KANVILIE JAYABALAN

BATCH27 GROUP C2
101303001
Patients profile
Name
: Siti Shuainidah Binti Ahmad
Age
: 43
Race
: Malay
Address
: Ayer Keroh
Occupation : Promoter
Parity index : G6P3+2
LMP
: Uncertain
EDD
: 16/11/2013
Period Of Gestation : 38weeks 5days
Date of admission
: 6/11/2013
Date of examination : 7/11/2013
Chief Concern
Leaking per vagina for 3 days
History of presenting concern
Patient went to Klinik Kesihatan Ayer Keroh at 9am (6/11/2013), with a complain of leaking per
vagina for 3 days. Leak is brownish, odorless, non-itching, sticky in nature and patient describes
the amount as a 50cents coin size spot on her undergarment and stains her bed too. She changes 2
pads per day.
It was associated with lower abdominal pain, intermittent, gripping in nature, mild in severity,
radiating from lower abdomen to the back. Pain aggravates depending on the side which she lies
on for a very long time and relieved by changing her sleeping position at intervals and by
massaging using topical ointments.
No anemia and her bowel and bladder is normal.
There is no irregular uterine contractions which increases in duration, frequency and intensity.
Fetal movements well appreciated by mother : 10 times/day
Patient is then referred to Malacca General Hospital, at 2pm (6/11/2013), upon arrival abdominal
examination was done and it was normal.
Transabdominal ultrasound and CTG were done and they were normal.
Blood and urine samples were taken and the results were normal.
Patient was warded at 10pm and vital signs were monitored every 4th hourly.
Currently patient is stable and pain free.

History of presenting pregnancy

This pregnancy was unplanned. She first noticed when she missed her period for 3 months in
duration. She then went to Klinik Kesihatan Ayer Keroh and confirmed her pregnancy by urine
pregnancy test. At 3 months of pregnancy, she did her booking visit at Klinik Kesihatan Ayer
Keroh. Physical examinations were done, urine, blood samples (Hb count,grouping, hepB,HIV,
syphilis) were taken and they were normal. She has been given folic acid and compliance to it.
Ultrasound was done showing single fetus inside the uterus and it was normal. She has no nausea
and vomiting. She went for regular antenatal check ups at Klinik Kesihatan Ayer Keroh.
Modified Glucose Tolerance Test (MGTT) was done at fifth and sixth months and it was normal.
Ultrasounds were done 4 times and all were normal. Quickening felt the fifth month. At the sixth
month, a dose of Tetanus toxoid was given. Fetal movements were well appreciated.
Past Obstetrics History
Patient is G6P3+2. Her first child was born in 1990, male, spontaneous vaginal delivery, 2.55kg, at
term. Her second male child was born in 1992, spontaneous vaginal delivery, 3.0kg, at term. Her
third child was born in 1993, female, spontaneous vaginal delivery, 3.0kg, at term. She had two
abortions in 1998 and 2004 due to lack of financial support. She was on Copper T IUCD for 8
years (2004 2012).
Menstrual History
She attained menarche at 14 years old. She had regular menstrual cycle of 27 days and 6-7 days
bleeding. She has no dysmenorrhea and menorrhagia problems.
Past history
No significant past medical and surgical history.
Personal history
Her appetite is good and she consumes balanced diet. Her sleep is normal. Bowel and bladder
habits are normal. She does not smoke or consume alcohol.
Family history
Her father and mother has hypertension. Patient is the fourth child of 7 siblings. Her siblings are
healthy. There is no family history of consanguinity marriages. No history of ischemic heart
diseases, TB, asthma, malignancies and blood disorders.
Social history
She stays with her husband with family income of RM 3000 per month. Her husband is a
promoter and owns a car as transportation. Their house is a terrace house which is 20 minutes
away from the hospital.
Summary
A 43 year old, G6P3+2, 38 weeks 5 days presented with leaking per vagina for 3 days
associated with lower abdominal pain radiating to the back. She is currently being monitored in
the ward for vitals and fetal heart rate.

General examination
Patient is alert and cooperative, sitting in upright position. She is moderately built and
moderately nourished.
No pallor.
Weight: 73.1kg, height: 151cm, BMI: 32.06 kg/m2
Vital signs : Pulse 80/min
Respiratory rate- 18/min
Blood pressure- 115/65 mmHg on right arm ,sitting up position
Temperature- 37o C
Eyes : No pallor, no icterus.
Mouth: No pallor, sublingual icterus, oral hygiene is good.
Neck : No obvious swelling, and no lymph node enlargement.
Breast and thyroid examinations were not done.
Bilateral pitting pedal edema present.
Abdominal examination
Inspection:
Abdomen is uniformly distended. Flanks are full. Umbilicus is central and inverted. All areas of
abdomen move equally on respiration. Linea nigra and stria gravidarum are present. No obvious
fetal movement. Hernial orifices are intact.
Palpation:
Clinical fundal height is at 38weeks of gestation and symphysiofundal height is 38-40cm.
Fundal grip: Firm round mass, non ballotable.
Right lateral grip: Irregular knob like structures
Left lateral grip: Curved broad surface
Pelvic grip : Hard globular mass
Auscultation:
Fetal heart sound can be heard.
Singleton pregnancy, cephalic presentation with longitudinal lie, on head 3/5th palpable.
Diagnosis: Suspected prelabor rupture of membrane (PROM)
Discussion:
DEFINITION:
- Rupture of membrane after 37weeks of gestation and before the onset of labor.
ETIOLOGY:
Common causes:
- Increased friability and decreased strength of membrane at term
- Cervical insufficiency
- Polyhydramnios

Multiple pregnancy
Previous history of PROM
Genital tract infection: Chlamydia trachomatis, N.gonorrhea
Pregnancy induced hypertension
Post cervical surgery
Antepartum hemorrhage
Nutritional deficiency
Smoking

DIAGNOSIS:
History and examination:
- Sudden gush of clear or yellowish fluid per vagina.
- Sterile speculum examination: Ask patient to cough, a gush of fluid from cervix
(Demostrable leak), demonstrates pooling of fliud in posterior fornix (Suggestive leak).
Confirmatory test:
- Litmus test: turns from red to blue when in contact with amniotic fluid (alkaline) and to
exclude urine due to urinary incontinence.
- Nitrazine test: turns from yellow to blue. 96% of accuracy.
- Ferning test: Amniotic fluid is spread on a slide and examined under microscope, for
ferning pattern. 85% accuracy. False positives: seminal fluid, cerviacal mucus,
fingerprints. False negative: Sample collection errors,contamination with blood.
- Amnisure: Immunochromatographic method. High sensitivity and specificity. To detect
placental alpha microglobulin-1 (PAMG-1): an excellent protein marker for amniotic
fluid. A negative test is certain and patients can be discharged.
- Ultrasound: Demonstrate oligohydramnios and confirming spontaneous rupture.
Investigations:
- High vaginal swab
- Urine analysis, FEME
- Full blood count,CRP
- Culture and sensitivity test
- Amniotic fluid index
- Biophysical profile
Management:
- Antibiotics: Erythromycin
- Steroids: IM Dexamethasone 12mg, 12 hours apart
- Tocolytics given in preterm: Salbutamol
- Bed rest
Diagnosis: Suspected prelabor rupture of membrane (PROM)

KANVILIE JAYABALAN
BATCH27 GROUP C2
101303001
Patients profile
Name
: Erna Fazleana Bt. Othman
Age
: 26
Race
: Malay
Address
: Sungai Abong, Muar
Occupation : Homemaker
Parity index : G3P 2
LMP
: 20/2/2013
EDD
: 27/12/2013
POA
: 37 weeks 0 days
Date of admission
: 4/11/2013
Date of examination : 6/11/2013
Chief Concern
Low hemoglobin count (8.6g/dL) was detected when she came for regular antenatal checkup.
History of presenting concern
Patient came for regular antenatal checkup on 4/11/2013 at 9am. Upon arrival, blood and urine
samples were taken. Blood sample shows low hemoglobin count (8.6g/dL). Abdominal
examination and CTG were done and both were normal. Patient was given 1 pine of blood and
transferred to the ward at 5pm.
Anemia is present and she feels lethargic. There is no breathlessness or palpitations. Her bowel
and bladder was normal.
There was no show and leaking per vagina.
Fetal movements well appreciated by mother : 10 times/day. The vital signs were monitored and
per vaginal examination done. Currently patient is stable, fetal heart sounds ,uterine contractions
and vital signs are monitored.
History of presenting pregnancy
This is a planned pregnancy. She first noticed when she missed her period for 2 months in
duration. She then confirmed her pregnancy by urine pregnancy test at home. At 2 months of
pregnancy, she did her booking visit at Klinik Desa Simpang Jeram. Physical examinations were
done, urine, blood samples were taken and they were normal. She has been given iron and
vitamin supplements and compliance to it. She developed severe nausea and vomiting in the first
trimester due to the iron supplements and symptoms regressed as she stopped that drug. Doctor
prescribed a newer one. There is no fever and bleeding per vagina. Ultrasound was done showing
single fetus inside the uterus and it was normal. Dating scan was done , fetal organogenesis was
normal. In her second trimester, quickening felt at 5th month and no congenital anomalies were
found. She went for regular antenatal check ups at Klinik Desa Simpang Jeram. Modified
Glucose Tolerance Test (MGTT) was done at seventh month and it was normal. Ultrasounds

were done 5 times and all were normal. At the sixth and eighth months, two doses of Tetanus
toxoid were given. Fetal movements were well appreciated.
Past Obstetrics History
Patient is G3P 2. Her first child was born in 2010, female, spontaneous vaginal delivery, 3.2kg at
39 weeks. Second child was born in 2012, female, spontaneous vaginal delivery, 3kg at 39
weeks. Breast feeding was initiated immediately.
Menstrual History
She attained menarche at 12 years old. She had regular menstrual cycle of 30 days and 7 days
bleeding. She has dysmenorrhea and she consumes pain killers to relieve the pain. No
contraceptives used.
Past history
No significant past medical and surgical history.
Personal history
Her appetite is good and she consumes balanced diet. Her sleep is normal. Bowel and bladder
habits are normal. She does not smoke or consume alcohol.
Family history
Both her parents passed away and she couldnt remember the cause of their death . Patient is the
youngest of three siblings. All her siblings are healthy.
Social history
She stays with her husband with family income of RM 2000 per month. Her husband is a
bussinessman and owns a car as transportation. Their house is a terrace house which is 30
minutes away from the hospital.
Summary
A 26 years old, Malay lady, G3P 2, 37 weeks presented with low hemoglobin count (8.6g/dL) and
was detected when she came for regular antenatal checkup. She is currently being monitored in
the ward and blood transfusion is being done.
General examination
Patient is alert and cooperative, sitting in upright position. She is moderately built and
moderately nourished. Intravenous canula inserted at the left dorsum of the hand and it is
stopered.
No pallor.
Weight :55kg, height:160cm, BMI: 21.48kg/m2
Vital signs : Pulse 88/min
Respiratory rate- 18/min
Blood pressure- 124/85 mmHg on right arm ,sitting up position
Temperature- 37o C

Eyes : Pallor present, no icterus.

Mouth: Pallor present, sublingual icterus, oral hygiene is good.
Neck : No obvious swelling, and no lymph node enlargement.
Breast and thyroid examinations were not done.
Pitting pedal edema absent.
Abdominal examination
Inspection:
Abdomen is uniformly distended. Flanks are full. Umbilicus is central and inverted. All areas of
abdomen move equally on respiration. Linea nigra and stria gravidarum is present. No obvious
fetal movement. Hernial orifices are intact.
Palpation:
Clinical fundal height is at 37weeks of gestation and symphysiofundal height is 36-38cm.
Fundal grip: Firm round mass, non ballotable.
Right lateral grip: Irregular knob like structures
Left lateral grip: Curved broad surface
Pelvic grip : Hard globular mass
Auscultation:
Fetal heart sound can be heard.
Singleton pregnancy, cephalic presentation with longitudinal lie, on head 3/5th palpable.
Diagnosis: Anemia in pregnancy

KANVILIE JAYABALAN
BATCH27 GROUP C2
101303001

Patients profile
Name
: Fauziah Zakarya
Age
: 32
Race
: Malay
Address
: Ayer Keroh
Occupation : Factory worker
Parity index : Nulliparous (P0)
LMP
: 28/8/2013
Date of admission
: 22/10/2013
Date of examination : 26/10/2013
Chief Concern
Elective admission for exploratory laparotomy
History of presenting concern
Patient came to MGH outpatient clinic on 22/3/2013 morning at 9am, due to intermittent diffuse
lower abdominal pains. The pain was moderate in severity with a pain score of 6 out of 10,
pricking in nature and radiates to the back. There were no aggravating and relieving factors. It
was associated with abdominal distension, nausea and vomiting. There is 10kg weight loss over
the past 1 year.
On arrival, blood samples were taken and ultrasound was done. A large mass measuring 100mm
x 176mm was detected in the right pelvic region. Patient is asked to return for CT scan due to
high tumour marker levels.
CT scan was done on 10/4/2013, revealed a large lobulated pelvic mass measuring 100mm x
176mm. It was solid with heterogenous density. Ascites was noted. There were no metastases to
other organs.
The diagnosis was made as ovarian malignancy. An ultrasound guided biopsy was done on
19/4/2013 together with a repeat measurement of tumour markers. Histopathological report
showed malignant cells.
The patient was started on chemotherapy. The patient has undergone three cycles of
chemotherapy, last taken last month.She is currently being admitted for an exploratory
laparotomy.
Currently patient is in an emotional state. She is concerned about her operation and worried
about her prognosis.
Obstetrics History
Nulliparous

Menstrual History
She attained menarche at 12 years old. She had regular menstrual cycle of 28 days and 6 days
bleeding. She has occasional dysmenorrhea and no menorrhagia. Patient does not use
contraceptives. She has never done pap smear before.
Past history
No significant past medical and surgical history.
Personal history
Her appetite is good and she consumes balanced diet. Her sleep is normal. Bowel and bladder
habits are normal. She does not smoke or consume alcohol.
Family history
Her father has diabetes mellitus and mother has hypertension. Patient is the third child of 8
siblings. All her siblings are healthy.
Social history
She stays with her husband with family income of RM 1500 per month. Her husband is a factory
worker and owns a car as transportation. Their house is a terrace house which is 20 minutes away
from the hospital.
Summary
A 32 years old, Malay lady, nullipara, came on elective admission for exploratory laparotomy
associated with intermittent diffuse lower abdominal pain radiating to the back. She has
finished 3 cycles of chemotherapy and currently on elective admission for exploratory
laparotomy.
General examination
Patient is alert and cooperative, sitting in upright position. She is moderately built and
moderately nourished. Intravenous canula inserted at the left dorsum of the hand and it is
stopered.
No pallor.
Weight :74kg, height:163cm, BMI: 27.85 kg/m2
Vital signs : Pulse 88/min
Respiratory rate- 18/min
Blood pressure- 120/85 mmHg on right arm ,sitting up position
Temperature- 37o C
Eyes : No pallor, no icterus.
Mouth: No pallor, sublingual icterus, oral hygiene is good.
Neck : No obvious swelling, and no lymph node enlargement.
Breast and thyroid examinations were not done.
Bilateral pitting pedal edema present.

Abdominal examination
Inspection:
Abdomen is flat. Flanks are not full.No dilated veins. Umbilicus is central and inverted. All areas
of abdomen move equally on respiration. Hernial orifices are intact.
Palpation:
Abdomen is soft and non tender. There is a 5x7 cm mass felt in the central midline below the
umbilicuscorresponding to 16-20 weeks of gestation. Borders are well felt and fixed. Liver not
palpable.
Percusion:
All quadrants are resonant.
Auscultation:
Bowel sounds were heard 1-2 times a minute.

Systemic examination

CVS: S1 and S2 are heard in all areas with no murmurs.

RS: Normal vesicular breath sounds are heard with no adventitious sounds.

KANVILIE JAYABALAN

BATCH27 GROUP C2
101303001
Patient profile
Name: Siti Fatimah Bt. Ismail
Age: 41
Address: Melaka
Occupation: Housewife
Date of admission: 5/11/2013
Date of examination: 7/11/2013
Parity Index: Nulliparous
Last Menstrual Period: 28/10/2013
Chief complaint
Patient was admitted from the emergency department due to prolonged and heavy menstruation
lasting for 8 days with symptomatic anemia.
History of Presenting Illness
Patient was having her menstruation since 28/10/13 and the bleeding lasted until the day of
examination (9th day of bleeding). She is bleeding heavily as she uses about 8-10 normal pads
every day during the menstruation and all pads are fully soaked. She passes a lot of clots;
however no complain of any abdominal pain. Due to this prolonged and heavy bleeding, patient
experiences generalized weakness and lethargy, she feels dizzy and giddy and unable to sit or
stand for long. No complain of shortness of breath, palpitation. There is no postcoital bleeding,
intermenstrual bleeding, no bleeding disorders, and she is not taking any anticoagulants. This is
the first episode. Currently she is keep in view to transfuse blood and repeat full blood count to
check for the Hb levels. If bleeding reduces, pipelle sampling will be done and keep for
discharge and to come for follow up.
Past Obstetric History
She is a nulliparous. She is married for 20 years.
Past Gynaecological History
As mentioned above.
Menstrual history
She attained her menarche at 15 years old. She had regular 28 days cycle with normal flow of 5
days. She has no dysmenorrhea. No contraceptives are used and no Paps smear was done before.

Past medical and surgical history

Not significant.She does not have diabetes mellitus, hypertension, asthma, any coagulopathies or
bleeding disorders. She is not on any anticoagulants.
Drug history
There is no long term intake of medication.
She is allergic to tranexamic acid as she developed rashes and urticarial upon taking it.
Family history
She is the 2nd out of 7th siblings. There is no similar complaint in the family. No history of
malignancies such as breast, endometrial, ovarian or colon running in the family. Both her
parents are well and healthy and they do not have diabetes mellitus, hypertension or any heart
diseases.
Personal history
She complained of recent loss of appetite and loss of weight. However she is unsure of the
weight that she has loss but she noticed loose clothing. Her sleep was normal and not disturbed.
Her bladder and bowel habits are also normal. She is not a smoker and does not consume
alcohol.
Social history
She is living with her husband. Her husband works as a factory worker. His salary RM2000. She
is financially supported by the husband.
Summary
41 years old, nulliparous, married women presented with prolonged and heavy menstruation to
the hospital for the first time and currently keep in view for blood transfusion and further
observation and management.
GENERAL EXAMINATION
Patient is lying down comfortably in supine position on the bed. She is moderately built
and moderately-nourished with a weight of 58kgs, height of 162cm and BMI of 22 kg/m2.
Hydration is fair.
There is an IV cannula on the dorsum of her left hand and was stopped.
There is pallor on her palms and nail beds but no koilonychia
Pulse rate: 66 beats/ minute with normal volume, regular rhythm and no special character
felt.
Blood pressure: 110/70 mmHg measured at her right arm in sitting position.
Respiratory rate: 16 breaths/ minute
Temperature 37oC
Eyes: There is pallor but no icterus.
Oral cavity: There is pallor but no sublingual icterus and oral hygiene are good.
Neck: No obvious thyroid and lymph nodes swellings present on neck.
There is no other significant finding on breast examination no lumps or nipple
discharge.
Pedal edema is absent.

GYNECOLOGICAL EXAMINATION
On Inspection

The abdomen is not uniformly distended as only the lower abdomen is distended and
flanks are not full.
There is no linea nigra,striae albicans, dilated veins and scars.
The umbilicus is centrally placed and inverted.
All quadrants move symmetrically with respiration.
Hernial orifices are intact.

On Palpation

There is no area of tenderness.

There is no enlarged liver, spleen or kidney.

On Percussion:

All areas of abdomen are resonant except it appears to be dull when percussing the lower
central abdomen.
Flanks are resonant, shifting dullness absent, no sign of free fluid.

On Auscultation: Bowel sounds are normal, 3/min.

Systemic examinations

CVS: S1 and S2 are heard in all areas with no murmurs.

RS: Normal vesicular breath sounds are heard with no adventitious sounds.