HISTORY, SUMMARY AND DIAGNOSIS SLIDES pdf

History and diagnosis

1. HISTORY, SUMMARY AND
DIAGNOSIS
FOR MY STUDENTS AND FUTURE COLLEAGUES
FROM DR.H

2. SUMMARISE AND COME UP WITH A WORKING
DIAGNOSIS FOR THE FOLLOWING CASE SCENARIOS

3. CASE 1

4. Mary Phiri F/37, Referral from Ng’ombe clinic for further management of vaginal bleeding. G6P5 at 35 weeks BD
alL delivered by SVD Currently complaining of minimal spotting which occurred yesterday. History of presenting
complaint Patient noted per vaginal bleeding when she arrived home from the market. There were no provoking
factors. The bleeding was not associated with any abdominal pain and it was bright red in color. She used one
cloth which was fully soaked and has not bled since yesterday. She is perceiving fetal movements. She is not
experiencing any headache/dizziness/palpitations/easy fatigability.
Obs and Gyn history LMP 7th May 2022, booked at 14 weeks with a BP of 120/62mmHg, she had 2 uneventful
visits. Has been taking folic acid and ferrous sulphate, received IPT twice. She has had 5 SVD deliveries at term
between 2004 and 2018 with biggest baby being 3.4kgs. She had good health during all her pregnancies and
normal puerperium. Screened for HIV and RPR which were non-reactive. She had one previous miscarriage at 12
weeks in 2010 due to unknown cause. She also had one previous cesarean section in 2012 due to fetal distress.
She has a history of uterine fibroids that were diagnosed in 2019 and treated with medication. She has a
multiple pregnancy with twins confirmed by ultrasound at 20 weeks.
Past medical history - There is no history of hypertension/diabetes/sickle cell disease/asthma or epilepsy RVT-NR
Past surgical history- One cesarean section in 2012 Past drug history –Uterine fibroid medication (name and
dosage unknown) Allergies – Nil Family history- No history of hypertension/diabetes/sickle cell disease/asthma
or epilepsy. Social/Economic history -she’s a married business lady who resides in ng’ombe and does not smoke
or drink alcohol

5. Presenting M.P F/37 G6P5 who is pregnant with twins at 35 weeks of gestation by dates . She has a
history of one previous cesarean section, one previous miscarriage, and five normal vaginal deliveries.
She also has a history of uterine fibroids that were treated with medication. She was referred from
Ng’ombe clinic for further management of vaginal bleeding that occurred yesterday. She reported
having bright red bleeding without abdominal pain or other symptoms. She used one cloth that was
fully soaked and has not bled since then. She is still feeling fetal movements. Her blood pressure and
screening tests were normal at her antenatal visits. She has no other medical or surgical history, no
allergies, and no family history of chronic diseases. She is a married business lady who lives in
Ng’ombe and does not smoke or drink alcohol.
Impression:The most likely diagnosis for Mary Phiri is placenta previa

6. POINTERS TO IMPRESSION

7. ➢The patient reported having bright red bleeding without abdominal pain or other symptoms. This
is consistent with placenta previa, which typically causes painless vaginal bleeding in the second
or third trimester. Vasa previa, on the other hand, usually causes fetal distress, fetal heart rate
abnormalities, or fetal bleeding.
The patient has a multiple pregnancy with twins confirmed by ultrasound at 20 weeks. This is
also a risk factor for placenta previa, as it can increase the placental mass and surface area, which
can increase the chance of placental migration or malposition. Multiple pregnancy does not
necessarily increase the risk of vasa previa, unless there is a shared placenta or monochorionic
twins.
The patient has a history of one previous cesarean section, one previous miscarriage, and uterine
fibroids. These are risk factors for placenta previa, as they can cause scarring or abnormality of
the uterine wall, which can affect the placental implantation.

8. CASE 2

9. Bertha Tembo F/37, Referral from Chipata level 1 clinic for further management of vaginal bleeding.
G6P5 at 35 weeks. Currently complaining of severe abdominal pain and dark red bleeding which
occurred yesterday.
History of presenting complaint Patient noted per vaginal bleeding when she arrived home from the
market. There were no provoking factors. The bleeding was associated with intense abdominal pain
and contractions and it was dark red in color. She used three cloths which were fully soaked and has
continued to bleed since yesterday. She is not perceiving fetal movements. She is experiencing
headache/dizziness/palpitations/easy fatigability. Obs and Gyn history LMP 7th May 2022, booked at
14 weeks with a BP of 120/62mmHg, she had 2 uneventful visits. Has been taking folic acid and
ferrous sulphate, received IPT twice. She has had 5 SVD deliveries at term between 2004 and 2018
with biggest baby being 3.4kgs. She had good health during all her pregnancies and normal
puerperium. Screened for HIV and RPR which were non-reactive. She has a history of hypertension
that was diagnosed in 2020 and treated with medication (name and dosage unknown). She also has a
history of trauma to the abdomen that occurred two weeks ago when she fell from a bicycle. She did
not seek medical attention at that time. She has a history of smoking half a pack of cigarettes per day
for the past 10 years. Past medical history - There is a history of hypertension RVT-NR Past surgical
history- Nil Past drug history –Hypertension medication (name and dosage unknown) Allergies – Nil
Family history- No history of hypertension/diabetes/sickle cell disease/asthma or epilepsy.
Social/Economic history -she’s a married business lady who resides in chipata and does smoke half a
pack of cigarettes per day but does not drink alcohol

10. Presenting B.T F/37 G6P5 who is pregnant at 35 weeks of gestation by dates. She has a history of five
normal vaginal deliveries, one previous miscarriage, hypertension, and smoking. She also has a
history of trauma to the abdomen that occurred two weeks ago when she fell from a bicycle. She was
referred from Chipata level 1 clinic for further management of vaginal bleeding that occurred
yesterday. She reported having dark red bleeding with intense abdominal pain and contractions. She
used three cloths that were fully soaked and has continued to bleed since then. She is not feeling
fetal movements. She is experiencing headache, dizziness, palpitations, and easy fatigability. Her
blood pressure and screening tests were normal at her antenatal visits. She has no other medical or
surgical history, no allergies, and no family history of chronic diseases. She is a married business lady
who lives in Chipata and smokes half a pack of cigarettes per day but does not drink alcohol.
Impression: Placenta Abruption

11. POINTERS TO IMPRESSION

12. ➢The patient reported having dark red bleeding with intense abdominal pain and contractions. This
is consistent with placental abruption, which typically causes painful vaginal bleeding in the
second or third trimester. Placenta previa, on the other hand, usually causes painless vaginal
bleeding in the second or third trimester.
The patient has a history of hypertension, trauma, and smoking. These are risk factors for
placental abruption, as they can increase the blood pressure, cause injury to the uterus, or
reduce the blood flow to the placenta. Placenta previa is more commonly associated with
multiple pregnancies, previous cesarean sections, uterine fibroids, and advanced maternal age.
The patient is not feeling fetal movements. This could indicate fetal distress or demise due to
placental abruption, which can compromise the oxygen and nutrient supply to the fetus.
Placenta previa does not necessarily affect fetal movements, unless there is severe bleeding or
infection.

13. CASE 3

14. Mirriam Chipasha F/27, Referral from Ng’ombe clinic for further management of vaginal bleeding. G6P5 at 35
weeks Currently complaining of sudden onset of excruciating abdominal pain and profuse bleeding which
occurred yesterday. History of presenting complaint Patient noted per vaginal bleeding when she arrived home
from the market. There were no provoking factors. The bleeding was associated with severe abdominal pain and
loss of uterine tone and it was mixed with amniotic fluid. She used five cloths which were fully soaked and has
continued to bleed heavily since yesterday. She is not perceiving fetal movements and has signs of fetal distress.
She is experiencing headache/dizziness/palpitations/easy fatigability. Obs and Gyn history LMP 7th May 2022,
booked at 14 weeks with a BP of 120/62mmHg, she had 2 uneventful visits. Has been taking folic acid and
ferrous sulphate, received IPT twice. She has had 5 SVD deliveries at term between 2004 and 2018 with biggest
baby being 3.4kgs. She had good health during all her pregnancies and normal puerperium. Screened for HIV
and RPR which were non-reactive. She has a history of hypertension that was diagnosed in 2020 and treated
with medication (name and dosage unknown). She also has a history of trauma to the abdomen that occurred
two weeks ago when she fell from a bicycle. She did not seek medical attention at that time. She has a history of
smoking half a pack of cigarettes per day for the past 10 years. She also has a history of previous cesarean
section in 2016 due to obstructed labor. She has a history of grand multiparity (more than five previous
deliveries). She has a history of induction of labor with oxytocin infusion for prolonged pregnancy in her last
delivery in 2018. Past medical history - There is a history of hypertension RVT-NR Past surgical history- One
cesarean section in 2016 Past drug history –Hypertension medication (name and dosage unknown) and oxytocin
infusion in 2018 Allergies – Nil Family history- No history of hypertension/diabetes/sickle cell disease/asthma or
epilepsy. Social/Economic history -she’s a married maid who resides in ng’ombe and does smoke half a pack of
cigarettes per day but does not drink alcohol

15. Presenting M.C F/27 G6P5 who is pregnant at 35 weeks of gestation by dates. She has a history of one
previous cesarean section, five normal vaginal deliveries, hypertension, smoking, and grand
multiparity. She also has a history of trauma to the abdomen that occurred two weeks ago when she
fell from a bicycle. She was referred from Ng’ombe clinic for further management of vaginal bleeding
that occurred yesterday. She reported having profuse bleeding with excruciating abdominal pain and
loss of uterine tone. The bleeding was mixed with amniotic fluid. She used five cloths that were fully
soaked and has continued to bleed heavily since then. She is not feeling fetal movements and has
signs of fetal distress. She is experiencing headache, dizziness, palpitations, and easy fatigability. Her
blood pressure and screening tests were normal at her antenatal visits. She has no other medical or
surgical history, no allergies, and no family history of chronic diseases. She is a married maid who lives
in Ng’ombe and smokes half a pack of cigarettes per day but does not drink alcohol.

16. POINTERS TO IMPRESSION

17. ➢Uterine rupture is when a scar from a previous surgery on the uterus tears open during labor.
The patient has a history of one previous cesarean section in 2016 due to obstructed labor, which
is a risk factor for uterine rupture.
The patient reported having profuse bleeding with excruciating abdominal pain and loss of
uterine tone. These are consistent with uterine rupture, which typically causes sudden onset of
severe abdominal pain with or without vaginal bleeding in the second or third trimester. The pain
can be accompanied by loss of uterine tone, fetal distress or demise, maternal shock, or
maternal death. The bleeding can be concealed or revealed, and can be mixed with amniotic
fluid.
The patient has a history of hypertension, trauma, and smoking. These are also risk factors for
uterine rupture, as they can increase the blood pressure, cause injury to the uterus, or reduce
the blood flow to the placenta.
The patient has a history of grand multiparity (more than five previous deliveries) and induction
of labor with oxytocin infusion for prolonged pregnancy in her last delivery in 2018. These are
also risk factors for uterine rupture, as they can cause excessive uterine stretching or
contractions, which can weaken the scar tissue or cause it to rupture.

18. CASE 4

19. Kutemwa Mwanza F/33, Referral from Ng’ombe clinic for further management of vaginal bleeding. G6P5
at 35 weeks BD all delivered by SVD Currently complaining of painless bleeding and signs of fetal distress which
occurred yesterday. History of presenting complaint Patient noted per vaginal bleeding when she arrived home
from the market. There were no provoking factors. The bleeding was not associated with any abdominal pain
and it was bright red in color. She used two cloths which were partially soaked and has not bled since yesterday.
She is not perceiving fetal movements and has signs of fetal distress, such as abnormal fetal heart rate and
decreased fetal movement. She is not experiencing any headache/dizziness/palpitations/easy fatigability or signs
of hypovolemic shock. Obs and Gyn history LMP 7th May 2022, booked at 14 weeks with a BP of 120/62mmHg,
she had 2 uneventful visits. Has been taking folic acid and ferrous sulphate, received IPT twice. She has had 5
SVD deliveries at term between 2004 and 2018 with biggest baby being 3.4kgs. She had good health during all
her pregnancies and normal puerperium. Screened for HIV and RPR which were non-reactive. She has a history
of hypertension that was diagnosed in 2020 and treated with medication (name and dosage unknown). She also
has a history of trauma to the abdomen that occurred two weeks ago when she fell from a bicycle. She did not
seek medical attention at that time. She has a history of smoking half a pack of cigarettes per day for the past 10
years. She also has a history of previous cesarean section in 2016 due to obstructed labor. She has a history of
grand multiparity (more than five previous deliveries). She has a history of induction of labor with oxytocin
infusion for prolonged pregnancy in her last delivery in 2018. She also has a history of multiple pregnancy with
twins confirmed by ultrasound at 20 weeks. She has a history of low-lying placenta or placenta previa diagnosed
by ultrasound at 28 weeks. Past medical history - There is a history of hypertension RVT-NR Past surgical history-
One cesarean section in 2016 Past drug history –Hypertension medication (name and dosage unknown) and
oxytocin infusion in 2018 Allergies – Nil Family history- No history of hypertension/diabetes/sickle cell
disease/asthma or epilepsy. Social/Economic history -she’s a married business lady who resides in ng’ombe and
does smoke half a pack of cigarettes per day but does not drink alcohol

20. Presenting K.M F/33 G6P5 who is pregnant with twins at 35 weeks of gestation. She has a history of
one previous cesarean section, five normal vaginal deliveries, hypertension, smoking, and grand
multiparity. She also has a history of trauma to the abdomen that occurred two weeks ago when she
fell from a bicycle. She was referred from Ng’ombe clinic for further management of vaginal bleeding
that occurred yesterday. She reported having painless bleeding that was bright red in color. She used
two cloths that were partially soaked and has not bled since then. She is not feeling fetal movements
and has signs of fetal distress, such as abnormal fetal heart rate and decreased fetal movement. She
is not experiencing any headache, dizziness, palpitations, easy fatigability or signs of hypovolemic
shock. Her blood pressure and screening tests were normal at her antenatal visits. She has no other
medical or surgical history, no allergies, and no family history of chronic diseases. She is a married
business lady who lives in Ng’ombe and smokes half a pack of cigarettes per day but does not drink
alcohol.
Impression: Vasa Previa

21. POINTERS TO IMPRESSION

22. ➢The patient reported having painless bleeding that was bright red in color and mixed with
amniotic fluid. This is consistent with vasa previa, which typically causes painless vaginal bleeding
in the second or third trimester. The bleeding can be mixed with amniotic fluid and can vary from
light to heavy. The bleeding can cause fetal distress, fetal heart rate abnormalities, or fetal
bleeding. Placenta previa, on the other hand, usually causes painless vaginal bleeding in the
second or third trimester that is not mixed with amniotic fluid.
The patient has a history of multiple pregnancy with twins confirmed by ultrasound at 20 weeks.
This is a risk factor for vasa previa, as it can increase the chance of velamentous cord insertion,
bilobed or succenturiate placenta, or low-lying placenta. These are conditions where the blood
vessels near the placenta are not protected by the umbilical cord or the placental tissue.
The patient has a history of low-lying placenta or placenta previa diagnosed by ultrasound at 28
weeks. This is also a risk factor for vasa previa, as it can indicate that the blood vessels near the
placenta are crossing or running near the cervical opening.