Master the Postnatal Case Presentation: The Ultimate Doctor’s Guide for OBGYN Viva Success
Mrs Shrestha 32 years homemaker , who passed education up to high school ,wife of Mr Shrestha 34years foreign employment from Parbat
She is a booked case of MANIPAL TEACHING HOSPITAL
She is on her 3rd POD following EM.LSCS at 32+6 WOG with out come of A/S/L/PT male baby B.W 1.6kg who cried immediately after birth
Presently complains of pain at the incision site x 3 days
HOPI : The pain was at the incision, which started after delivery dull aching in character with no radiation on and off type aggravated on movement and relieved on rest an pain is mild in severity
The patient also mention PV discharge which is red in color non foul smelling moderate in amount soaking 3 pads fully with no clots and decreasing in amount
The patient has passed urine and stool is ambulating and having semi solid diet and is able to breastfed her baby
There is no h/o fever SOB, cough , burning micturition, calf pain swelling of legs, breast discomfort, feeling of sadness
The baby is by the side of mother / or he might be in NICU Cried immediately, breastfed after an hour and no any congenital anomaly
Labour
she was presented to MTH 2 days back on dec 2 with complain of abdominal pain which was gradual in onset progressively increasing in frequency dull aching with no aggravating factor Also she complain of PV bleeding since 6:30am that morning after waking from sleep, odourless scanty in amount red in color no clots
Then she came to MTH and was planned for Em.LSCS
HOPP
She is P2L2A1
The pregnancy was planned and detected by UPT after 2 month of missed pregnancy later confirmed by USG at 3 months she had mild N and V in 1st trimester which was relieved on medication . She took folic aid tablets and no PV leak ,discharge bleeding burning micturition drug use or radiation use
She first perceived fetal movement at 5 months took Fe and calcium tablets and took 2 doses of Td vaccine 1 months apart
She complain of pv bleeding on 29 WOG for which she was admitted in Manipal hospital and on evaluation it was found she had placenta previa and was discharge on regular follow up
High yield surgery 1 MCQ for KU final year MBBS
Menstrual hx
Menarche :15yrs
Regular cycles of 28+-2days for 4-5 days with 2 fully soaked pads/day
clots(-) dysmenorrhea (-)
LMP 29th chaitra 2080
EDD :06 magh 2081
Obs hx:
married for 11yrs
p2L2A1
L1 : 10 years ago LSCS done for ….with outcome girl/boy? B.W….kg
A1 : At 4 weeks spontaneously
Contraceptive : no hx of contraceptive use
Past history :
She complain of pv bleeding on 29 WOG for which she was admitted in Manipal hospital and on evaluation it was found she had placenta previa and was discharge on regular follow up
No any comorbidites HTN ,DM ,CARDIAC DIS , THYROID DIS
Family hx : not significant
Personal hx
She is non veg
Normal sleep and appetite
Non alcoholic and non smoker
S/e hx
Surgical instruments
Examination
After taking consent patient was examined in a well lit room with adequate exposure
Ht: … wt:… kg. BMI: …
Patient is conscious cooperative well oriented to time place and person
And is lying comfortably on the bed
PICCLOD :
Vitals
Puls is 74bpm regular normal in character and volume with no radioradial delay
RR:20br/min
Temp 98.2F
BP :130/70 mmhg
CNS : grossly intact
Thyroid : no visible or palpable swelling on the neck , no scar over neck
Breast :
On inspection: B/l symmetrical enlarged breast
Nipple is erectile with expression of milk
No cracked everted nipple
On palpation : no sign of increasing temperature or tenderness
CVS : s1s2 no murmurs
RESP: b/l equal normal vesicular breath sound with no added sound
Abdominal examination:
On inspection:
Dressing in situ about 10 cm long intact no soakage discharge Abdomen appears ovoid with centrally placed umbilicus
All quadrant movs equally on resp.
Linea nigra present from xiphhisternum to pubic symphysis
There was no visible pulsation ,venous prominence, scar swelling
Striae gravidarum over lower abdomen
On palpation
On sup: temp(-) tenderness(-)
On deep : fungus was palpated and was 2 fingers below umbilicus corresponding to 20 weeks size 13 cm above pubic symphysis
On auscultation
3 bowl sound were heard
Loch examination : red in color scanty(how many pads changed ?) odorless discharge
Summary
Mrs Shrestha 32 years on her 3nd POD following EM.LSCS at 32+6 WOG with out come of A/S/L/PT male baby B.W 1.6kg who cried immediately after birth Presently complains of pain at the incision site x 3 days dull aching in character with no radiation on and off type aggravated on movement and relieved on rest an pain is mild in severity The patient has passed urine and stool is ambulating is having semi solid diet and is able to breastfed her baby
During her intrapartum period She complain of pv bleeding on 29 WOG for which she was admitted in Manipal hospital and on evaluation it was found she had placenta previa and was discharge on regular follow up
On/e GC is fair
Vitals stable
Abdominal examination
Inspection dressing in situ intact no soakage
Palpation : fungus at 13cm from pubic symphysis
Diagnosis
32 years P2L2A1 on her 3rd POD following EM.LSCS at 32+6WOG with outcome of come of A/S/L/PT male baby B.W 1.6kg who cried immediately after birth
