CLINICAL

HISTORY AND
PHYSICAL
EXAMINATION
JI Jollo Villasan
MM

34 year old

Gravida
Mercury 8 Para 6 (6016)

Caloocan City
Chief Complaint:
Hypogastric
Pain
LMP: June 14, 2020 (?)
PMP: 2nd week of May 2020

AOG: 10-11 weeks

 History of Present Illness
5 DAYS
2 DAYS PTA
PTA

 (+) Intermittent Epigastric  (+) Intermittent Epigastric &

pain, 4/10 Hypogastric pain, 4/10
 (+) Dysuria  (+) Dysuria
 (-) vaginal bleeding/spotting  (+) Frequency
 (-) fever  (-) vaginal bleeding/spotting
 (-) nausea/vomiting  (-) fever
 No consult done, no  (-) nausea/vomiting
medications taken  Sought consult at a Health
Center with an assessment of
Acid Peptic Disease
 No medications taken
 History of Present Illness
1 DAY PTA

 (+) Hypogastric pain, 6-7/10

 (+) Dysuria  Sought consult at a Secondary
 (+) Frequency Hospital wherein CBC and
 (-) Epigastric pain Urinalysis were done
 (-) Vaginal bleeding/spotting  No pregnancy test requested
 (-) Fever
 (-) Nausea/vomiting
 (-) Difficulty of Breathing
 Complete Blood Count Urinalysis
RBC 1.82 SEVERE Color Yellow
Hemoglobin 49 ANEMIA
Character Hazy
Hematocrit 0.16 pH 6.0
Platelet Count 324 Specific Gravity 1.015
WBC 10.7
Protein Negative
Neutrophils 0.61
Glucose Negative
Lymphocytes 0.31
Monocytes 0.04 Pus Cells 20-25/hpf
Eosinophils 0.04 Red Cells 7-10/hpf
Epithelial Cells Few
Bacteria Moderate
 History of Present Illness
1 DAY PTA 6 hours PTA

 Assessment: UTI; Severe Anemia  Patient

 (+) Hypogastric
went topain,
6 6-7/10
 (+) Dysuria
different hospitals but
 (+) Frequency
 Advised transfer to a tertiary
hospital for blood transfusion due  was denied admission
(+) Weakness
to lack of facilities of the said  due to lack of blood
(+) Palpitations
institution  products
(+) Easy fatigability
 (-) Epigastric pain
 Persistence of symptoms
 No medications given  (-) Vaginal bleeding/spotting
 led patient to seek
(-) Fever
 consult at our institution
(-) Nausea/vomiting
 (-) Difficulty of Breathing
 AT THE EMERGENCY ROOM

1:00 pm: Patient decked to Internal Medicine due to her chief

complaint of hypogastric pain
Assessment: UTI; Severe anemia; R/O Gyne Pathology
• CBC, Urinalysis with Pregnancy test were done
• Hooked to O2 via nasal cannula
 Complete Blood Count Urinalysis
RBC 1.64 SEVERE Color Yellow
Hemoglobin 47 ANEMIA
Character Slightly turbid
Hematocrit 0.144 pH 6.0
Platelet Count 263 Specific Gravity 1.013
WBC 13.25
Protein Negative
Neutrophils 0.679
Glucose Negative
Lymphocytes 0.180
Monocytes 0.079 Leukocytes 1+
Eosinophils 0.060 Pus Cells 18.9/µL
Basophils 0.002 Red Cells 48.9/µL
Epithelial Cells 0.8
Pregnancy test: Positive Bacteria 99,999
 AT THE EMERGENCY ROOM
Speculum Examination:
VITAL SIGNS clean looking cervix, with scanty
BP 100/60 mmHg brownish vaginal discharge
3:00
HR pm: Patient was referred to OB
87 bpm
RR 21 cpm• Internal test
Positive Pregnancy Examination:
result Normal
Temp 36.5 looking external genitalia, parous
introitus, vagina admits 2 fingers
• Pale palpebral conjunctiva, with ease, Cervix firm & closed, (+)
pale lips, pale palms & soles cervical motion tenderness,
• Abdomen: Flabby, Soft uterus slightly enlarged, with
abdomen, with direct 4x4cm adnexal mass at the right,
tenderness on all quadrants with cul de sac fullness, no left
adnexal mass palpated
PAST MEDICAL HISTORY FAMILY HISTORY
● Non-hypertensive ● Father: hypertensive,
● Non-diabetic deceased due to stroke
● Non-asthmatic ● Mother: 64 years old,
● (-) Thyroid Disease Diabetic, Non-hypertensive
● (-) Cardiac Disease ● Siblings: Apparently well
● (+) Allergy to seafood
● (+) Measles, Mumps,
Chickenpox
PERSONAL & SOCIAL GYNECOLOGIC HISTORY
HISTORY
● Highschool graduate ● M: 14 years old
● Sim card retailer ● I: 28-30 days
● Occasional Smoker ● D: 3-4 days
● Occasional alcoholic beverage ● A: 3-4 pads/day,
drinker moderately soaked
● Denies history of illicit drug ● S: (-) dysmenorrhea
use
● Married for 1 year to RA, who
is in prison since 2019
 OBSTETRIC HISTORY
Gravida 8 Para 6 (6016)
Number of Year Location of Manner of Assisted by Outcome  
Pregnancy Delivery Delivery
G1 2003 Hospital Spontaneous Obstetrician Completion 1st
Abortion Curettage Filipino
partner
G2 2007 Home NSD Midwife Term birth 13 years
living boy, old,
Birth weight apparently 2nd
well
2.4kg
birth 12 years
Filipino
G3 2008 Hospital NSD Obstetrician Term
living boy, old, partner
Birth weight apparently
well
2.8kg
G4 2013 Hospital NSD Obstetrician Term birth 7 years old, 3rd
living girl, apparently Filipino
Birth weight well partner
2.6kg
 OBSTETRIC HISTORY
Gravida 8 Para 6 (6016)
Number of Year Location of Manner of Assisted by Outcome  
Pregnancy Delivery Delivery
G5 2014 Hospital NSD Obstetrician Term birth 6 years old,
living girl, apparently
Birth weight well
2.8kg 3rd Filipino
G6 2015 Hospital NSD Obstetrician Term birth 5 years old, partner
living boy, apparently
Birth weight well
3.0 kg
G7 2018 Hospital NSD Obstetrician Term birth 2 years old,
living boy, apparently Japanese
well
Birth weight parrtner
2.8kg
6th Filipino
G8-Current Pregnancy
partner
 METHOD OF SEXUAL HISTORY
CONTRACEPTION ● Coitarche: 17 years old
● # of Sexual Partners: 6
● Combined Oral ● Polygamous, heterosexual
Contraceptive relationship
Pills from 2016- ● No history of leukorrhea, dyspareunia
2018 or post-coital bleeding
● Denies exposure to sexually
transmitted diseases
● Papsmear done: 2019 with normal
results
 REVIEW OF SYSTEMS
Constitutional
Hematology
Central Nervous System
Head, Ears, Eyes, Nose, Throat
Respiratory
Cardiovascular System
Gastrointestinal tract
Genitourinary tract
Neuromuscular System
no chills, no malaise, no weight loss
no easy bruisability
no headache, no vertigo, no syncope
no blurring of vision, no hearing loss, no
tinnitus
no dyspnea, no cough, no colds, no apnea
no orthopnea
no diarrhea, no constipation, no melena
no urgency
no malaise, no arthralgia, no numbness, no
myalgia
PHYSICAL EXAMINATION
 General conscious, coherent, afebrile, not in cardiorespiratory distress
Survey Vital signs:
BP: 100/60 mmHg
CR: 87 bpm
RR: 21 cpm
Temp: 36.5 C
02 sat: 97%
 HEENT anicteric sclera, pale palpebral conjunctiva, pale lips, no
nasoaural discharge, no tonsillopharyngeal congestion
 Neck supple neck, no neck vein engorgement, no cervical
lymphadenopathy
 Chest symmetrical chest expansion, no retractions, vesicular breath
sounds
PHYSICAL EXAMINATION
 Heart Adynamic precordium, normal rate, regular rhythm, no murmur
 Abdomen Flabby, Soft, with direct tenderness on all quadrants
 Speculum Clean looking cervix, with scanty brownish vaginal discharge
exam
 Internal Normal looking external genitalia, parous introitus, vagina admits 2
Exam fingers with ease, Cervix firm & closed, (+) cervical motion
tenderness, uterus slightly enlarged, with 4x4cm adnexal mass
at the right, with cul de sac fullness, no left adnexal mass
palpated
 Extremities Pale palms & soles, no gross deformities, no edema, no cyanosis,
CRT > 2 seconds
ASSESSMENT
Gravida 8 Para 6 (6016)
To Consider Ectopic Pregnancy Right,
Probably Ruptured
Severe Anemia Secondary
Urinary Tract Infection
 • Admit
• To Operating Room
• For Emergency Exploratory
Laparotomy, Bilateral Salpingectomy

PLAN •
•
•
For Chest xray, Blood typing
Give Cefoxitin 2 grams TIV ( ) ANST
Secure 4 units pRBC properly typed
and crossmatched for transfusion
and OR use
• Refer to Anesthesiology service
 CASE
DISCUSSION
 Salient Features
MM

34 year old

Gravida 8 Para 6 (6016)

10-11 weeks AOG

Hyogastric pain accompanied by

dysuria
 Salient Features
Pale palpebral conjunctiva, pale palms & soles

Soft abdomen, Direct tenderness at the hypogastric area

Cervical Motion Tenderness

4x4cm Right Adnexal Mass

Fullness at the cul de sac

 • Admit
• To Operating Room
• For Emergency Exploratory
Laparotomy, Bilateral Salpingectomy

PLAN •
•
•
For Chest xray, Blood typing
Give Cefoxitin 2 grams TIV ( ) ANST
Secure 4 units pRBC properly typed
and crossmatched for transfusion
and OR use
• Refer to Anesthesiology service
 TIMELINE
3:15pm
Admitted patient for Emergency Exploratory laparotomy
Referred to Anesthesia Service
Chest Xray, Blood typing and 4 units pRBC properly typed and
crossmatched requested

Chest Xray: Unremarkable

3:30 pm: Patient at the Operating Room

 DIFFERENTIAL DIAGNOSIS
OBSTETRICS
Threatened Abortion
Ruptured Corpus Luteum
Ectopic Pregnancy - Positive Pregnancy Test
- Slightly enlarged uterus
THREATENED - No cervical motion tenderness; no adnexal
ABORTION mass/tenderness
- (+/-) Vaginal Bleeding

RUPTURED CORPUS - Sudden onset of pain

LUTEUM - (+) Vaginal Bleeding

- Positive Pregnancy Test

ECTOPIC PREGNANCY - (+) Abdominal pain
- (+) Vaginal Bleeding
- (+) Adnexal Mass
ECTOPIC PREGNANCY

Any pregnancy in which

the fertilized ovum
implanted outside the
uterine cavity
INCIDENCE

• 1% to 2% of all
pregnancies
• Most common cause
of maternal mortality
in the first trimester
of pregnancy
LOCATION OF ECTOPIC PREGNANCY
 RISK FACTORS
Tubal Corrective Surgeries Previous Genital Infections
Prior Ectopic Pregnancy Early Age at First Intercourse
Tubal Sterilization Multiple Sexual Partners
Documented Tubal Pathology Smoking
Infertility Prior Abortion/ CS Delivery
Assisted Reproductive Progesterone only Emergency
Technology Contraceptives/ IUD
 PATHOGENESIS
Multiple Sexual Partners & Early Coitarche:
development of STIs, ascending infection or both

Distortion of the normal tubal anatomy or Scarring of the tube

Blocking the normal transport of the ovum

RUPTURED ECTOPIC PREGNANCY

Bimanual Pelvic
Abdominal Pain: Abdominal Examination:
Severe & Sharp, Palpation: elicits cervical motion
Stabbing or Tearing tenderness causes exquisite
pain

Posterior Vaginal
Fornix may bulge Tender, boggy
from blood in the mass felt beside
rectouterine cul-de- the uterus
sac
MANAGEMENT
 LAPAROSCOPY vs LAPAROTOMY

Patients with ruptured ectopic pregnancy and massive

hemoperitoneum, laparoscopy is feasible and safe, with
significantly shorter operating time compared with laparotomy.
While the mode of surgery should be based on the surgeon’s
experience and preference, the significantly lower
hemoperitoneum volume associated with laparoscopy may be a
reflection of shorter operating times and quicker hemorrhage
control.
The FASTEST AND SAFEST approach is always the one that the
surgeon feels more comfortable with
SALPINGOSTOMY vs SALPINGECTOMY
Status &
Status of the
Salvageability
Contralateral
of Affected
Tube
Tube

Pelvic
Desire for
Anatomic
Future Fertility
Pathologies
 SALPINGECTOMY

Uncontrolled
Ruptured Tube
Tubal Bleeding

Moderately or
Severely
Damaged Tube
 SALPINGECTOMY

“In women desiring permanent sterilization,

the unaffected tube can be ligated or
removed concurrently with salpingectomy for
the affected fallopian tube”
 PLAN
For Emergency
Exploratory
Laparotomy, Bilateral
Salpingectomy
INTRAOPERATIVELY
Hemoperitoneum:
2000cc

Left fallopian tube with

products of conception was
pushed to the right side by
the massive
hemoperitoneum. Filmy
adhesions were also noted
INTRAOPERATIVELY
Left fallopian tube:
6.5x1.2x1cm

Ampullary portion of the Left

Fallopian tube area:
1.5cm point of rupture with
blood clots and products of
conception surrounding the
point of rupture
INTRAOPERATIVELY

The left ovary, right

fallopian tube, right
ovary and uterus
appears normal
 INTRAOPERATIVELY

LEFT RIGHT
 HISTOPATHOLOGY

• Extrauterine (Tubal) Pregnancy, Ruptured, Left

• Paratubal cyst, Left
• No pathologic diagnosis, Right fallopian tube
 COMPLETE BLOOD COUNT
08/28/20 (Pre-op) 09/03/20
SEVERE RBC: 1.64 MODERATE RBC: 3.20
ANEMIA ANEMIA
Hgb: 47 Hgb: 91
Hgb: 91
Hct: 0.144 Hct: 0.287
Platelet Count: 263 Platelet Count: 303
WBC: 13.25 WBC: 11.62
Neu: 0.679 Neu: 0.489
Lymp: 0.180 Lym: 0.274
Mono: 0.079 S/P 3u pRBC Mono: 0.071
Eos: 0.060 Eos: 0.161
Baso: 0.002
 COMPLETE BLOOD COUNT
09/03/20 09/17/20
MODERATE MILD
ANEMIA RBC: 3.20 ANEMIA RBC: 3.79
Hgb: 91 Hgb: 112
Hct: 0.287 Hct: 0.339
Platelet Count: 303 Platelet Count: 437
WBC: 11.62 WBC: 12.11
Neu: 0.489 Neu: 0.308
Lym: 0.274 S/P 2 weeks of Lym: 0.268
Mono: 0.071 FeSO4 1 tab BID Mono: 0.072
Eos: 0.161 Eos: 0.0342
 COURSE IN THE WARD
• Patient tolerated the procedure well

• Postoperatively, patient was given Doxycycline 100mg

1 tab BID for 14 days

• Discharged on her postoperative day 24 due to financial

constraints
 FUTURE PLANS
• Advised daily perineal hygiene

• Advised monogamous heterosexual relationship

• STD prevention counselling for patient

• For STD Work-up as outpatient (HBsAg, VDRL/RPR, HAATS)

• For HPV Vaccination

• Advised annual papsmear

 FINAL DIAGNOSIS
• Gravida 8 Para 6 (6026) Tubal Pregnancy 10-11weeks,
Left Ampullary- Ruptured;
• Exploratory Laparotomy; Evacuation of
Hemoperitoneum; Bilateral Salpingectomy under
General Anesthesia- Orotracheal Intubation;
• Severe Anemia Secondary- underwent correction; Status
Post Transfusion with 3 units pRBC;
• Pelvic Inflammatory Disease