Identification

Name: ilhan cisman farah

Age: 35 Sex: female
Address:jigjiga kebele 04 , Phone No.0915073784
Occupation: House Wife
Marital Status: Married Ethnicity:
SOMALI
Religion: muslim Ward: OBS AND GYN
Date of Admission: 9 /5/2016 E.C Bed no. 7
Date of clerking: 10/5/2016 E.C

Previous admission: No previous admission

Chief Complaint: lower abdominal crampling and vaginal

bleeding 3 hrs duration
History of present illness

This is a gravida 4 para 3 (all alive and femal`s) mother whose LNMP was
5/01/16 E.C which makes her EDD on 9/81/16E.C, and gestational age 20
weeks .after She is presented with lower abdominal pain and
execessive vaginal bleeding of one day duration before she
arrived the hospital . The pain was occurring since a day
ago, gradually, in different intervals, but the one occurred
last 6 hour was severe enough to make her go to a hospital
It is more painful in the lower abdominal , exacerbated by
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walking, and doing different activities, but relieved by rest,

especially when she sleep on the bed). She also complains of
inability to walk for one and half of the last three hours ,
despite she has adequate sexual intercourse (4x/week). She
has no history of condom use , also no any other
contraceptive use. She was around 15-18 years of age during
her first menses. Since then she had regular menstrual
cycles with 28+/-2days interval, 3-4 days of flow. Previously
there is no clot, during last menstrual flow there is no clot
formed, . There is no severe pain associated with it, she
never used any drugs for it, to avoid drug adaptation.
She had female genital cutting, but no history of C/S,
gynecologic surgeries and procedures. She was 18 years old
during her first coitus; she is sexually active and has no
unstable sexual relationship but safe sexual practice. Her
husband has two children from his previous wife & he works
in small building works (material worke shop’), working
privately.
She has urinary frequency (D/N=3:2), otherwise no history of
vaginal discharge, GI complaints, fever, chills, rigor, and no
history of UTIs or STIs, liver and thyroid disease, hormonal
replacement therapy, immunosuppressive therapy or
chemotherapy. No self or family history of Diabetes Mellitus,
hypertension, renal, cardiac disorder, TB, mental disorders
and twinning, any medical or gynecological surgery.
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Past obstetric history:

There is no past obstetric history
Gynecologic History:
See HPI
Past Medical and Surgical History
See HPI
Personal/ Family history
She was born, raised and, completed grade 12 in
jigjiga .She has history of intramuscular vaccination
when she was 5-10years of age. She has no history of
measles, chickenpox, mumps or meningitis infection
during childhood. She has no history of smoking, Chat
addiction or alcohol use. , even though she stays in
home,most of the times. Both her parents are alive and
relatively healthy. She has 3 brothers and no sister; all
first degree family is relatively healthy. She is happy in
her marriage. They live in a house with 3 rooms and
toilet. Their monthly income is variable. They have flat
screen TV, but no car.

FUNCTIONAL INQUIRY
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H.E.E.N.T
Head: normal hair distribution No headache or trauma.
Ears: no loss of hearing,earache,discharge,deafness, tinnitus
or vertigo.
Eyes: Good vision, ptosis, lid lag no pain, strain, lacrimation
or photophobia.
Nose: has sinusitis (related to common cold), but no epistaxis
or unusual discharge
Mouth and throat: clean her tooth daily, No dental pain or
bleeding from gums no artificial denture.
Glands
No mass in the neck, groin, axillae or lump in the breast. No
discharge from the nipples, no goiter, no heat or cold
intolerance.
Respiratory
No cough, expectoration, no hemoptysis, no night sweats
chest pain, no shortness of breath, Wheezing or cyanosis.
Cardiovascular system
No fatigue, dyspnea, orthopnea, PND, no chest pain, no
dyspnea. No leg swelling, syncope or hypertension.
Gastrointestinal system
Good appetite No nausea, vomiting, black discoloration of the
stool, constipation or diarrhea. She has regular bowel habits.
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Genitourinary system
no dysuria, urgency, hesitancy, dribbling, hematuria or
pyuria.
Integumentary system
Small scar on her right face, moist skin, full hair distribution
otherwise, no pigmented changes or changes in fingernails.
No known allergy or drug sensitivity.
Locomotor system
No bony deformities, no chest pain, no joint pain or swelling,
loss of function of limbs, muscle wasting or weakness.

Central Nervous System

Good memory and orientation, No seizure, syncope,
blackouts transient loss of function, spasms or involuntary
movements.
Physical Examination
GENERAL APPEARANCE
The patient looks conceseous & she is comfortable. She is
not in respiratory or cardiac distress.

VITAL SIGNS
PR: 80 beats/min; regular, full volume, at left radial artery
RR: 20breaths/min
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BP: 110/70mmHg; left hand in a sitting position

To: 37.OC, left axilla

HEENT
Head: Normal size and shape. No scar,
depression. Normal hair distribution.
Ears: Normal contour of pinna. Clear external
ear canal. Good equal hearing.
Eyes: Normal eyebrows. No periorbital edema,
ptosis, exophthalmos, excessive
lacrimation or strabismus. The
conjunctivas are pink. The sclerae are not
icteric. The pupils are equal in size.
Nose: Central nasal septum. There is no polyp or
unusual discharge
Mouth & The lips have no fissure, ulceration. The
throat: gums are intact and clean. There is no
carious tooth,no artificial denture.

Lymphatic and glandular System:

The occipital, pre & postauricular, submandibular,
submental, supraclavicular, epitrochlear, axillary and
inguinal areas are free of palpable lymph nodes. The thyroid
gland is not enlarged. Breasts has no mass, no lump or
nodule, no retraction of skin,no nipple discharge.

Chest Examination
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Inspection: No scar, no use of accessory muscle while

breathing, symmetrical chest movement, no cyanosis and no
clubbing.
Palpation: central trachea, no tenderness, symmetrical chest
expansion. Symmetrical tactile fremitus both anteriorly and
posteriorly.
Percussion: Symmetrical, resonant notes, diaphragmatic
excursion =4cms
Auscultation: normal bronchial breath sounds
CardioVascularSystem
Arterial pulse volume is tabulated as follows:

Caroti Brachia Radia Femo Poplit Dorsali Posterior

d l l -ral -eal s Pedis Tibialis
R +++ ++ + ++ + ++ +
L +++ ++ + ++ + ++ +

veins
The jugular venous pressure observed at one pillow
elevation (45o couch was not available) has a
measurement of 7cm,no hepatojugular reflux, no
distended veins over the neck or chest wall, no varices
or phlebitis in the legs.
Precordium
Inspection: quite precordium, no scar, no deformity, no
bulging.
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Palpation: The point of ma/ximum impulse is felt at the 5 th

intercostals space, no palpable heart sounds, no para sternal
heave or thrill.
Auscultation: Normal S1 & S2 heart sounds, no murmur or
gallop
Abdomen
Inspection: Abdomen is asymmetrically distended,more on
the left side the lower quadrant. Flanks are full. No striae
gravidarum, linea nigra,scar. Inverted Umbilicus ,no
distended veins, no visible peristaltic movement,or
pulsations. No visible hernia while coughing.
Superficial Palpation: there is tenderness in the lower
abdominal, no superficial mass.
Deep palpation: :positive rebound tenderness in the lower
abdominal, there is 20 weeks sized mobile mass, that has
irregular surface, firm in consistency whose upper border is
localized but lower border is not. The mass is felt more in the
left side. Liver & spleen are not palpable. Kidneys are not
bimanually palpable.
Percussion: No shifting dullness or fluid thrill
Auscultation: Bowel sounds well heard thre is bruits sound
in the lower abdominal.
Pelvic Exmination
External genitallia:
-I pubic hair :nverted triangle
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-Labia majora and minora: no, ulcers, swelling, or tumors

-Urethral Orifice: no sign of inflammation
-Bartholin gland: no swelling or tenderness
Speculum:
-pink vaginal wall
-no septa or stenosis
-no mass
-closed cervix
-no cervical polyp, cyst o ulcer
But there is bleeding in the vaginal and its color is bright but
there is no offensive order

Digital Vaginal examination:

-wa not done
Central Nervous System
Mental Status
The patient is well oriented to person, place and time.
Normal speech, good memory, attention, no hallucination.
Cranial Nerves:

1. Smells alcohol via each nostril

2. Good visual field, acuity and color sense
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3,4 & 6. The eyes can move in all directions. No nystagmus

or diplopia.good Pupilary reflex and accommodation.
5. Trigeminal: Positive corneal reflex,touch and pain
sensation over the face. Normal contraction of temporalis
and, masseter, muscles.
7. Facial: symmetrical face both at rest and during voluntary
movement,identiferd orange taste.
8. Vestibulocochlear: good balance, no hearing loss
9, 10 Glossopharyngeal and Vagus: symmetrical soft palate
and good phonation
11. Spinal accessory: Sternocledomastoid and Trapezius
contract with full power
12. Hypoglossal: tongue can move to all directions, no
tremor, no atrophy, protrusion of the tongue
Motor:
Normal muscle, size, tone, bulk and power. No spontaneous
or induced fasciculation.
Sensory:
Light touch, pain, temperature, deep pressure, position
sense, vibrations and passive movements are well
appreciated.
Reflexes:
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 Superficial
Corneal Abdomen Plantar
Right ++ +  (down
going)
Left ++ (down
going)
 Deep
Biceps Triceps Supinato Patellar Ankle
r
Right + + + + +
Left + + + + +

Summary
Subjective-
-she is a 35 years old patient
-presented with lower abdominal pain of one day
duration.
- Objective-
- PR:80 beats/min,RR: 20breaths/min,BP:
o O
110/70mmHg,T : 37.0 C,
- tenderness in the lower abdominal, by superficial
palpation
- positive rebound tenderness
-
- no Flanks are full
-20 weeks sized mobile mass that has irregular
surface, firm in consistency, of pelvic origin. More felt
in the left side
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Differential Diagnosis

Include: gynecological and non-gynecologic causes:

1. Intestinal obstruction
2. Bladder tumor
3. Endometrial cancer
4. Uterine myoma
5. Ovarian tumor
6. Adenomyosis

1. Intestinal obstruction
Obstruction of the GI may occur at any level but the small
intestine is most often involved because of its relatively
narrow lumen. Collectively hernias, intestinal adhesions,
intussusceptions and volvulus account for 50 % of
mechanical obstruction, while tumor and infarction account
for 10 % of small bowel obstructions. The clinical
manifestations of clinical intestinal obstruction include
abdominal pain and distension vomiting and constipation.
Even though this patient has abdominal distention, she
doesn’t show other manifestations that are typical for bowel
obstruction like constipation, vomiting or diarrhea. Making
intestinal obstruction a less likely cause.

2. bladder tumor
Most common and significant finding of bladder tumors,
especially bladder cancer is hematuria. Although bladder
tumor may be one of the causes of abdominal mass, its very
unlikely diagnosis, given the history of the patient.(e.g.no
hematuria)
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3.endometiral cancer
It is the most common cancer in woman. Its peak incidence
is in the 7th decade but 25% can occur in perimenopausal
women. Exogenous estrogen is a risk factor for it. The most
important and early symptom of endometrial cancer is
abnormal vaginal discharge especially after menopause or
intermittent spotting. This is associated with lower
abdominal cramps. The uterine enlargement is symmetrical
and smooth surfaced. Although this may be one of the
palpable cause of abdominal mass, this patient doesn’t have
any of the above mentioned symptoms making it an unlikely
diagnosis. i.e

In favour not in favour

-uterine enlargement -irregular surface
-nulliparous -no history of prolonged estrogen use
-reproductive age
-no vaginal discharge

4. adenomyosis
adenomyosis is the preence opf endometrial gland in the
myometrium of the uteruas.it affecttts 20%of women . it is
common in parous women.the essential of diagnosis for
adenomyosis are dysmenorrheal,menorrhagia and
uniform,symmetrical uterine enlargement.Anemia might be
present as a complication.

In favour not in favour

-Vaginal bleeding -no dysmennorrhea
-utrine enlargement -the mass is not symmetrical &
not regular
-she is nulliparous
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=>So, this diagnosis is most unlikely

5.ovarian tumor
Any type of ovarian tumor develops with few warning signs
and symptoms. Most ovarian tumors produce few symptoms
until wide dissemination.A history of GI complaints,
including nausea, dyspepsia and altered bowel habits is
particularly common. Early satiety and abdominal distension
as a result are generally signs of advanced disease.
Constipation and decreased stool caliber are occasionally
noted.Evenyhough ovarian tumor might be a cause of this
abdominal mass.this patient doesn’t have all the above
symptoms,so the diagnosis is most unlikely, Ultrasound and
lab tests for serum tumor markers should be done. i.e

In favour not in favour

-Abdominal mass - no cachexia, or signs of
malignancy
-

7.uterine myoma
Myoma is generally characterized by causing irregular
enlargement of the uterus, bleeding, pain, pressure that is
symptoms from neighboring organs like urinary
incontinence, frequency of urination, difficulty of voiding, low
back pain, with bleeding being the most common and
pertinent symptom. Although the patient has some of the
symptoms like frequency or urination, myoma is the likely
cause of abdominal masses as it is generally common in a
woman of reproductive age
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In favor not in
favour
-vaginal bleeding -no
bleeding
-lower abdominal mass & pain
-mass is irregular and asymmetric
-meneorrhagia
-reproductive age woman
-black and nulliparous
-frequency of urination
-inability to concieve

Impression

the most likely diagnosis is uterine myoma.

Investigations
 Pregnancy test
 LFT & RFT ,
 TSH,PRL…
 Tumor markers (
 CBC,Hgb,Hct
 Urine analysis
 Stool examination
 Abdominopelvic ultrasound
 Hystero salpingography
 Endometrial biopsy
 Intravenous pilogram
 GI-contrast
 Cystoscopy
 Rectosigmoidoscopy
 Chest X-ray
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Management plan

-The woman has already become symptomatic so expectant

management has no place here .
-blood should be prepared for emergency situations &
surgery (she is now hemodynamically stable)

-we can use medical therapy to relieve symptoms:

. GnRh agonists- to decrease tumor size,

temporarily until surgery is done.
.OCPs- to control pain to conrol menorrhagia.
-surgical:
is the main treatment plan after ruling out other pelvic
neoplasms
 Hysterectomy:
-eliminates symptoms and recurrence ,ovaries should be
preserved because she is in reproductive age group
 Uterne artery embolization:
-occlusion of the uterine arteries ,as alternative to
the hysterectomy,has low risk of recurrence.but she
want to be pregnant if possible.
 Myolysis:
-laparascopic thermal coagulation of myomas
 Endometrial Ablation

 Myemectomy:

-even though it has risk of recurrence,this is the best

treatment for a woman like her, who wants to have a
child.
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Abdominal Examination
Inspection: No scar, grossly distended, no dextrorotation. There is
Linea nigra and stria gravidarum.
Palpation:
Superficial palpation: There is no mass or tenderness.
Deep palpation: There is no tenderness. The liver was not
palpable below the right costal margin. The spleen was also
not palpable.
Percussion: There is no flank dullness. There is no fluid thrill. The
total liver span was difficult to assess.

Obstetric Palpation
Fundal palpation: The fundus is 9 fingers above level of
umbilicus (38 weeks)
: The fundus contains soft, bulky, irregular, non
ballotable mass (breech)
Lateral palpation: Irregular, soft parts are felt on the left side
and a flat, straight surface is palpable on the right.
(Longitudinal lie, fetal back on the right side)
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Pelvic palpation:: cephalic prominence first felt on the left

side and anterior shoulder 5 fingers above the symphysis
pubis. (Cephalic presentation, flexed, undescended)
Auscultation: FHR is 140b/min, best herd at right lower
quadrant

Fetal weight assessment -The fetus is estimated to be big fetus