Grand round 24 nov case discussion. .pptx

Discuss termination by end date

1. CASE PRESENTATION 1

2. 25 year old Para 0 +1 Chronically unwell PTB and Stroke patient whose care began in South Africa. Had a miscarriage 3 weeks ago and was managed medically using cytotec however reportedly did not expel anything. Now presented at SMCH with a 2 week history of foul smelling PV discharge and lower abdominal pain. Sputum positive pTB 1 month prior. On initiation phase – HRZE and pyridoxine CVA 3 weeks prior- right mca

3. EXAMINATION O/E stable, pink, wasted LOC 15/15
BP 121/70 P130 SpO2 98% OFA 100% on O2
ABD soft, generalized tenderness.. No guarding, no rebound tenderness. VE- foul smelling discharge, no blood on glove
CVS- S1 S2 no murmurs, no gallop
RS- EAEB, vesicular, no added sounds
CNS- LOC 15/15, PEARL, Power 4/5 left side 5/5 right side.

4. Results Fbc . WCC 7.89 HB 12.6 MCV 87 PLT 425 U and E Na 138.9 K 4.7 Ur 3.0 Cre 292 USS normal size non gravid uterus 7.3x3.0x3.9 cm. Echogenic material in endometrial cavity measuring 3.3 x 1.9 Increased echogenicity around the uterus suggestive of infection No free fluid in POD Cervix long and closed. Impression: septic abortion

5. Plan Admit A2 Ceftriaxone 1g iv bd Clindamycin 600mg iv bd Metronidazole 500mg iv tds Consult physicians 1L R/L or N/S 6 hourly 4 hourly vitals

6. Diagnosis Impression: 1.Gestational Hypertension 2. Shortness of breath – Pulmonary odema , Pulmonary embolism, Psychosocial

7. Progress Patient is now day 13 post admission .First week of admission patient was commenced on antihypertensives and O2 PFM Physician Consulted in ELW Furosemide 80mg iv stat given in ELW . Commenced on IOL with pv cytotec then oral Magnesium course completed On antihypertensives Now she is 38/40 weeks plus 3 days , perceiving fetal movements and on second cycle of IOL

8. Gynae Case

9. 30 /F, PARA 2 +1 20/11/23 PC :HEAVY PV BLEEDING X 3/52 HPC Patient who had a miscarriage 10/10/2023. She was managed medically then had an USS pelvis(27/10/23) which showed significant RPOCs. An MVA was done. However since then she has had heavy PV bleeding for past 3 weeks and changes about 4-5 soaked pads. She was however asymptomatic of anemia (no SOB, dizziness, or headache).

10. Obs Hx: Para 2 – NVD Gyn Hx 28 day cycle, regular menses. Duration 3 days average. No dysmenorrhea PMHX No Hx of chronic illnesses SR Unremarkable

11. O/E Stable, Alert, Pale+ BP 139/90 P 115bpm S1 & S2 present, no murmurs.. Abdomen SNT VE OS closed, blood on glove. Impression: ? Miscarriage with RPOCs ? Molar pregnancy PLAN * Preg Test stat - Positive Admit ward C3 FBC, BHGG, G&R, TSH Tranexamic 50mg po tds PCT 1g iv/ po QID 1L R/L fast then 6hrly USS Pelvis

12. 21-11-23 Day 1 post admission. Hb noted to be 6.6. c/o dizziness ,GBW and headache O/E Stable, alert, pale ++ BP 157/86 T 36.8 Abdomen SNT ; HOF 22/40 PLAN Xmatch 3 units PCs USS Pelvis, BHCG Ct Tranexamic Ceftriaxone 1g iv bd Metronidazole 500mg iv tds 1L R/L 8hrly Transfer to Madziyire firm

13. 23/11/23 DX: Symptomatic Anaemia secondary to ? incomplete miscarriage *Patient still symptomatic of anemia. Bleeding stopped. Pending results: BHCG – 10 244 TSH- 1.2 (Normal) Repeat USS – 15cm 3 of RPOCs R/O Molar Pregnancy. Plan Repeat BHCG Chase and transfuse 3 units Ct Ranferon Ct IV antibiotics

14. DISCUSSION

15. Gynae Case 2 T.Chimuti

16. 33/F PARA 2+2 (T1 T2 miscarriages); LNMP 29/10/2023 22/11/23 PC :GBW + SOB X 4/7 BG: Patient with DVT ( Rt LL)confirmed 2/52 ago on Rivaroxaban HPC Patient who was previously being managed for DVT by c8 physicians, came in with a 4/7 hx of sudden onset central chest pain(stabbing), palpitations, GBW, exertional dyspnea with associated headache. No orthopnea, no PND. She also had an USS Pelvis showing: Moderately bulky uterus. IUCD in situ. 3 small body uterine fibroids. Largest in anterior submucosa-23mm FBC result(18/11/23): HB 9.7

17. Obs Hx: Para 2+2 – 2009 –miscarriage @ 2010 & 2013 – NVD 2022 – miscarriage @4/12 Gyn Hx Menarche @ 12 Coitarchy @ 20. Heavy menses past 5yrs with clots. 28 day cycle. 6 days duration of menses. No intermenstrual bleeding. Has dysmenorrhea. No hx of STI Tx Last VIAC 3years ago – normal COCs used for past 4 years Currently using IUCD

18. O/E Stable, Alert, Pale+ BP 127/80 P 97 Rt leg swelling Abdomen Soft and non tender Problems: 1. Fibroid uterus 2. DVT 3. Anaemia PLAN Ranferon 2 tabs po od Ct Rivaroxaban PCT 1g po tds CXR Physicians to see Book Madziyire OPD for fibroid uterus mgt

19. Patient was seen by physicians who gave a diagnosis of Symptomatic Anaemia secondary to AUB. They sent her back to Gynae to review physicians prn. *She was then admitted for Madziyire Firm. 23/11/2023 Day 1 post admission. Patient still complaining of central chest pain, SOB, palpitations, exertional dyspnea and associated headache. However she has no cough, no dizziness, no fever, no cyanosis. o/e Stable,alert , pale + Vitals normal Abd soft and non tender. LL swelling Plan Chase blood Ranferon 2 tabs po od Ct Rivaroxaban 150mg po od Ct PCT Remove loop Consult C8 physicians

20. Results : FBC (22-11-23) WCC 6.75 Hb 9.4 PLT 596 MCV 70.4

21. DISCUSSION