAGNOSIS: Severe Anaemia in pregnancy 2° poor diet.

Differential diagnosis: Malaria in pregnancy.

Sickle cell disease.

Hookworm manifestation

Stomach and duodenal disease

INVESTIGATIONS:

FBP

BS for MPS

49
 Urinalysis

Stool analysis

Sickling test

Urgent blood Grouping and cross matching

TREATMENT

Tab PCM 1g 8 hourly 3/7.

Tab fefol 200 mg 12 hourly 4/52

Caps ammoxycillin500mg 8 hourly 5/7

blood transfusion 1unit

Tab mebendazole 500mg start

Monitor haemoglobin level

Encourage food rich in iron

COMPLICATIONS:

Heart failure.

Still birth.

Abortion.

Pre-term labour.

Intra uterine growth restriction.

Premature baby

PREVENTIONS:

Early booking antenatal care.

Proper balance diet like food which are high in folic acid and vitamin C such as dark green leafy
vegetables, wheat germ, citrus fruits and raw vegetables.

Family planning.

50
CASE 10: Term pregnancy not in labour & Gestational diabetes in term of pregnancy

NAME : XXX XXX XXX

AGE : 26 years old

SEX : Female

ADDRESS : Mtemani

DATE OF ADMISSION : 23th May 2022

LAST NORMAL MENSTRUAL PERIOD : 29thAugust 2021

EXPECTED DATE OF DELIVERY : 5th June 2022

GESTATIONAL AGE : 37 weeks plus 4 days by date

51
 GRAVIDA 2 , PARA 1 ,LIVING 1

Know case of Asthma with irregular medication ( prednisolone and salbutamol inhaler ) and also is the
known patient of diabete mellitus.

HISTORY OF PRESENTING ILLNESS :

The patient referred from ANT NATAL CLINIC due to elective c/ section ( 1 previous scar ,gestational
diabetes and obesity )

The patient have history of gestational diabetes to their previous pregnancy and one previous scar
which may lead to delivered by c/ section with the baby weight of about 2.08kgs with cerebral palsy and
that is cause to be planned elective c/ section in order to prevent complications to their new baby .

REVIEW OF OTHER SYSTEM

•Respiratory system

- No history of coughing , no history of chest pain , no history of chest tightness , no history of shortness
of breath

• Cardiovascular system

- No history of heartbeat awareness , no history of lower limbs edema

• Gastrointestinal Tract - No history of abdominal pain ,no history of difficult in passing stoo ,no history
of loosing of stool , no history of blood in stool.

• Genito urinary system. - No history of blood in urine , no history of difficult in passing urine ,no history
of frequently urination.

•Musculoskeletal system - No history of muscles tightness , no history of joint pain , no history of

muscle pain

PAST MEDICAL HISTORY - Have history of admission due to the elective c/ section of their first child at
South African Hospital

- No history of blood transfusion

- No history of foods and drugs allergy

52
INDEX PREGANCY - She made her first booking when their pregnancy have 4 months old and attending
to the clinic 4 times .She felt foetal movement when the pregnancy have 4 months and she received of
all Tetanus Toxoid Vaccines , Hemoglobin level(Hb level ) , PMTCT , Urinalysis all were clear and FBS of
about 8.6 mmol/l .She get mosquito treated net and Tab Ferrous sulphate and folic acid .

GYNAECOLOGICAL HISTORY - She start their menarche since 14 years old with regular menses of about
5 days with cycle of 32 days ,she changed pads 3 times per day which are partially socked .

OBSTETRICS HISTORY - She have one child born at South Africa throug Spontenous Vaginal Delivery with
birth weight of about 2.08 kgs and after birth the baby get complications of infection due to the
medications used by their mother.

FAMILY AND SOCIAL HISTORY - She is married with one child and live with her family

- She is a teacher and her husband are businessman

- No history of cigarette smoking , alcohol taking in their family

- No history of tobacco use in their family

- But have history of chronic disease in their family like hypertension,

diabetes mellitus ,Asthma to their maternal side .

GENERAL EXAMINATION ; Conscious ,well oriented with peoples ,place and time with GCS
15/15 ,afebrile , no cyanosis , no pallor , no jaundice ,no any discharges from eyes ,nose and ears ,no any
lymph nodes enlargement ,no lower limbs edema.

VITAL SIGNS ;

Blood pressure - 130 /80 mmHg ,Pulse rate - 98 beat / min

Respiratory rate 25 breath / min , Temperature - 36.8 ° C

SYSTEMIC EXAMINATION ;

• PER ABDOMINAL EXAMINATION - Is gravida abdomen , moves with respiration ,the umbilicus was
everted ,gravida striae ,linea alba , abdominal incision were present .

- The fundal height is 38 cm ,lie was longitudinal ,cephalic [Link]

circumference is 130 cm where by approximately baby weight is about 4.9kgs

- The foetal heart rate were normal of about 140 beat /min

53
 RESPIRATORY SYSTEM - The chest was symmetry moves with respiration trachea were cental
located ,normal chest expansion .

- No mass ,no any deformity ,normal tactile vocal fremitus were normla

on palpation .

- Resonance sound were hearded on percussion .

- Vesicular breathing sound were hearded on auscultation.

CARDIOVASCULAR SYSTEM - The hands were warm ,not pale , no cyanosis with normal capillary refill
within 3 sec with normal pulse rate 90 beat / min which are synchronised ,no jugular vein distension ,no
bulged on precordium area .

- Apex beat was felt at 5th left intracoastal space at midclavicular line.

-Sound 1 and sound 2 were hearded

CENTRAL NERVOUS SYSTEM; Concious with people, place and time with both intact memory long term
memory and short term memory .All cranial nerves were intact ;

CNS 1 ( Olfactory nerves ) - The patient were able to smell

CNS 2 ( Opticl nerves). - The patient were able to see the objects

CNS 3 ,4 ,6 ( Occulomotor ,trochlea ,abduscent nerves) - The patient were able to move the eyes in all
direction

CNS 5 ( Trigeminal nerve ) - The patient chew the food and blow the cheek

CNS 7 ( Facial nerve) - The patient were able to smile ,blinking ,rinking the face .

CNS 8 ( Vestibulo - chochlea) - The patient was able to hear and to mantain balance.

CNS 9 ,12 ( Glosso pharyngeal and hypoglossal )- The patient was able to test the food .

CNS 10 ( Vagus nerve ) - The patient have positive gurg reflex

CNS 11( Accessory nerve) - The patient . were able to move the shoulder with or without the resistance.

MUSCULO SKELETAL SYSTEM - Normal appearance of the limbs with no mass , no scars , no any
deformity , no swelling .

- Normal sensation and power .

54
 - No edema , no tenderness on palpation.

SUMMARY ; 26 years old female from Mtemani admitted on 25th May ,2022 with gestational age of
37weeks plus 4 days by date and was known case of asthma with irregular medication like prednisolone
and salbutamol inhaler . Also is referral case from ANC due to the elective c/ section because of the one
previous scar the case of gestational diabetes .

Impression diagnosis ; Term pregnancy not in labour

- Gestational diabetes in term of pregnancy

INVESTIGATIONS:

Blood group and cross matching

Monitor Blood pressure and Foetal heart rate

Monitor First Blood Sugar

MANAGEMENTS :

IV cannulation ,urethral catheterisation

Informed consent

Injection dexamethasone 8mg bid for 48 hours

Tab FeFo 1tab od to 2 weeks

Prepared for elective c / section ( Save 1 unit of blood)

PREVENTION;

Primary preventions

Early diagnosis ,investigations and treatment of diabetes mellitus

Early booking to ANC

Proper diet about diabetes mellitus

Secondary preventions

Health care provider and relative should ensure that the patient take the medicine at accurate
time and correctly.

55
Tertiary prevention

Health care provider should manage the complications effectively in oder to prevent death.

COMPLICATIONS

• Foetal complications

Hypogycemia

Respiratory distress syndrome

Cardiomyopathy

Jaundice

•Maternal complications

Infections

Diabetic neuropathy

Diabetic nephropathy

Diabetic retinopathy

PROGNOSIS

The patient condition was good because the was able to follow all instructions given to their
health care provider and now are able to be prepared with elective c /section.

FOLLOW UP

The patient should be returned for dressing of their wound every one day inorder to be assessed
to prevent infections.

56
 CASE 11: Molar pregnancy

NAME: XXX XXX XXX

AGE: 27 year’s
SEX: FEMALE
ADRESS: CHANJAANI

G5P4L4 A0
LNMP: 16/3/2022
EDD: 23/12/2023
GA 12 weaks
DATE OF ADMITION: 1/6/20227

C/C Vaginal discharged for 2 weaks

HISTORY OF PRESENTING ILLNESS

The patient complain about vaginal discharge for 2 weaks, which was gradual onset, brownish
in colour and grapes like structure, no smell not itching, it has no specific time but mostly
during urination, this condition increase in severity as time goes on, no agriviating factor, no
releaving factor, no associating factor.
The patient deny history of abdominal pain, nausea but had a history of vomiting at the first
day's of pregnancy, the vomiters was non projectile, small amount and contain food content,
no history of loose appetite, no history of loose of stool, no pain during urination, no blood in
urine

REVIEW OF OTHER SYSTEMS

Central nervous System: no headache, no dizziness, no confusion, no conversion, no blurred

vision, no numbness.

57
Respiratory system: no coughing, no chest pain, no chest tightness, no difficult in , no shortness
of breathing.

Cardiovascular system: no heart beat awareness, no difficulty breathing on exertion, no chest

tightness, no lower limb swelling .breathing
Muscular-skeletal system: no joint pain, no muscle pain, no muscle stiffness, no muscle
swelling, no muscle cramps.

PAST MEDICAL HISTORY

The patient had no history of admission, no history of surgery,no history of blood transfusion,
no history of food and drugs allergic, but had a history of asthma. No history of alcoholism and
smoking.

GYNAECOLOGICAL HISTORY

Her first monarch start when she was 16 years, she get period for 7 days, with 27 cycles.
Associated with slightly abdominal cramping, she change pad 3-4 times in a day with full
socked. No painful during sexual intercose, she start sex when she is 20 years old after
marriage. No history of contraceptive uses.

OBSTRACTIC HISTORY
She had 4 children

- 1st child was born at Chakechake hospital though SVD with 2.5 kg and she was girl baby.
-2nd child was born at Chakechake hospital though SVD with 3 kg and also she was baby girl.
-3rd child was born at Chakechake hospital though SVD with 3 kg and he was a baby boy.
-4th child was born at Chakechake hospital though SVD with 2.8 kg and she was baby girl.

INDEX PREGNANCY
She didn't start clinick until now.

FAMILY AND SOCIAL HISTORY

58
She is married woman, live with her husband , at there own house with good ventilation, she
is house wife and her husband is business man. There is history of asthma and hypertension in
her family but no history of sickle cell disease and DM. No history of smoking and alcoholism in
her family.

SUMMARY 1
Ramla Abdallah Moh’d 27 years from Chanjaani, she is G5 P4 L4 A0 with GA of 12 weaks, she
was admitted on 1/6/2022 with the complain of vaginal discharge for 2 weeks, which was
gradual onset, brownish in colour and grapes like structure, no smell not itching, it has no
specific time but mostly during urination, this condition increase in severity as time goes on.

Also the patient has a history of vomiting at the first day's of pregnancy, the vomiters contain
food content and was non projectile and small amount.

GENERAL EXAMINATION

The patient was conscious, oriented with people place and time. The hair well distributed all
over the head with black in colour with normal texture, no discharged at aye ear and nose, she
slightly pale at the conjuctiver, not joundice and a febrile, no cyanosis,
No angular stomatitis no chelitis, no peripheral palpable lymph node no lower limb swelling .

Vital sign

Temperature 36.9 C
Blood pressure 121/70 mmHg
Pulse rate 104 b/min

Respiratory rate 22 b/min

SYSTEMIC EXAMINATION

PER ABDOMINAL EXAMINATION

59
Gravida abdomen move with respiration, no linear nigra no surgical mark no scar no
therapeutic mark no strider. The umbilical is invested , not tender on superficial palpation no
organomegally on deep palpation.
On leopard maneuver not done only the fundus height was 16 cm.

RESPIRATORY EXAMINATION

Inspection: The chest was flat, symmetry move with respiration with respiratory rate of 22
b/min, no surgical mark, no tradition mark no visible mases.

Palpation: The tracheal was central located, tactile vocal fremitus was normal, the apex beat
felt at 5th left intercostal space mid clavicular line, the chest expansion was symmetry.

Percussion: Normal resinous were noted.

Auscultation: vesicular breathing sound was heard.

CARDIOVASCULAR SYSTEM

Inspection: The chest was flat, symmetry move with respiration, no pericardial hyperactivity, no
bulging of pericardial area, no tradition no therapeutic mark no scar.

Palpation: The palms was warm, capillary refills retain within 2 min, pulse rate was 104 b/min,
regular-regular synchronised with right redial artery, the apex beat located at 5th left intercostal
space mid clavicular line, the blood pressure was 121/70 mmHg.

Auscultation: S1 and S2 were heard.

CENTRAL NERVOUS SYSTEM

60
The patient is conscious, oriented with people place and time, with GCS 15/15, with good long
and short memories, the thinking capacity was good, speech and language was good .
The cranial nerve were interct and was tested as followed:-

1st Olfactory nerve: Patient was able to smell.

2nd Optic nerve: Patient was able to see 5m away.
3rd Oculomotor 4th Trochlea 6th Abducent nerve: Patient was able to rotate eye in all
directions.
5th Trigeminal nerve: Patient was able to chewing and blowing.
7th Facial nerve: Patient was able to smile and blinking.

8th Vestibular cochlear nerve: Patient able to stand properly when closes eyes and headed
properly.

9th Glossopharyngeal 12th Hypoglossal nerve: Patient was able to test food and rotate young in
all directions.

10th Vegas nerve: Gag reflex was positive by using toung depressor.
11th Accessory nerve: Patient can rise shoulders and rotate head under resistance

MUSCULAR-SKELETAL SYSTEMS
Normal muscle tone, muscles bulk and strength, patient was able to flex and extend knee,
normal muscles stretch reflex.

SUMMARY 2
27 years felame from Chanjaani, she is G5 P4 L4 A0, with LNMP at ,admitted on 1/6/2022,
come with complain of vaginal discharge for 2 weaks, which was suddenly onset, brownish in
colour and grapes like structure not smelled, not itching . On general examination the patient
was slightly pale at conjuctiver and on systemic examination during palpation the fundus height
was 16 cm that was greater than GA in a weak ( 12 weaks).

Provision diagnosis

61
 Molar pregnancy
Differential diagnosis
Missed abortion.

Anaemia in pregnancy.
Uterine fibroid
Investigation
Pelvic ultrasound
B- HCG

Thyroid profile T3 and T4

Urinalysis
Chest ex- ray
Full blood pictures
Management

Sanction and curretage then take tissue for history pathology

Tab amoxicilline 500mg tds for 5 days
Tab fefol 1×1 for 1 month
Control HCG
Complications
Ovarian cyst
Hyperthyroidism
Anaemia
Health education and counselling
Counselling the patient to use family planning (barrier method or condom).

Counselling mother not consive at least for aone year

Monitoring of HCG level within 1 year .

62
 CASE 12: Inevitable abortion

NAME: XXX XXX XXX

AGE:27 YEARS
SEX: F
ADDRESS: BOPWE
DOA: 24-5-2022
TOA: 16:30
GA: 20 weeks by U/S
G5 P4 L1 A3
CHIEF COMPLAIN: Lower abdominal pain 1∕7
PV bleeding

HPI: The patient was feeling well few hours prior to admission until started
to experience lower abdominal pain which was cramping in nature, no
aggravating factor, no relieving factor, associated with per vaginal bleeding
which was light in nature (reddish in color).
Patient denied history of fever, dizziness, headache, loss of consciousness,
convulsion.

REVIEW OF OTHER SYSTEM

Respiratory system: -No history of chest pain

63
 -No history of cough
Genital urinary system: -No history of frequent urination
-No history of pain during urination
Cardiovascular System: - No history of awareness of heartbeat

- No history of lower limb edema

PAST MEDICAL HISTORY: -Has history of admission

-Has history of blood transfusion
-Has history of surgery
-No history of food/ drug allergy

INDEX PREGNANCY: patient started clinic in 2 months of pregnancy, and she

felt fetal activity during 4 months, she received all doses of Tetanus toxoid
vaccines, malaria treated net.
GYNAECOLOGICAL HISTORY: She started menarche since she was 15 years
old, she was having regular menstrual bleeding associated with slightly
abdominal cramps, she changed pads 2 times per day, and the blood was in
normal amount, she gets menstruation for 3 days in each month, no history
of using family planning methods, no history of pain during sexual
intercourse, no history of sexual transmitted diseases.
OBSTETRIC HISTORY: The patient has 4 previous pregnancies but has 1
living child.
1st pregnancy (2014), born SVD, no any complication after birth
2nd pregnancy (2018), born with C/S at GA of 30 weeks and baby died
soon after birth.
3rd pregnancy (2019), born SVD at GA 28 weeks but the baby died soon
after birth
4th pregnancy (2020), abortion at GA of 14 weeks.
FAMILY AND SOCIAL HISTORY: She is married with 1 child and live with her
family, she is housewife and her husband a business man, no history of

64
using alcohol & cigar rete smoking in a family, no history of chronic diseases
in the family like HTN, DM, Asthma.
GENERAL EXAMINATION: The patient was alert, full conscious, well oriented
with people, place and time, with GCS 15/15, afebrile, she was pale, she has
angular stomatitis to both sides of the mouth, no jaundice, no cyanosis, not
dyspnea, no lower limb edema.
VITAL SIGNS: Blood Pressure =135/104mmHg, Pulse Rate =96b/min,
Respiration Rate =23b/min, Temperature =37.4c, Hemoglobin level
=11.6g/dl
SYSTEMIC EXAMINATION:
PER ABDOMEN: Gravida abdomen, move with respiration, umbilical was
averted, there is scar, tender on palpation, on auscultation fetal heart rate
were heard.
CARDIOVASCULAR SYSTEM: The hands were warm, but pale, no cyanosis,
normal capillary refill, no finger clubbing, pulse rate was 96b/min which was
regular and normal volume, non-collapse and synchronal, no jugular vein
distention and precordium area not bulged, apex beat was felt in 5th
intercostal space at the left midclavicular line, S1 and S2 were heard and no
added sound in auscultation.
RESPIRATORY SYSTEM: The chest was symmetrical, move with respiration,
tracheal is centrally located, normal chest expansion, no scar and no mark,
no mass and no deformity palpable, resonance percussed note, normal
breathing sound hard on auscultation
CENTRAL NERVOUS SYSTEM: Patient was alert, full conscious, with an intact
memory both short and long-time memory, well oriented with people, place,
and time, normal muscle tone and power, no sign of any meningeal
irritation.
MUSCULOSKELETAL SYSTEM: Normal appearance of the limbs with no scar
no marks no deformity no swelling, normal sensation, tone and power, on
palpation no edema but tender, on percussion patella is normal.

Summary: 27 years, F, from BOPWE came with complain of Lower

abdominal pain associated with PV bleeding (reddish in color), no
aggravating factor, no relieving factor, on systemic examination (per
abdomen), the abdomen was tender on palpation on auscultation fetal heart
rate were heard.

65
IMPRESSION DIAGNOSIS: Inevitable Abortion

DIFFERENTIAL DIAGNOSIS: Ectopic pregnancy

Incomplete Abortion

Cervicitis

INVESTIGATION

• FBP (Full blood picture).

• Abdominal pelvic ultrasound

MANAGEMENT

IV RL 1L

Oxytocin 20IU in 500ml RL

IV Tramadol 100mg stat

• Tab FEFO OD for one months

Tab metronidazole 500mg TDS 5/7

• Counseling on family planning.

PREVENTION

Primary prevention.

Early clinical diagnosis, investigation and treatment.

Early booking anti natal care.

Hypertension screening.

Secondary prevention.

Early diagnosis and prompt treatment.

Health care providers and relatives should ensure that the patient take
medicine at accurate time and correctly.

Tertiary prevention.

66
Health care providers should manage complications effectively in order to
prevent death.

COMPLICATIONS

Early

Hemorrhage -anemia-shock-renal failure

Sepsis

Late

Pelvic Inflammatory Disease, which may lead to infertility

Chronic pelvic pain, Emotional disturbance: Depression-marital disharmony

CASE 13: False labour with 2 previous scars

NAME : XXX XXX XXX

AGE : 27 years old

SEX :Female

ADDRESS :Bopwe

DATE OF ADMISSION : 26/08/2022

TIME OF ADMISSION : 11:00 AM

LNMP : 26/08/2021

G.A :39 Weeks

67
 EDD : 02/06/2022

GRAVIDA 4, PARITY 2, LIVING 1 , ABORTION 1

Refferal case from Wete antenatal clinic for elective cesarean section.

CHIEF COMPLAIN : Lower abdominal pain 7Hours

HISTORY OF PRESENTING ILLNESS :

The patient is apparently well until 7 hours ago when she experience lower abdominal pain ,with
sudden onsent,and cramping in nature, the pain radiate to the back, go on and off, aggriviated when
sitting, relieved by walking, associated with the nausea but the patient denied per vaginal discharge .

Also in the ward pv was done ,the cervix was on the tip of fingers.

But the patient has the history of delivery big babies in the 2 previous pregnancy, and delivered by
cesarean section,but the first baby has weight of 3.9 kg ,and second baby has the weight of 4.1kg.

REVIEW OF OTHER SYSTEMS:

Central nervous system :No history of fever,no history of dizziness,no history of headache , no history of
convulsions.

Respiratory system : No history of coughing, no history of sputum production,no history of chest pain.

Cardiovascular system : No history of heart beat awereness,no history of lower limbs swelling .

Genitourinary system : No history of blood in the urine,no history of frequently urination,no history of
pain during urination.

Muscular skeletal system : No history of muscle pain,no history of joint pain.

PAST MEDICAL HISTORY : No history of admission ,no history of blood transfusion ,no history of
surgery,no history of food and drugs allergies.

68
FAMILY AND SOCIAL HISTORY:She is a married woman with 1 child,she finished education level at form
two at Miti Ulaya secondary School,she is a house wife and her husband is a pet [Link] history of
chronic disease in her families like hypertensive and diabetic mellitus,no history of cigarettes smoking
and alcohol drinking.

INDEX PREGNANT:

She made her first booking when the pregnant were 3 months,she visit 4 times,she receives tatenus
toxoid vaccine 4 doses,she do all investigation like HB,RBG,MRDT,PMCT and all results are normal ,but
she does not received malaria treated net .

OBSTETRICS HISTORY :

She had 1 child ,other child were die.

But the first child was female,born at Wete hospital through cesarean section,with birth weight of 3.9kg
at 2017.

Second child were male born at 2019 at Wete hospital through cesarean section,with birth weight of
4.1kg,but he die 1 day after born.

GYNAECOLOGICAL HISTORY:

She started menachy since 12 years old ,with regular menstrual bleeding,but associated with the
abdominal pain,she get cycle of 30 days and duration of 7 days,she changed pads 3 times a day which
are partial soaked.

No history of sexually transmitted disease,no history of pain during coitus,no history of using family
planning method.

GENERAL EXAMINATION :

The patient is well oriented with the people, place and time, with GCS 15/15,the hair is well distributed
with normal texture and black in colour, afebrile,no jaundice,no pale,no discharge on eyes, ears and
nose,no cyanosis,no angular stomatitis,no chelaitis, all group of lymphnoid not palpable,no lower limbs
edema.

VITAL SIGNS:

Blood pressure (BP) =110/60mmhg

69
Pulse rate (PR) = 80 beat/minute

Respiratory rate (RR)=20 breath /minutes

Temperature (T) =37.1 °C.

SYSTEMIC EXAMINATION:

PER ABDOMEN : This is the GRAVIDA abdomen ,with striae gravidarum and linear nigra,move with
respiration,the umbilical was flat,no therapeutic marks ,but has incision scars.

On leopard maneuver :The fundus occupied by the buttock,the lie of the baby is longitudinal and
presenting part is cephalic .

Fundus height is 33 cm , circumference is 109 cm, approximately baby weight is 3.56kg

Fetal heart rate (FHR ) is 135 b/minutes.

No mass and no organomegaly.

CENTRAL NERVOUS SYSTEM :The patient is full conscious ,with well oriented with the people,place and
time,with GCS 15/15, short term memory and long term memory are intact, language and speech are
normal,and the all cranial nerves are intact and was tested as the following

Cranial nerves l: Olfactory nerves ,the patient was able to smell

Cranial nerves ll :Optic nerve,the patient was able to see different object.

Cranial nerves lll,lV and Vl: Occulamotor, trochlear and abducent nerves,the patient was able to move
the eyes in the different direction.

Cranial nerves V: Trigeminal nerves,the patient was able to chew food and blow the cheek

Cranial nerves Vll :Facial nerves,the patient was able to smile, blinking and wrinking the face.

Cranial nerves lX and Xll: Glossopharyngeal nerves and hypoglossal nerves,the patient was able to teste
the different food and movement of the tongue.

Cranial nerves Xl : Accessory nerves ,the patient was able to move the head.

RESPIRATORY SYSTEM:The chest was symmetrical,move with respiration,no scars and therapeutic marks
on inspection.

The trachea is central located,with normal chest expansion,normal tactile vocal fremitus,no mass and no
tenderness on palpation,and respiratory rate was 20b/minutes which was normal.

And resonance purcussion note were heard on purcussion .

70
Vesicular breathing sound were heard on auscultation .

CARDIOVASCULAR SYSTEM:

The hand were warm,no cyanosis,with normal capillary refills within 3 second,pulse rate was 80
b/minutes which was regular regular with normal volume, synchronized with right radial artery,the
blood pressure was 110/70 mmhg which was [Link] hyperactivity,no bulging of precordium area ,no
scar and no jugular vein distension

The spex beat was felt at 5th intercoastal space left along midclavicular line,sound 1 and sound 2 were
heard with no added sound.

SUMMARY :

27 years old female from Bopwe,came with the compain of lower abdominal pain, associated with
nausea,but patient denied history of per vaginal discharge ,but has history of delivered big baby and 2
previous scars,On examination no any abnomality detected.

IMPRESSION DIAGNOSIS : False labour with 2 previous scars.

DIFFERENTIAL DIAGNOSIS :Urinary tract infection

Candidiasis

MANAGEMENT:

INVESTIGATION :

- Obstetrics ultrasound

- Blood grouping and cross matching

- Urine dipstick

- Urinalysis

-Bleeding time and clotting time.

TREATMENT

-Admit the patient

71
- Insert urethral catheterization

-IV cannulation

- Informed consent form

- Prepare the patient for elective cesarean section (c/s) due to the present of 2 previous scars.

- Ambulation

PREVENTION

-Early visit of antenatal clinic

-Regular

- To plan early ways of delivery in order to prevent ruptured of uterus.

COMPLICATION:

Intra operative complications

-Anaesthesia complication , example high spine

-Haemorrage

-Injury of visceral organ

Post operative complications

-Pain

-Wound infection

-Post partum haemmorage (PPH)

-Anaemia

FOLLOW UP:

The patient should return to the clinic one week in order to check the progression of the incision wound
and to remove the suture.

PROGNOSIS :

The patient condition was good if the patient do proper wound dressing and increase personal
hygiene,and the condition will be poor if the patient had poor personal hygiene and if do improper
wound dressing .

72
 CASE 14: Post C-Section 2° Malpresentation of the fetus

NAME: XXX XXX XXX

AGE: 34 year old.

SEX: female

ADRESS: paje

D.O.A 23 /5/2022

T.O.A 11: 00am.

PARA 6, LIVING 5

5 days post cesarean section

CHIEF COMPLAIN

Lower abdominal for 1/52

HISTORY OF PRESENTING ILLINESS .

73
 Patient was apparently well until seven days prior to addimission, when she started

experience lower abdominal pain for 1/52 which was gradually onset , on and off in nature,

progress into severity as the time goes on, agrivating when walking and reliving when

lie down , no associated factor . Patient denied the history of vomiting,loose of stool, difficulty

in passing stool, painful during urination, and blood in the urine.

Patient is five days post cesarean section due to malpresentation of the baby which is

transverse lie , the baby was extracted with 3.2 kg and did not cried immediately after

delivery .

To day patient complains of headache for 5 days , gradually onset ,on and off nature ,no

agrivating factor, but relieved when taken [Link] convulsion , no blurred vision ,no loss

conciusnes. Patient is now in medication of cefriaxone 1g for five days, metronidazole tab

500mg and diclofenac 75 mg and also to day Hb level is 5. 7 g/ DL.

REVIEW OF OTHER SYSTEM

CARDIOVASCULAR SYSTEM

No history of lower limb swelling.

No history of heart beat awareness.

No history of chest pain.

RESPIRATORY SYSTEM

No history of cough.

74
No history of chest tightness.

PAST MEDICAL HISTORY

No history of medical surgical case.

No history of surgery.

No history blood transfusion

No history of food and drug allergy.

GYNAECOLOGICAL HISTORY

She started menarche since 14years, she was having regular menstrual bleeding which was

associated with slightly abdominal cramps, she changed pads three times a day and the blood

was in normal amount, and she get menstruation for 7 days in each month. No history of using

family planning methods, no history of pain during sexual intercourse, no history of sexual

transmitted diseases, no history of gynecological problems, no history of any gynecological

procedure.

OBSTETRIC HISTORY

She had six children but one child died with unknown cause (according to the mother

information).

The first child was male, born at mnazi mmoja hospital through spontaneously vaginal delivery

with birth weight of 3.5kg, and no any complication after birth.

75
And second child was female, born at the makunduchi hospital through spontaneously vaginal

delivery with birth weight of 3.2kg and no further complication get during and after birth.

And the third child was female, born at the makunduchi hospital through spontaneously vaginal

delivery with birth weight of 2.8kg and no further complication get during and after birth.

And the fourth child was male, born at the hospital through spontaneously vaginal delivery with

birth weight of 3.0kg and no further complication get during and after birth, but this child died at

seven month after birth.

The fifth child was male born at makunduchi hospital through spontaneously vaginal delivery

with the baby weight of 3. 4 kg no further complications get during and after birth .

And the sixth child was male born at makunduchi hospital through cesarean section with baby

weight of 3. 2kg no any further complications during and after delivery.

FAMILY AND SOCIAL HISTORY

She is married woman with five children and live with her family, but her one child passed away

since he was in seven month.

She is a house wife and her husband is a business man.

No history of using alcohol and cigarette smoking in a family.

No history of chronic diseases in his family.

GENERAL EXAMINATION

76
The patient was conscious well oriented with people time and place with GCS 15/15 afebrile,

slightly pale, not jaundice, no angular stomatitis, no cynosis, not dyspnea,no abnormal discharge

on ear , nose and mouth, no nasal polyps, no lymphnode enlargement,no lower limb edema.

VITAL SIGNS

Blood pressure was 110/79 mmHg.

Pulse rate was 75 b/ minutes.

Respiratory rate was 18b/minutes.

Temperature was 36.5 b/minutes.

Hb level was 5.6g/DL.

SYSTEMIC EXAMINATION

PER ABDOMEN EXAMINATION

INSPECTION

The abdomen was slightly distended , moves with respiration , the umbilicus was averted , there

was pfanenstial incision 2 cm above pubic symphis , wound was clean with stitches and no any

discharge.

PALPATION

There was tendernes on pubic symphis area

PERCUSSION

77
Typanic percussion note was heard.

AUSCULTATION

Three bowel sound was heard per minutes.

CENTRAL NERVOUS SYSTEM EXAMINATION

patient was alert ,full conscious with GCS 15/15 well oriented with people time and place , with

an intact memory both short and long time memory , have good though,

All cranial nerve are intact

Normal muscle tone and power.

No sign of any meningeal irritation

CARDIOVASCULAR SYSTEM EXAMINATION

INSPECTION

Precordium region was not bulged.

No hypereactivity on precordium region.

No rise of jungular vein.

PALPATION

Hands were warm ,no finger clubbing,,there was normal. Capillary refill of less than two
seconds,radial pulse rate was 75 b/ min regular regular with strong volume synchronised with
brachial artery, blood pressure was 110/79mmHg taken on left arm on sitting position. Apex
beat felt at fifth intercostal space at midclavicular line.

AUSCULTATION

Sound one and sound two were heard per minute

78
RESPIRATORY SYSTEM EXAMINATION

INPECTION

Chest was flat symmetrically moves with respiration.

No traditional mark or surgical mark on chest.

PALPATION

Trachea was centrally located.

There was normal tactile vocal fremitus.

There was symmetrically chest expansion.

PERCUSSION

Resonant sound was heard.

AUSCULTATION

Vesicular breathing sound was heard

MUSCULAR AND SKELETON SYSTEM EXAMINATION

Normal appearance of the limbs with no scar no marks no deformity no swelling

Normal sensation, tone and power.

On palpation no edema and no tenderness.

On percussion patella is normal.

SUMMARY

34 years old female from Paje was apparently well until seven days prior to addimission, when

she started experience lower abdominal pain for 1/52 which was gradually onset , on and off in

nature, progress into severity as the time goes on, agrivating when walking and reliving when

79
lie down , no associated factor . Patient denied the history of vomiting,loose of stool, difficulty

in passing stool, painful during urination, and blood in the urine.

Patient is five days post cesarean section due to malpresentation of the baby which is

transverse lie , the baby was extracted with 3.2 kg and did not cried immediately after

delivery .

To day patient complains of headache for 5 days Patient is still on medication of cefriaxone 1g

for five days, metronidazole tab 500mg and diclofenac 75 mg and also to day Hb level is 5. 7 g/

[Link] general examination the patient was slightly pale and on systemic examinationthere was

pfanenstial incision 2 cm above pubic symphis , wound was clean with stitches and no any

discharge and it was tender on touch.

My provision diagnosis is Post cesarean section secondary to malpresentation of the baby

Differential diagnosis are cephalopelvic disproportion ,pelvic tumor, prolonged labour.

INVESTIGATION

Full blood picture

Hb level

Obstetrics autrasound

Urinalysis.

MANAGEMENT

80
IV Metronidazole 500mg TDS for 5 days

Tab paracetamol 1g TDSfor 3 days

Iv cefriaxone Ig start

Wound dressing

HEALTH EDUCATION

Mother should eat a proper diet

Encourage personal hygiene.

Mother should come to remove stitches after ten days.

COMPLICATIONS

Anemia

Septicemia

Urinary tract infections due to catheterization

Endometriatitis.

81
 CASE 15: [Link] in pregnancy 2° poor diet

NAME: XXX XXX XXX

AGE: 23years

SEX: FEMALE

ADRESS: PETE

DATE: 8/06/2022

LAST NORMAL MENSTRAL PERIOD: 04/11/2021

ESTIMATED DATE OF DELIVERY: 11/8/2022

GASTATION AGE: 31 weeks plus 4 days by dates.

GRAVIDA 2, PARA 1, LIVING 1

Referral from Kitogani clinic as regular visit to Makunduchi hospital due to low hb level 6.0g /dl

MAIN COMPLAINS: - Headache 2/7

HISTORY OF PRESENTING ILLNESS:-The patient was well two days ago, since she

started to experience headache of gradually onset, no aggravating factors , no relieved factors ,

82
associated by dizziness , but no history of blurred vision ,loss of consciousness, fever,

convulsion.

REVIEW OF OTHER SYSTEM

Respiratory System: -No history of coughing

- No history of chest pain

- No history of chest tightness

Cardiovascular System: - No history of awareness of heart beat.

- No history of lower limb swelling.

Gastro Intestinal Tract: -No history of abdominal pain

- No history of diarrhea

-No history of vomiting.

Gastro Urinary System: –No history of pain during urination

- No frequency in urination

-No history of blood in urine

PAST MEDICAL HISTORY: - No history of admission

- No history of food and drug allergy

- No history of blood transfusion

-No history of surgery.

83
INDEX PREGNANCY: She made her first booking when the pregnancy was 3 months old, she

felt fetal movement when the pregnancy was 3 months old up to now she received 3 doses of

Tetanus toxoid vaccines, malaria treated net.

GYNAECOLOGICAL HISTORY: She started menarche since 15years, she was having

regular menstrual bleeding which was associated with slightly abdominal cramps, she changed

pads three times a day and the blood was full socket, and she get menstruation for 7 days in each

month. No history of using family planning methods, no history of pain during sexual

intercourse, no history of sexual transmitted diseases, no history of gynecological problems, no

history of any gynecological procedure.

OBSTETRIC HISTORY:-She had one children, born at the hospital through spontaneously

vaginal delivery with birth weight of 3.4kg at 2019 year .No any complication after birth .

FAMILY AND SOCIAL HISTORY: - She is married woman with one children and live with

her family, She is a house wife and her husband is a business man. No history of using alcohol

and cigarette smoking in a family, No history of chronic diseases in his family such as asthma,

hypertension, diabetic .

DIETARY HISTORY: The patient says that she eat two times a day that is morning ,evening

.On morning eat only bread, urojo and tea and on evening rice and eat fishes and night and

sometimes eat chips.

GENERAL EXAMINATION : The patient was alert, full conscious ,well oriented with

people ,place and time , with GCS 15/15 , afebrile, she was pale , no jaundice, no cyanosis ,

not dyspnea, has pitting lower limb edema.

84
 VITAL SIGN: Blood Pressure =110/70mmHg, Pulse Rate =80b/min, Respiration Rate

=23b/min, Temperature =36.4c Hemoglobin level =6.0g/dl

SYSTEMIC EXAMINATION.

CENTRAL NERVOUS SYSTEM : - patient was alert ,full conscious , with an intact memory

both short and long time memory , well oriented with people, place, and time .

-Normal muscle tone and power.

-No sign of any meningeal irritation.

RESPIRATORY SYSTEM: -The chest was symmetrical; move with respiration, tracheal is

central located, normal chest expansion, no scar and no mark.

-No mass and no deformity on palpation

-Resonance percussed note.

-vesicular breathing sound hard on auscultation.

CARDIOVASCULAR SYSTEM : - the hands were warm , but pale, no cyanosis ,normal

capillary refill ,no finger clubbing ,pulse rate was 80b/min which was regular and normal

volume ,non-collapse and synchronal, no jugular vein distention and precordium area not

bulged.

85
 -Apex beat was felt in 5th intercostal space at the left midclavicular line.

-S1 and S2 were heard and no added sound in auscultation.

GASTROINTESTINAL SYSTEM: -The gravida abdomen, move with respiration, the

umbilical was averted, linea alba and striae were present, no scar and no surgical mark on

inspection.

-On palpation, the fundal height was 33cm, lie was longitudinal, cephalic presentation.

-On auscultation, the fetal heart rate was normal which was 150b/min.

SUMMARY: 23years female from PETE, referral from Kitogani clinic as regular visits to

makunduchi hospital due to low hb level of 6.0g/dl but came with the complain of headache

associated with dizziness but no blurred vision loss of consciousness, fever, convulsion. On

examination she was pale , has pitting lower limb edema .

IMPRESSION DIAGNOSIS: Severe anemia in pregnancy secondary to poor diet.

DIFFERENTIAL DIAGNOSIS:-worms infection

-malaria

INVESTIGATION

FBP (Full blood picture).

Stool analysis

MRDT

MANAGEMENT

86
 Tab ferrous sulphate 200mg OD for one month.

Syrup haemovit 15 mls tds for three months.

Tab albendazole 400mg start.

Counseling on good diet so as to increase her blood level.

PREVENTION

Primary prevention.

Early clinical diagnosis, investigation and treatment.

Early booking anti natal care.

Promote and ensure adequate nutrition to all women in reproductive age.

Provision of hematinic.

Secondary prevention.

Early diagnosis and prompt treatment.

Health care providers and relatives should ensure that the patient take medicine at accurate time

and correctly.

Tertiary prevention.

Health care providers should manage complications effectively in order to prevent death.

COMPLICATIONS

Fetal complications

87
A pre-term or low birth weight baby.

Fetal distress.

Intrauterine growth retardation.

Still-birth.

Maternal complications.

Cardiac failure.

Acute kidney injury

Preterm labor

PROGNOSIS.

The patient condition was well but she needs hematinic supplements so as to keep her condition

better. And the condition will be poor if she will not use proper medication, preventive measure

and poor personal hygiene will increase risk factor of worms’ infection.

88
 CASE 16: [Link] in pregnancy 2° poor diet

NAME: XXX XXX XXX

AGE: 22years

SEX: FEMALE

ADRESS: KI0NGONI

DATE: 10/05/2022

LAST NORMAL MENSTRAL PERIOD: 02/08/2021

ESTIMATED DATE OF DELIVERY: 30/05/2022

GASTATION AGE: 39 weeks plus 5 days by dates.

GRAVIDA 5, PARA 4, LIVING 3, ABORTION 0

MAIN COMPLAINS: - Headache

- Mouth ulcer (angular stomatitis) 2/7

- Right leg weakness

HISTORY OF PRESENTING ILLNESS:

-The patient was well prior the of an admission.

89
-A patient had started to experience headache which was gradually onset, the pain was at the

both sides of the head(right and left side of the head),associated with dizziness,it was relieved by

resting and aggravated by doing any activities.

-The patient had complained on having mouth ulcer which was gradually onset, localized at the

corners of the mouth, no relieving factors and no aggravating factors associated with pain during

eating.

-The patient experienced gradually onset right leg weakness, associated with knee joint

pain,which was relieved when applying Vicks to the leg and aggravated when doing activities.

-A patient had No history of fever, no history of convulsion, no history of loss of

consciousness, no history of numbness, no history of muscle pain, no history of tongue ulcer, no

history of difficult in swallowing

-The patient was poor in diet that noticed to eat twice a day that was morning eat only bread with

tea and on evening rice and curry sometimes eat fishes and vegetables and fruits but not every

day.

REVIEW OF OTHER SYSTEM

Respiratory System: -No history of coughing

- No history of chest pain

- No history of chest tightness

Cardiovascular System: - No history of awareness of heart beat.

- No history of lower limb edema.

90
Gastro Intestinal Tract: -No history of abdominal pain

- No history of frequently on passing stool.

- No nausea and vomiting.

-No history of vomiting.

Gastro Urinary System: –No history of pain during urination

- No frequency in urination

-No history of blood in urine

PAST MEDICAL HISTORY: - No history of admission

- No history of food and drug allergy

- No history of blood transfusion.

- No history of chronic diseases such as hypertension.

- No history of cigarette smoking and alcohol use.

-No history of surgery.

INDEX PREGNANCY: She was attend at clinic at 3 months of age,the fetal movement was

felt at 3 months of age.

-She had also received all doses of Tetanus toxoid vaccines and malaria treated net.

GYNAECOLOGICAL HISTORY: She was started monarche at 14years, she was having

regular menstrual bleeding which was associated with slightly abdominal cramps, she changed

91
pads three a day and the blood was in normal amount. No history of using family planning

methods, no history of pain during sexual intercourse, no history of sexual transmitted diseases,

no history of gynecological problems, no history of any gynecological procedure.

OBSTETRIC HISTORY

-She had four children but one child died with unknown cause (according to the mother

information).

The first child was male, born at the hospital through spontaneously vaginal delivery with birth

weight of 3.5kg, and no any complication after birth.

And second child was female, borned at the hospital through spontaneously vaginal delivery with

birth weight of 3.2kg and no further complication was observed during and after birth.

And the third child was female, borned at the hospital through spontaneously vaginal delivery

with birth weight of 2.8kg and no further complication was observed during and after birth.

And the fourth child was male, borned at the hospital through spontaneously vaginal delivery

with birth weight of 3.0kg and no further complication was observed during and after birth.

FAMILY AND SOCIAL HISTORY: - She is married woman with four children and live with

her family, but her one child passed away since he was in seven month.

-She is a house wife and her husband is a farmer.

- No history of using alcohol and cigarette smoking in a family.

- No history of chronic diseases in his family such diabetes.

92
GENERAL EXAMINATION : The patient was alert, full conscious ,well oriented with

people ,place and time , with GCS 15/15 ,afebrile,she was slightly pale , she had angular

stomatitis on both sides of the mouth, no jaundice, no central and peripheral cyanosis , not

dyspnea, no lymphnoid enlargement.

Hg, Pulse Rate =90b/min, Respiratory Rate =23b/min, Temperature =37. 0°C

Hemoglobin level =5.6g/dl.

SYSTEMIC EXAMINATION.

CENTRAL NERVOUS SYSTEM

-A patient was alert ,full conscious , with an intact memory both short and long time memory ,

well oriented with people, place, and time .

-Normal muscle tone and power.

-No sign of any meningeal irritation.

MUSCULOSKELETAL SYSTEM: Normal appearance of the limbs with no scar no marks no

deformity no swelling.

-Normal sensation, tone and power.

-On palpation no edema but tender.

-On percussion patella is normal.

93
RESPIRATORY SYSTEM: -The chest was symmetrical, move with respiration, tracheal is

central located, normal chest expansion, no scar and no any traditional mark.

-No mass and no deformity palpable.

-Resonance percussed note.

-Normal breathing sound hard on auscultation.

CARDIOVASCULAR SYSTEM : -The hands were warm , but pale, no cyanosis ,normal

capillary refill which retain within a 2 seconds,no finger clubbing ,pulse rate was 90b/min which

was normal with normal rhythm which was regular regular with normal volume ,non-collapse

and synchronal, no jugular vein distention and precordium area not bulged.

-Apex beat was felt in 5th intercostal space at the left midclavicular line.

-S1 and S2 were heard and no added sound in auscultation.

GASTROINTESTINAL SYSTEM: -The abdomen was distended, move with respiration, the

umbilical was averted, linea alba and striae were present, no scar and no surgical mark on

inspection.

-On palpation, the fundal height was 33cm, lie was longitudinal with cephalic

presentation.

-On auscultation, the fetal heart rate was normal which was 150b/min.

94
SUMMARY: 22 years old female from KIONGONI came with the complain of headache

localized at sides parts associated with dizziness,and also complained on having mouth

ulceration(angular stomatitis) in both sides of the mouth and presents with right leg weakness

associated with knee joint pain for two days.

On examination, she was pale and have angular stomatitis and tenderness to the right knee joint

with hemoglobin level of 6.0g/dl.

IMPRESSION DIAGNOSIS: Severe anemia in pregnancy secondary to poor diet intake.

DIFFERENTIAL DIAGNOSIS: - Vitamin C deficiency.

-Worms infection.

-Malaria.

INVESTIGATION

FBP (Full blood picture).

Abdominal pelvic ultrasound ultrasound.

Stool analysis.

Urinalysis.

MRDT(Malaria Rapid Diagnostic Test).

HIV test.

MANAGEMENT

Tab ferrous sulphate 200mg OD for one month.

95
 Syrup haemovit 15 mls tds for three months.

Tab albendazole 400mg start.

Tab pregnant care I tab od for one month.

Vitamin B Complex

Counseling on good diet so as to increase her blood level.

PREVENTION

Primary prevention.

-Early clinical diagnosis, investigation and treatment.

-Early follow of anti natal care.

-HIV screening.

-Promote and ensure adequate nutrition to all women in reproductive age.

-Provision of hematinic.

Secondary prevention.

-Early diagnosis and prompt treatment.

-Health care providers and relatives should ensure that the patient take medicine at accurate time

and correctly.

Tertiary prevention.

96
-Health care providers should manage complications effectively in order to prevents other

complication.

COMPLICATIONS

-Fetal complications.

-A pre-term or low birth weight baby.

-Fetal distress.

-Intrauterine growth retardation.

-Still-birth.

Maternal complications.

-Cardiac failure.

-Acute kidney injury

-Preterm labor

PROGNOSIS.

The patient condition was well and she's in medication.

FOLLOW UP.

The patient should return the clinic after one month.

97
 CASE 17: [Link] in pregnancy 2° poor diet

NAME: XXX XXX XXX

AGE: 24years

SEX: FEMALE

ADRESS: KIZIMBANI

DATE: 27/05/2022

LAST NORMAL MENSTRAL PERIOD: 3/12/2021

ESTIMATED DATE OF DELIVERY; 10/9/2022

GASTATION AGE: 32 weeks plus 6 days by dates.

GRAVIDA 4, PARA 3, LIVING 3, ABORTION 0

MAIN COMPLAINS: - Headache 3/7

- Mouth ulcer

- Right leg weakness

98
HISTORY OF PRESENTING ILLNESS:-The patient was well two days ago, since she

started to experience headache of gradually onset, the pain was especially at the both sides of

the head(right and left side of the head),associated with dizziness, get relieved by resting and

aggravated by doing any activities.

Also the patient had mouth ulcer which was gradually onset, localized at the corners of the

mouth, no relieving factors and no aggravating factors associated with pain during eating.

And also the patient experienced gradually onset right leg weakness, associated with knee joint

pain, get relieved when applying Vicks to the leg and aggravated when doing activities. No

history of fever, no history of convulsion, no history of loss of consciousness, no history of

numbness, no history of muscle pain, no history of tongue ulcer, no history of difficult in

swallowing.

REVIEW OF OTHER SYSTEM

Respiratory System: -No history of coughing

- No history of chest pain

- No history of chest tightness

Cardiovascular System: - No history of awareness of heart beat.

- No history of lower limb edema.

Gastro Intestinal Tract: -No history of abdominal pain

- No history of diarrhea

99
 -No history of vomiting.

Gastro Urinary System: –No history of pain during urination

- No frequency in urination

-No history of blood in urine

PAST MEDICAL HISTORY: - No history of admission

- No history of food and drug allergy

- No history of blood transfusion

-No history of surgery.

INDEX PREGNANCY: She made her first booking when the pregnancy was 3 months old, she

felt fetal movement when the pregnancy was 3 months old up to now she received all doses of

Tetanus toxoid vaccines, malaria treated net.

GYNAECOLOGICAL HISTORY: She started menarche since 14years, she was having

regular menstrual bleeding which was associated with slightly abdominal cramps, she changed

pads three times a day and the blood was in normal amount, and she get menstruation for 7 days

in each month. No history of using family planning methods, no history of pain during sexual

intercourse, no history of sexual transmitted diseases, no history of gynecological problems, no

history of any gynecological procedure.

OBSTETRIC HISTORY:-She had 3 children .

100
The first child was male, born at the hospital through spontaneously vaginal delivery with birth

weight of 3.5kg, and no any complication after birth.

And second child was female, born at the hospital through spontaneously vaginal delivery with

birth weight of 3.2kg and no further complication get during and after birth.

And the third child was female, born at the hospital through spontaneously vaginal delivery with

birth weight of 2.8kg and no further complication get during and after birth.

FAMILY AND SOCIAL HISTORY: - She is married woman with 3 children and live with her

family, but her one child passed away since he was in seven month.

-She is a house wife and her husband is a business man.

- No history of using alcohol and cigarette smoking in a family.

- No history of chronic diseases in his family.

DIETARY HISTORY: The patient says that she eat two times a day that is morning and

evening on morning eat only bread and tea and on evening rice and curry sometimes eat fishes

and vegetables and fruits but not every day.

GENERAL EXAMINATION : The patient was alert, full conscious ,well oriented with

people ,place and time , with GCS 15/15 , afebrile, she was pale , she has angular stomatitis to

both sides of the mouth, no jaundice, no cyanosis , not dyspnea, no lower limb edema.

VITAL SIGN: Blood Pressure =120/70mmHg, Pulse Rate =85b/min, Respiration Rate

=23b/min, Temperature =37.4c Hemoglobin level =7.0g/dl

101
SYSTEMIC EXAMINATION.

CENTRAL NERVOUS SYSTEM : - patient was alert ,full conscious , with an intact memory

both short and long time memory , well oriented with people, place, and time .

-Normal muscle tone and power.

-No sign of any meningeal irritation.

MUSCULOSKELETAL SYSTEM: Normal appearance of the limbs with no scar no marks no

deformity no swelling.

-Normal sensation, tone and power.

-On palpation no edema but tender.

-On percussion patella is normal.

RESPIRATORY SYSTEM: -The chest was symmetrical, move with respiration, tracheal is

central located, normal chest expansion, no scar and no mark.

-No mass and no deformity palpable.

-Resonance percussed note.

-Normal breathing sound hard on auscultation.

CARDIOVASCULAR SYSTEM : - the hands were warm , but pale, no cyanosis ,normal

capillary refill ,no finger clubbing ,pulse rate was 80b/min which was regular and normal

102
volume ,non-collapse and synchronal, no jugular vein distention and precordium area not

bulged.

-Apex beat was felt in 5th intercostal space at the left midclavicular line.

-S1 and S2 were heard and no added sound in auscultation.

GASTROINTESTINAL SYSTEM: -The abdomen was distended, move with respiration, the

umbilical was averted, linea alba and striae were present, no scar and no surgical mark on

inspection.

-On palpation, the fundal height was 33cm, lie was longitudinal, cephalic presentation.

-On auscultation, the fetal heart rate was normal which was 150b/min.

SUMMARY: 24years female from KIZIMBANI, came with the complain of headache localized

at sides parts associated with dizziness, mouth ulcer (angular stomatitis) in both sides of the

mouth and right leg weakness associated with knee joint pain for two days, on examination, she

was pale and have angular stomatitis and tender to the right knee joint with hemoglobin level of

7.0g/dl.

IMPRESSION DIAGNOSIS: Severe anemia in pregnancy secondary to poor diet.

DIFFERENTIAL DIAGNOSIS: - Vitamin C deficiency.

-worms infection

-malaria

INVESTIGATION

103
 FBP (Full blood picture).

Abdominal pelvic ultrasound ultrasound

Stool analysis

Urinalysis

MRDT

HIV test

MANAGEMENT

Tab ferrous sulphate 200mg OD for one month.

Syrup haemovit 15 mls tds for three months.

Tab albendazole 400mg start.

Tab pregnant care I tab od for one month.

Vitamin B Complex

Counseling on good diet so as to increase her blood level.

PREVENTION

Primary prevention.

Early clinical diagnosis, investigation and treatment.

Early booking anti natal care.

HIV screening.

104
Promote and ensure adequate nutrition to all women in reproductive age.

Provision of hematinic.

Secondary prevention.

Early diagnosis and prompt treatment.

Health care providers and relatives should ensure that the patient take medicine at accurate time

and correctly.

Tertiary prevention.

Health care providers should manage complications effectively in order to prevent death.

COMPLICATIONS

Fetal complications

A pre-term or low birth weight baby.

Fetal distress.

Intrauterine growth retardation.

Still-birth.

Maternal complications.

Cardiac failure.

Acute kidney injury

Preterm labor

105
PROGNOSIS.

The patient condition was well but she needs hematinic supplements so as to keep her condition

better. And the condition will be poor if she will not use proper medication, preventive measure

and poor personal hygiene will increase risk factor of worms’ infection.

FOLLOW UP.

The patient should return the clinic after one month of treatment to check hemoglobin level and

look for the progress.

EVALUATION.

After one month the mother returned to clinic and condition had improved well also the

hemoglobin level was 9g/dl also is on hematinic drugs for another 2 months also had improved

on diet.

106
 CASE 18: [Link] 2° PPH & Maternal Puerperal Sepsis

NAME: XXX XXX XXX

AGE: 28 YEARS

SEX: FEMALE

ADRESS: NGWACHANI

PARA 5, LIVING 5 ABORTION 1

20 days post SVD

4 DAYS POST ADMISSION.

CHIEF COMPLAIN

Per vaginal bleeding - 1/7

Fever – 1/7

HISTORY OF PRESENTING ILLNESS The patient was apparently well until 1 day prior to admission when

she experienced per vagina bleeding of sudden onset dark red in color and with heavy clots. The

bleeding was so heavy that she used 5 pads all soaked with blood. It was associated with difficulty in

breathing that was aggravated by activities and relieved by resting but denied history of heartbeat

awareness, chest tightness, chest pain or cough. She denied history of dizziness, loss of consciousness or

headache. She also complained of high grade fever of gradual onset for one day and chills which had no

aggravating factor but relieved by covering with blankets. She denied history of convulsions or headache.

In the ward, she has received 2 units of blood and other medications.

107
REVIEW OF OTHER SYSTEM

Gastrointestinal tract – No history of abdominal pain, vomiting, nausea, loose stool, difficulty passing

stool or blood in stool.

Genitourinary system – No history of painful urination, frequent urination or blood in urine.

Muscular-skeletal system – No history of joint pain, muscle pain or spasms. Ears, nose and throat – No
history of ear and nose pain and discharge, no history of painful throat, difficult in swallowing or painful
swallowing.

PAST MEDICAL AND SURGICAL HISTORY. This is the third admission. 1st admission in 2013 at Chake
chake hospital due to same condition was treated and cured. 2nd admission in 2016 at Abdalla Mzee
Hospital due to abortion. No history of surgery, has history of blood transfusion in both admission, no
history of chronic illness such as hypertension, sickle cell diseases or heart diseases, no history of foods
and drugs allergy.

OBSTETRIC HISTORY She delivered all her babies at Abdalla Mzee Hospital via spontaneous vertex
delivery with no complications and all children are alive. 1st child was a boy born at 2012 with 3kg, 2nd
was a girl at 2013 with 4kg, 3rd pregnancy was aborted at 3 months, 4th pregnancy in 2018 she had
twins; 1st twin was a girl with 2.8kg and 2nd twin was a boy with 2.9kg and in 2022 a girl with 3.3 kg.

GYNAECOLOGICAL HISTORY She attained menarche at 14 years old. The menstrual cycles is regular 5/30
days. Light bleeding she changes 2 to 3 clothes per day not fully soaked. She started coitus coitus at 17
years old. No history pain during and after sexual intercourse, no history of using contraception, no
history of any sexual transmitted infection. FAMILY AND

SOCIAL HISTORY She is married live with her husband. She is a house wife and her husband is a small
business man. Both have form 4 level of education. No history of chronic disease in the family like
hypertension, Diabetes mellitus, sickle cell diseases or heart diseases. No history of cigarette smoking
and alcohol use.

108
GENERAL EXAMINATION

The patient is conscious and oriented. She is afebrile, not dyspnic, not jaundiced not cyanosed but pale
in the conjunctiva. Has normal black hair distributed all over the head with normal texture, no ear and
nose discharge, no angular stomatitis, no patches or dental caries in oral cavity no palpable peripheral
lymph node, no lower limb edema. Vital signs Temperature - 36.9O C Blood Pressure - 123/66
mmHg Pulse Rate - 80 b/min Respiration Rate - 14 b/min

SYSTEMIC EXAMINATION PER ABDOMEN

The abdomen is distended symmetrically, moves with respiration and has no scar or therapeutic marks,
has no visible mass and is not tender on palpation and fundus not palpable. Liver, spleen and kidney also
not palpable. It is tympanic on percussion and 3 bowels sounds per minute heard on auscultation.

RESPIRATORY SYSTEM

Inspection: Normal chest moves slightly with respiration, symmetrically, no flair chest, no any visible
mass, no surgical and traditional marks, respiration rate is 20 b/min. Palpation: Trachea is at center,
normal tactile vocal fremitus, no palpable peripheral lymph node, apex beat is at left 5th intercostal
space mid-clavicular line, normal chest expansion. Percussion: Normal resonant note. Auscultation:
Normal breathing vesicular sound heard.

CARDIOVASCULAR SYSTEM

The palm is warm, capillary refill less than 2seconds, no finger clubbing or spoon shaped nails, pulse rate
has taken on left radial artery was 90 b/min, which was regular - regular with synchronicity to right
radial artery. no jugular Vein raise. Inspection: Chest is flat, symmetrically move with respiration, no
precordial hyperactivity, no any visible mass, no surgical or traditional mark. Palpation: apex beat
located at 5th intercostal space mid clavicular line. Auscultation: S1 and S2 heard with no added sound.

CENTRAL NERVE SYSTEM.

Full conscious, oriented to People, Place and Time. Glasgow Coma Scale is 15/15, and memory is good
in short and long term memory. Motor and sensory centers were intact. Speech and language was intact.

Cranial nerves:

1st olfactory nerve: Patient was able to identify orange smell.

109
2nd optic nerve: Patient was able to sense light.

3rd, 4th and 6th occulomotor, trochlear and abducens nerve: Patient was able to rotate eyes in all
direction.

5th trigeminal nerve: Patient was able to chew and masticate foods.

7th facial nerve: Patient was able to control facial expression such as smile.

8th vestibular cochlear: Patient was able to hear by using turning fork and able to walk with balance.

9th glossopharyngeal nerve: Patient was able to identify orange taste.

10th vagus nerve: gag reflex positive by using tongue depressor.

11st accessory nerve: Patient was able to rotate heads and rise shoulders.

12nd hypoglossal nerve: patient was able to taste bitter fruits and control tongue in all directions.

SUMMARY

This is the history of a 28 years old female from Ngwachani, prime gravida 20 days post SVD, P5L5A1
with complain of heavy pv bleeding for 1 day with clots associated with difficulty in breathing and
complained of high grade fever with chills. She had already received 2 units of blood. The vitals were
stable, physically she was pale in conjunctiva and no other findings were significant.

Provisional Diagnosis:

1. Severe anaemia secondary to Secondary postpartum hemorrhage. Due to being 20 days post SVD and
experienced heavy bleeding per vagina.
2. Maternal puerperal sepsis due to high grade fever in postpartum period.

Differential diagnosis:

 Malaria
 Urinary tract infection
 Acute pyelonephritis

INVESTIGATION

 Full blood picture

 Obstetric ultrasound: To see if there is retained products of conception.
 BS for Mps

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  Urinalysis
 RFT

MANAGEMENT

 IV Ceftriaxone 1g od for 5/7

 Tab Metronidazole 400mg tds 5/7
 Tab fefol bd for 1/12
 Tranexamic acid 1g stat

COMPLICATION

 Septicemia
 Shock
 Pelvic abscess
 Renal failure
 Cardiac Failure
 Sheehan syndrome

PREVENTION

 Manage 4 th stage of labour carefully.

 Observe personal hygiene.

PROGNOSIS: is good when getting proper management, will be easily cured.

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