CASE
Medical Number: **********
General information
Name:** Age: 25 years old Sex: Female Race: Han
Occupation: others Nationality: China
Marital status: Married Address:ChangZhou JiangSu Tel: *********
Date of admission: Dec.27th, 2020 Date of record:11am, Dec.27th, 2020 Complainer of history: the patient herself Reliability: Reliable
Chief complaint: The patient was found cessation of menstruation for 36+2w and Present illness: The patient had regular menses previously. The first time when she was
vaginal bleeding for over one week.
14. Lasting4days every times and its cycle is about 30-45 days.LMP: 2020-4-17. Uric HCG test was positive after 50 days of amenorrhea. On 2020-6-10,her type-B ultrasonic revealed Intrauterine early pregnancy,correspond to gestational week of 6weeks+.According to the early ultrasonic result,we calculate EDC is 2021-2-2.The patient did not have obvious nausea and vomiting of pregnancy (NVP)in early stage of pregnancy .Fetal movements were felt in 4 months’ gestation. She did ante-partum examination for totally seven times,but did not do down's screening and TORCH screening.OGTT showed that the level of her fasting blood glucose is 5.17mmol/L,while the level of postprandial blood sugar is normal.In the course of gestation, the patient did not get in touch with any radioactive rays,toxicant or pets. On 2020-12-20,the patient went to local hospital for treatment as a result of a little vaginal bleeding. After admission,she was given magnesium sulfate for fetus protection and dexamethasone for promotion of fetal lung maturity.when her bleeding station is under control, she left hospital. On 2020-12-26,as a result of “large amount of vaginal bleeding,more than menstrual blood volume”, she went to Central Hospital of Wujin with emergency visit. After admission, she was given Ritodrine for fetus protection. And then she was sent to our hospital for further treatment. Until today, the patient is found cessation of menstruation for 36+2w,and further accounting gestational age is 35 weeks according to the ultrasonic. There is still some dark red vaginal bleeding. While the patient did not feel abdonimal pain, and there was no vaginal discharge. So she was accepted to our hospital and her diagnosis was “36+2weeks of gestation, Dangerous placenta previa”. After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation. Her strength is a little diminished, and the weight has physiological changes.
Past history
Health status:good.
Operative history: She received cesarean operation in 2011.
Infectious history: No history of severe infectious disease.
Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system: No history of anemia and mucocutaneous bleeding.
Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Changzhou and almost always lived in Changzhou. There was no any endemic disease in Changzhou. Her living conditions were good. No bad personal habits and customs.
Menstrual history: The first time when she was 14. Lasting 4days every times and its cycle i
s about 30-45 days. LMP: 2020-4-17.
Obstetrical history: marital age:22 years old.Pregnacy 4 times, once cesarean
delivery.induced abortion 2 times.
Family history: Her parents are both alive. COVID-19 epidemic area：NO.
Physical examination
T: 36.0℃ P: 76/min R: 20/min BP: 112/67mmHg
General appearance: Patient is a 25 years old female who appears pleasant, in no apperant distress, given her age, well developed and well nourished. Oriented to person, place and time. Lymph nodes: Not enlarged.
Skin: No jaundice or rashes. No cyanosis and bruises. No edema. Head: Skull and scalp normal. No tenderness. No loss of hair.
Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No jaundice. Pupil’s size and shape is normal. Corneal is clear. No exophthalmos. Ears: Auditory acuity is excellent. No ear purulent discharge.
Nose: Shape is normal. No obstruction. No deviation of nasal septum.
Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.
Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.
Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass. Lung:
Inspection: Respiration regular. Degree of expansion is symmetry. Plapation: Tactile fremitus symmetrical.
Percussion: extensive resonance to percussion.
Ausculation: Clear to ausculation with no rubs noted. Heart:
Inspection: No abnormal pulsation or retraction.
Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.
Percussion: The border of cardiac is not enlarged.
Ausculation: The heart sounds were of good quality and the rhythm was regular. Heart rate: 76/min. No bruits. Right(cm) Rib interspace Left(cm) 2.5 Ⅱ 2 2.5 Ⅲ 4 3 Ⅳ 6 Ⅴ 8 The left mid-clavicular line is 8.5 cm away from front midsternal line. Radial pulse is normal. Abdomen:
Inspection: Universial abdominal bulge. Dilated veins unobserved.
Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details see obstetric examination.
Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space. Ausculation: Bowl sound clear. 4/min.
Spine and extremities: Severe edema in both lower extremities. No clubbed finger. No disorder of the movement of axial and appendicular bones.
Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negative.
Obstetric examination
Fetus: Abdominal girth: 116cm; height of fundus: 35cm; fetal heart rate: 148/min,regular. Uterine contraction is untouched. Internal Examination is not done. Pelvis: 23-27-19-9 cm. Outpatient data: one copy of medical record of outpatient.
Features of the case:
1. Patient was female, 25 years old ,married.
2. The patient was found “cessation of menstruation for 36+2w and vaginal bleeding for over one week.”
3. No special past history.
4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above.
5. investigation information: see above
Impression: 1. 36+2weeks of gestation.
2. G4P1 3. LOA
4. Dangerous placenta previa 5. GDM
6. Scarred uterus
Signature:***. 2020-01-21,11am
Discussion
Placenta praevia is an obstetric complication in which the placenta is inserted partially or wholly in the lower uterine segment. It is a leading cause of antepartum haemorrhage . So it should be taken seriously . Firstly, the situation should be stabilized. Secondly , relevant inspection should be carried to further prove our diagnosis and evaluate whether to terminate pregnancy. After admission, the patient was advised a complete rest in bed and was given Ritodrine to suppression uterus contraction. As for the examination results, we can see that NST is responsible, and FHR is 145bpm. Blood routine is normal, there is no anemia and infection. Besides, the level of blood glucose is normal. The diagnosis is proved to be central type of placenta previa, according to the ultrasonic. Besides ,it is likely that there exists partial placental implantation. Since the patient received cesarean section in the past, the situation is more dangerous. So we should terminate pregnancy as soon as possible. On the third day after admission, the patient received cesarean section and Lower uterine segment narrow suture operation. Because the placenta was not delivered completely and partial placental implantation existed, the patient needed to reexamined the ultrasonic some time later. Exact cause of placenta praevia is unknown. So we can not prevent it well. But if we take regular ante-partum examination, we can find it early and take serious attitude to it, it is better for both the mother and the babies.
实用产科英文病例模板(包含疫情问诊)
