Medical history

Main complications: no

Concomitant diseases: no

Faculty of Medicine

Pushkin Igor Igorevich

Vitebsk, 2017

PASSPORT PART

8. Complications of the main one: none.

PATIENT'S COMPLAINTS

HISTORY OF THE DISEASE

LIFE HISTORY

There were no blood transfusions.

Menstrual function:

Sexual function:

Fertility

the patient denies.

OBJECTIVE STUDY OF THE PATIENT

General inspection

General condition is satisfactory.

Consciousness is clear. Position active.

The physique is correct.

Height 150 cm, weight 54 kg, temperature 36.6.

The skin and visible mucous membranes are pale pink. Turgor is preserved. The presence of focal pigmentation, rashes, hemorrhages, peeling, and scars was not detected.

Occipital, parotid, submandibular, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal, cervical lymph nodes are not palpable, painless.

The musculoskeletal and articular system is without deviations from the norm.

No varicose veins were detected.

There is no swelling.

Examination of the mammary glands: round shape, soft consistency, no pain or lumps. Pronounced nipple. There is no secret.

Respiratory system

Nose: the nasal mucosa is pale pink, there is no discharge. The nature of breathing through the nose is free.

Breathing is rhythmic, deep with a frequency of 16 per minute. No pathological type of breathing was detected.

There is no shortness of breath. Accessory muscles are not involved in the act of breathing.

Palpation of the chest: the chest is elastic, there is no pain on palpation. The width of the intercostal spaces is normal (1 cm).

The pleural friction noise, the sound of fluid splashing in the pleural cavity, the crunching sound is not detectable.

Percussion of the chest: clear pulmonary sound.

Auscultation of the lungs: vesicular breathing, adverse respiratory sounds (wheezing, crepitus, hymenal friction noise) are not detected.

Cardiovascular system:

The pulse is the same on both hands, synchronous, rhythmic, 88 beats per minute, moderate tension, filling and size. The wall of the radial artery is elastic and homogeneous. There is no pulse deficit.

Blood pressure 120/80 mm. rt. Art.

Borders of the heart: not expanded, right 1 cm outward from the right edge of the sternum, upper upper edge of the third rib, left 1 cm outward from the midclavicular line.

Heart sounds are muffled and rhythmic.

There are no pathological noises.

There is no pericardial friction rub.

Digestive system

The mucous membrane of the oral cavity is pink, there are no pathological changes. The tongue is pink, coated with white. The pharynx is not hyperemic.

There is no vomiting.

Palpation of the liver: the edge of the liver is soft, slightly rounded, smooth, painless, protruding from under the right hypochondrium by 1 cm.

The gallbladder is not detected.

Intestinal peristalsis is abundant and not changed.

The abdomen is soft, accessible for palpation in all parts, painless.

There are no peritoneal symptoms.

Stool every day.

Urination is free, painless, there is no urination disorder.

The symptom of effleurage is negative.

Gynecological status

Examination: female type hair growth. Labia majora and minora, clitoris, paraurethral passages, Bartholin glands, perineum, anus without pathology.

Stage I prolapse of the vaginal wall is observed.

Inspection using speculum: the vaginal mucosa is clean, pale pink. The cervix is cylindrical, deformed by old tears, clean, hypertrophied, elongated.

The discharge is mucous and moderate.

The channel is closed.

Bimanual examination: the body of the uterus is dense in consistency, enlarged due to fibroids, and mobile. The uterus is in the antefltxio position. The appendages on the right and left are not identified and are not painful. Displacement behind the cervix is painless. The uterosacral ligaments are not changed. The parameters have not been changed.

Rectal examination: the rectal mucosa is smooth, without formations. There is no blood on the glove.

PRELIMINARY DIAGNOSIS

Based on the patient’s complaints (the patient complains of nagging pain in the lower abdomen, prolapse of the vaginal walls).

Based on the medical history, life history (according to the patient, she fell ill in early July 2017, when she began to notice prolapse of the vaginal walls, nagging pain in the lower abdomen. On July 22, 2017, the patient went to the antenatal clinic where she underwent an ultrasound of the pelvic organs , after which she was diagnosed with uterine fibroids and scheduled for consultation with a gynecologist. During an examination with a gynecologist, the patient was diagnosed with cicatricial deformation, hypertrophy and elongation of the posterior wall of the uterus;

After an examination by a gynecologist, she was sent to maternity hospital No. 2 in the city of Vitebsk, where she was re-examined by a gynecologist. Since there were no emergency indications for hospitalization, she was placed on planned hospitalization. The patient was admitted to maternity hospital No. 2 on November 8, 2017. During the time before admission to the hospital, the patient did not feel a worsening of the disease.

From the moment of illness until admission to the maternity hospital, the patient did not take medications.

On November 9, 2017, the patient was scheduled for cervical amputation and posterior vaginal plastic surgery. After the operation, the patient noted an improvement in her health).

Based on obstetric and gynecological history (not burdened).

Based on objective data, gynecological status (examination: Stage I prolapse of the vaginal wall is observed.

Examination using mirrors: the cervix is cylindrical, deformed by old ruptures, clean, hypertrophied, elongated.

Vaginal examination: the vagina is free. The arches are free, deep, painless. The cervix is cylindrical, elongated, descended, and softened.

The channel is closed.

Rectal examination: the rectal mucosa is smooth, without formations. There is no blood on the glove.)

A preliminary diagnosis can be made:

Main diagnosis: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. uterine fibroids.

Main complications: none.

Concomitant diseases: none.

PATIENT EXAMINATION PLAN

1) General blood test.

2) Biochemical blood test (glucose, urea, creatinine, protein, cholesterol).

3) General urine analysis.

4) Coagulogram.

5) Ultrasound of the pelvic organs.

7) Blood test for viral infections Anti HCV, HBsAg.

UAC 10/30/2017

Red blood cells – 4.75*10*12/l

Hemoglobin – 133 g/l

Platelets - 322*10*9/l

Leukocytes – 7.8*10*9/l

Eosinophils – 1%

Basophils – 0%

Neutrophils:

Band - 9%

Segmented – 60%

Lymphocytes – 26%

Monocytes – 8%

ESR – 13 mm/h

Conclusion: General blood test without pathology.

OAM 10/30/2017

Physical properties:

Color – straw yellow

Reaction: acidic

Relative density – 1014

Chemical properties:

Protein – no

Glucose - no

Microscopic examination:

Flat epithelium – 0-1 vpz

Leukocytes – 0-1 vpz

Cylinders -

Conclusion: General urine analysis is within normal limits.

BAK 10/30/2017

Glucose – 3.6 mmol/l

Urea – 3.8 mmol/l

Creatinine – 55.0 mmol/l

Protein – 78 g/l

Total bilirubin – 38.0 µmol/l

Direct bilirubin – 4.8 µmol/l

AlAT – 14 units.l.

AsaAT – 18 units.l.

Cholesterol – 5.7

Conclusion: Biochemical blood test is within normal limits.

HEMOSTASIOGRAM 10/30/2017

APTT – 214

Fibrinogen A – 3.4

Conclusion: APTT is increased.

ECG FROM 09/13/2017

Conclusion: Sinus rhythm. Normal EOS. Incomplete blockade of the right bundle branch.

HISTOLOGY 10/17/2017

Conclusion: blood, mucus, small pieces of endometrium.

CLINICAL DIAGNOSIS

Main diagnosis: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. Uterine fibroids.

Main complications: no

Concomitant diseases: no

ETIOLOGY AND PATHOGENESIS

The main role in the origin of uterine prolapse and prolapse is played by factors that determine pressure on the genitals from above. Under normal conditions, pressure on the genitals from above is balanced by counterpressure from the pelvic floor and anterior abdominal wall. All causes that cause disruption of the structure and functions of the pelvic floor, abdominal wall and ligamentous apparatus of the uterus contribute to prolapse and prolapse of the uterus from the vagina. When the abdominal wall relaxes (multiple births, asthenia), the mutual support of the internal organs is disrupted and their pressure on the pelvic organs increases. The pelvic floor muscles and ligamentous apparatus of the uterus withstand pressure from above for some time, but subsequently they relax, which contributes to the displacement of the uterus downward.
In the pathogenesis of displacement of the uterus and vagina, conditions that promote relaxation of the abdominal wall and pelvic floor play a significant role; relaxation of the ligamentous apparatus of the uterus occurs secondaryly and is not of primary importance. Downward displacement of the uterus is usually preceded by retroflexion, so the origin of uterine prolapse and prolapse is ultimately associated with those reasons that contribute to retrodeviation of the uterus. With retroflexion and retroversion of the uterus, pressure from above falls on the anterior wall of the uterus and the posterior-superior part of the bladder; intestinal loops are located in the excavatiovesicouterina. As a result of pressure from above on these organs, a gradual lowering of the bladder with the anterior wall of the vagina, as well as the cervix, occurs; subsequently the entire uterus descends.
Causes of prolapse and prolapse of the uterus and vagina
1. Relaxation of the abdominal muscles due to asthenia, severe exhaustion or repeated, especially complicated, pregnancies and childbirth (polyhydramnios, multiple pregnancies, narrow pelvis, which contributes to the formation of a pointed and saggy abdomen, etc.). In this case, the downward displacement of the uterus is one of the manifestations of general ptosis of the internal organs.
2. Birth injuries, resulting in relaxation or excitation of the muscles and fascia of the pelvic floor, mainly the levator. The occurrence of birth injuries is facilitated by extension presentations, large fetal sizes, tissue rigidity in elderly primiparas, surgical interventions (application of obstetric forceps), etc. Birth injuries that disrupt the fixation apparatus of the uterus, mainly the main and sacrouterine ligaments, play a significant role.
3. All reasons causing a decrease in uterine tone and retroflexion, in particular delayed development of the genital organs and age-related atrophy of the uterus, ligamentous apparatus and pelvic floor muscles. It should be noted that uterine prolapse and prolapse occur mainly in old and senile age.
4. Prolapse and prolapse of the genital organs can occur due to developmental anomalies that cause disturbances in the innervation of the pelvic floor muscles (spinabifida) and congenital hypoplasia of its muscles.

In this patient, the disease arose against the background of age-related changes in the structure and function of the pelvic floor, abdominal wall and ligamentous apparatus of the uterus.

TREATMENT PLAN AND PREVENTION

Diet No. B, regimen No.

1) Ciprofloxacin 0.2% - 200.0 IV drip.

2) Metranidazole 0.5% - 100.0 IV drip.

3) Fraxiporin 0.3 s.c.

4) Ringer's solution 500.0 IV 1 hour before surgery.

5) Diclofenac 3.0 IM for pain.

6) UV treatment of the perineum.

Indications for surgery:

1. Cicatricial deformation of the cervix.

2. Cervical hypertrophy.

3. Elongation of the cervix.

4. Prolapse of the posterior vaginal wall, stage I.

Diagnosis after surgery: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. Uterine fibroids.

OBSERVATION DIARIES

11/13/2017 BH = 16 per minute. Heart rate = 57/min BP = 120/80 T = 36.6

At the time of supervision, the patient has no complaints. The condition is satisfactory. Consciousness is clear. Position active. The skin is clean. Mucous membranes unchanged. The tongue is not coated. Lymph nodes are not enlarged. The pulse is symmetrical. Heart sounds are muffled. Breathing is clear and vesicular. No wheezing. The abdomen is soft and painless. There is no pain on deep palpation. Stool and urine output are normal. Treatment: see prescription sheet.

11/14/2017 BH =16 per minute. Heart rate = 58/min BP = 120/80 T = 36.6

At the time of supervision, the patient has no complaints. The condition is satisfactory. Consciousness is clear. Position active. The skin is clean. Mucous membranes unchanged. The tongue is not coated. Lymph nodes are not enlarged. The pulse is symmetrical and rhythmic. Heart sounds are muffled. Breathing is clear and vesicular. No wheezing. The abdomen is soft and painless. There is no pain on deep palpation. Stool and urine output are normal. Treatment: see prescription sheet.

FORECAST

EPICRISIS

The patient (46 years old) was admitted on November 8, 2017, as planned, at the referral of the antenatal clinic diagnostic center.

Clinical diagnosis:

Main diagnosis: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. Uterine fibroids.

Main complications: no

Concomitant diseases: no

A course of drug treatment is carried out:

Diet No. B, regimen No.

7) Ciprofloxacin 0.2% - 200.0 IV drip.

8) Metranidazole 0.5% - 100.0 IV drip.

9) Fraxiporin 0.3 s.c.

10) Ringer's solution 500.0 IV 1 hour before surgery.

11) Diclofenac 3.0 IM for pain.

12) UV treatment of the perineum.

Surgical treatment:

09.11.2017 Amputation of the cervix according to Sturmdorff, posterior vaginal plastic surgery, levatororrhaphy.

After the course of treatment, positive dynamics are observed.

The prognosis for life is satisfactory.

The prognosis for work ability is satisfactory.

The prognosis for menstrual function is satisfactory.

Prevention of complications and relapse of the disease consists of observation in the antenatal clinic, timely referral for further treatment. The patient is recommended to normalize the daily routine, nutritious nutrition, general strengthening measures (hardening, physical education), and careful adherence to the rules of personal hygiene.

Medical history

Full name patients: Shketik Svetlana Vladimirovna

Main diagnosis: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. Uterine fibroids.

Main complications: no

Concomitant diseases: no

Curator: 5th year student, 1st group

Faculty of Medicine

Pushkin Igor Igorevich

Supervision time: from 11/13/17 to 11/16/17

Vitebsk, 2017

PASSPORT PART

1. Full name patient: Shketik Svetlana Vladimirovna

2. Age: 09/16/1971 (46 years old).

3. Place of work, profession: Verkhnedvinsk Regional Department of the Ministry of Internal Affairs, accountant.

4. Permanent place of residence: Verkhnedvinsk, st. Kobzuna, building 9a, apt. 28.

5. Date of admission: November 8, 2017, as planned, in the direction of the diagnostic center for the antenatal clinic.

6. Diagnosis of the referring organization: Prolapse of the vaginal walls I-IIst. Uterine fibroids.

7. Final clinical diagnosis: Cicatricial deformation, hypertrophy and elongation of the cervix. Prolapse of the posterior vaginal wall, stage I. uterine fibroids.

8. Complications of the main one: none.

PATIENT'S COMPLAINTS

Upon admission, the patient complains of nagging pain in the lower abdomen and prolapse of the vaginal walls.

At the time of supervision, the patient has no complaints.

HISTORY OF THE DISEASE

According to the patient, she fell ill in early July 2017, when she began to notice prolapse of the vaginal walls, nagging pain in the lower abdomen. On July 22, 2017, the patient went to the antenatal clinic where she underwent an ultrasound of the pelvic organs, after which she was diagnosed with uterine fibroids and A consultation with a gynecologist was scheduled. Upon examination by a gynecologist, the patient was diagnosed with cicatricial deformation, hypertrophy and elongation of the cervix; prolapse of the posterior wall of the uterus; uterine fibroids.

From the moment of illness until admission to the maternity hospital, the patient did not take medications.

On November 9, 2017, the patient was scheduled for cervical amputation and posterior vaginal plastic surgery. After the operation, the patient noted an improvement in her health.

LIFE HISTORY

The patient was born on September 16, 1971. She developed according to age without deviations.

Past diseases: ARVI, chicken pox.

Denies the presence of operations during life.

There were no blood transfusions.

He denies hereditary diseases in himself and his immediate family.

There is no allergic history.

Denies bad habits (alcohol, smoking, drugs).

Social conditions are satisfactory.

Meals are regular, varied, high in calories.

Working conditions are satisfactory. There are no occupational hazards.

The patient did not live or be in unfavorable areas of epidemiological diseases.

OBSTETRIC-GYNECOLOGICAL HISTORY

Menstrual function: age of first menstruation: 14 years; nature of menstruation – frequency every 26 days, duration 3-4 days, amount of blood lost is moderate, painful in the first days, the nature of the pain is constant; I did not notice any changes in the nature of menstruation after the onset of sexual activity or childbirth; the date of the last normal menstruation was 10.30.17.

Sexual function: at what age did you start having sex: 21 years old; does not live a regular sexual life, does not have casual sex; divorced; did not notice the presence of pain or bleeding during sexual intercourse; does not use contraceptive methods.

Fertility: pregnancy occurred two years after the start of sexual activity; number of pregnancies: 1; proceeded normally and ended in a normal birth. The birth is normal, the course of the postpartum period is unchanged, the child is full-term, alive, growing and developing according to age. Denies abortion.

Past gynecological diseases: the patient denies.

OGA is a term that accompanies pregnancy management with any deviation from the norm. According to statistics, in Russia about 80% of women have OGA, and their number does not decrease from year to year. When compiling an anamnesis, all previous pregnancies are taken into account, regardless of their outcome, as well as gynecological diseases and operations.

OAS: the essence of the problem

The abbreviation OAGA stands for burdened obstetric and gynecological history. This is the presence in each individual patient of factors associated with past pregnancies, as well as with gynecological health, which can complicate the current condition and have a negative impact on the fetus. In medical practice, this diagnosis is made when a woman has premature birth, miscarriages, stillbirths, abortions, the birth of children with developmental defects, and the death of a child within 28 days after birth. The anamnesis is also complicated by pathologies of the uterus and ovaries, infertility of any origin, hormonal imbalance, and Rh conflict.

What can a woman do

If a woman has already had unsuccessful pregnancies or has gynecological diseases in her medical history, then each new conception plan should be approached very seriously. Accidental pregnancies should not be allowed, especially if the timing recommended by the gynecologist is not followed after miscarriages, childbirth and induced abortions. It is important for a woman with OGA to register with a antenatal clinic or private clinic as early as possible, since, for example, the first screening to detect genetic pathologies in the fetus must be carried out strictly before 12 weeks of gestation. The patient should inform the gynecologist about each episode associated with previous pregnancies, abortions, surgical treatment of the uterus and appendages, and chronic gynecological diseases. Only with the woman’s complete frankness will the doctor be able to minimize the factors that complicate the course of pregnancy and lead to pathology or death of the fetus.

Fight infections!

A mandatory test before conception is a test for TORCH infections - determination of antibodies to rubella, cytomegalovirus, herpes and toxoplasmosis, as well as sexually transmitted diseases. Remember: infection with rubella during pregnancy is almost always an indication for its artificial termination at any stage, since it entails pathologies of the fetus - deafness, blindness, and other developmental defects. As gestation continues, intrauterine fetal death occurs in 20 percent of cases. If there are no antibodies to the rubella virus, you should get vaccinated against it no later than two months before the planned conception.

Rubella infection during pregnancy is an indication for abortion

With toxoplasmosis, the severity of the prognosis directly depends on the time of infection. When Toxoplasma is introduced into the fetus's body in the first trimester, spontaneous abortions and severe developmental pathologies are possible. Late congenital toxoplasmosis is characterized by intracranial calcification, chorioretinitis, seizures, and edema of the brain. Fixed. CMV infection during pregnancy also provokes the onset of perinatal pathology - prematurity, stillbirth, defects of organs and systems. Infection with herpes is most dangerous in the first 20 weeks of pregnancy; vertical infection of the fetus is possible with subsequent development of pathologies.

What is important to remember regarding infection? You can become infected at any time, even a few days before conception, which means that the absence of certain pathogens in your body does not guarantee a positive outcome of your pregnancy. Therefore, most doctors argue that carriage of a number of infectious pathogens (not all, of course) is much better than their absence in the body. Why? Because if you come into contact with a sick person, you are not in danger of being reinfected - you already have protection against this type of pathogen. This does not apply to bacteria and fungi, where the mechanism of defense against these microorganisms is different, so you can become infected with many bacterial and fungal infections more than once.
Elena Berezovskaya
http://lib.komarovskiy.net/mify-ob-infekciyax.html

Hormonal swing

During pregnancy planning, it is important for a woman to have her hormonal levels examined and normalized. A good place to start is with thyroid hormones. This organ produces triiodothyronine (T3) and tetraiodothyronine (T4, thyroxine). Thyroid-stimulating hormone (TSH) is produced in the pituitary gland. Thyroid dysfunction can cause menstrual irregularities, miscarriage, and fetal pathology.

Table of thyroid hormone norms

By gender

Sex hormones should be checked in case of menstrual irregularities, male-pattern body hair growth, a history of missed pregnancies, excess weight, and PCOS.

Video about hormone tests before a planned pregnancy

Ultrasound will show the exit

The release of an egg from the ovary, which will help a woman determine the period of possible conception, and also give an objective picture of the condition of the uterus and appendages. The procedure is prescribed on days 9–10 of a 28-day cycle (to control ovulation) or on days 5–7 to detect possible pathological changes.

OAGA: medical tactics

Whether the expectant mother belongs to a certain risk group, taking into account the OGA, is determined by an obstetrician-gynecologist after clinical and laboratory tests. An individual observation plan is entered into the patient’s chart with the appointment of modern methods of examining the mother and fetus. It also contains information about recommended preventive hospitalizations, as well as an indication of where the birth will take place - in a regular or specialized maternity hospital.

At-risk groups

In Russia, obstetricians and gynecologists use a systematic approach to determine the degree of perinatal risk. The first - low - includes repeat pregnant women with a maximum of three quiet births in the anamnesis. This group also includes primary pregnant women who have no obstetric complications or non-gynecological pathologies; one uncomplicated abortion is allowed in their medical history.
The second degree of risk is childbirth in women with compensated pathological conditions of the cardiovascular system, mild diabetes mellitus, kidney disease, hepatitis, and blood diseases.

Also complicating the medical history:

pregnancy after 30 years;
placenta previa;
clinically narrow pelvis;
large fruit;
its wrong position;
perinatal mortality recorded in previous pregnancies;
gestosis;
operations on the uterus.

The third degree of risk includes women with severe pathologies of the heart and blood vessels, exacerbation of systemic diseases of connective tissue, blood, placental abruption, shock during childbirth, and complications during anesthesia.

Just what the doctor ordered

Pregnant women of high risk groups may be prescribed a consultation with a geneticist with a possible chorionic villus biopsy, amnio-, cordo-, placentocentesis to determine abnormalities in the development of the unborn child. The most accessible of all these studies is amniocentesis. With it, by micropuncture of the amniotic membrane, a portion of amniotic fluid is obtained, which contains embryonic cells. They are examined for the presence or absence of genetic damage.
Examination of amniotic fluid will help determine fetal pathologies

All pregnant women with OGA, according to indications, are referred for consultation to specialists to resolve the issue of prolonging pregnancy. In cases where it is necessary to conduct examinations in a hospital setting, the patient is placed in the gynecological department of the hospital or maternity hospital.

Important attitude

Women with OGA often experience pessimism during pregnancy. The need to visit the doctor more often and stay in the hospital worsens their mood. Constant thoughts about the upcoming birth and the health of the unborn child also add to the problems. Soft psychological relaxation techniques, which are used by specialist psychologists who conduct courses for expectant mothers in maternity hospitals and antenatal clinics, can come to the rescue. Physical activity is also indicated, of course, with the permission of the gynecologist observing the woman: walking, swimming in the pool, yoga. It must be remembered that the OAGA is not a sentence, but an instruction to the doctor in choosing the optimal way to manage the pregnancy.
Yoga is good for you during pregnancy

Forecast for the future

It is worth knowing that childbirth with a burdened obstetric and gynecological history, as a rule, ends in the birth of a healthy child. Only in some cases, the mother’s simple medical history can affect the health of the newborn. For example, if a woman has sexually transmitted infections, the fetus may become infected during childbirth. A predisposition to certain diseases is also inherited - hypertension, diabetes. They can complicate future pregnancies for the girl born. But OAGA itself is by no means a hereditary phenomenon, but the medical history of a particular person.

Menstrual function:
Menstruation from the age of 16, established immediately, 3 days at a time, occurs after 27 days, moderate, painless, regular.
Last menstruation: January 10 – 13
Gynecological history.
Sexual life since the age of 17, is in her first marriage, the marriage is registered, currently she does not live with her husband, but dates periodically, her husband’s age is 28 years old, healthy, builder by profession. Contraception: does not apply.
Past gynecological diseases: denies.
Obstetric history.
History of 4 pregnancies: 1 birth, 3 miscarriages
The first pregnancy ended in term birth in 1992, there was no toxicosis in the first and second (i.e. edema, protein in the urine, increased blood pressure) half of the pregnancy, the child was a Rh-positive boy, birth weight 3200.
The 2nd, 3rd, 4th pregnancies (the patient does not remember the exact dates) ended in early miscarriages (2 - 3 months). First miscarriage - I felt a strong urge to defecate, a miscarriage occurred. I didn’t go to the doctor. The second and third miscarriages - first spotting bloody discharge from the genital tract, then more severe bleeding (the patient cannot describe it more specifically), there was no severe pain. Curettage of the uterine cavity was done. The causes of miscarriages were not established; the patient was not examined
Allergy history:
There are no allergic reactions to medications or food products. On impregnated leather clothes - urticaria

History of the disease.
For a week (from about 02/12/2003) she noted nausea without vomiting, not associated with food intake, which she associated with a possible pregnancy: she was sexually active and did not use protection, and her menstruation was delayed (last menstruation January 10 - 13) for 3 weeks. On the afternoon of February 18, severe weakness and spots appeared before the eyes. At about 3 a.m. on February 19, I woke up from severe pain in the left iliac region radiating to the rectum. To reduce the pain, she took a forced position: on her right side with her knees pressed to her chest. She did not apply cold or heat to her stomach, and did not use medications to relieve pain. I measured the temperature - 37.5 o. In the morning (after 7 o'clock), at the insistence of my brother, an ambulance was called. The patient was admitted with a diagnosis of ectopic pregnancy, acute adnexitis.
Objective research.
General inspection.
The general condition of the patient is satisfactory.
Temperature 36.8 o C.
Consciousness is clear.
Constitutional type - normosthenic.
The physique is correct.
Height 165 cm, weight 61 kg.
The skin is pale. No pronounced cyanosis or areas of pathological pigmentation are observed. Skin moisture and elasticity are normal. No rashes were found.
Visible mucous membranes are pale pink in color, clean, there is no icteric staining of the frenulum of the tongue and sclera. The hairline is developed according to age. Female pattern hair growth. No increased brittleness of nails was noted. The examination was carried out in natural light.
The subcutaneous fat layer is moderately developed and evenly distributed. No edema was detected.
The occipital, parotid, chin, submandibular, cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal lymph nodes are not palpable.
The mammary glands are symmetrical, painless and homogeneous on palpation.
The muscles are moderately developed, painless on palpation, without compaction. Muscle tone is preserved.
The joints are not deformed and are painless on palpation. There is no limitation of mobility observed. There is no crunching or pain when moving.
The physique is correct. Posture is correct. There are no chest deformities. The angles of the shoulder blades are directed downwards. The physiological curves of the spine are sufficiently expressed; there are no pathological curves.
Respiratory system.
Breathing is free, through the nose, deep, rhythmic. There is no discharge from the nose. There is no shortness of breath.
The pharynx mucosa is not hyperemic. The tonsils are not enlarged.
The chest is conical in shape (normosthenic), symmetrical.
Chest breathing type. Respiration rate 20 per minute.
The chest is painless and elastic on palpation.
With comparative percussion in symmetrical areas, a clear pulmonary sound is determined over the entire chest; no focal changes in the percussion sound are noted.
Vesicular breathing. Wheezing, crepitus, and pleural friction noise are not heard.
Cardiovascular system.
The pulse is symmetrical, rhythmic, of normal tension and filling. The shape (speed) of the pulse is not changed. Frequency 74 beats per minute. There is no pulse deficit. The pulse is the same in both arms. The vessels were not changed during external examination. There are no varicose veins. Pulsation of the radial, temporal, carotid, subclavian, femoral, popliteal, axillary, brachial, and foot arteries is palpated. There is no pathological pulsation on the body.
Blood pressure 115/70 mmHg in both arms.
The chest in the area of the heart is not changed. There is no visible pulsation in the heart area. On palpation, the apical impulse is determined in the fifth intercostal space two centimeters inward from the midclavicular line, localized (2 cm wide). Diastolic, systolic tremor, symptom, "cat purring" are not detected. No epigastric pulsation is detected.
Limits of relative dullness of the heart.
Right - 1 cm outward from the right edge of the sternum in the 4th intercostal space;
Left - in the 5th intercostal space 1 cm medially from the midclavicular line;
Upper - on the third rib (along a line passing 1 cm outward from the left edge of the sternum).
Auscultation. Heart sounds are muffled and rhythmic. No bifurcation or splitting of heart sounds was detected. Heart rate 74 beats per minute. There is no noise.
Gastrointestinal organ system.
Lips are pale pink and moist. There are no cracks, ulcerations, or rashes. The tongue is pink, of normal shape and size, the back of the tongue is covered with a white coating, along the edges there are imprints from the teeth, the papillae are well defined. The mucous membrane of the tongue is moist. The gums are pink, there are no bleeding or defects. The oral cavity has been sanitized. There is no smell from the mouth.
Abdominal examination:
Inspection. The abdomen is of normal shape and symmetrical. No bloating is observed. Peristaltic movements are not visible. The navel is retracted. In the right iliac region there is a scar after surgery for acute appendicitis.
Superficial indicative palpation. The abdomen is soft, painful on palpation above the pubis, more on the left. The Shchetkin-Blumberg symptom is negative.
Pancreas. There is no pain on palpation and no tension in the abdominal muscles in the area of the projection of the pancreas (Kerthe's symptom).
Examination of the liver and gallbladder:
The gallbladder is not palpable. There is no pain on palpation at the point of the gallbladder.
There is no liver pulsation observed. The edge of the liver is not palpable.
Urinary organ system.
Pasternatsky's symptom is negative.
Genital system.
The genitals are developed correctly, hair growth is of the female type. The development of primary and secondary sexual characteristics corresponds to age.
Endocrine system.
Fine tremor of the fingers of outstretched arms and exophthalmos are absent.
There is no increased shine or dullness of the eyeballs. There are no changes observed on the anterior surface of the neck. The lateral lobes and isthmus of the thyroid gland are palpated (increased to stage 1a).
Nervous system and sensory organs.
Smell and taste are not changed. Pupil reaction to light. The function of the hearing aid is not impaired. There are no speech disorders. Vestibular apparatus without deviations.
The movements of the facial muscles are free. Tremor is not observed. There is no pain on palpation along the nerve trunks. There are no meningeal symptoms.
Gynecological examination.
In the mirrors:
The visible mucous membrane of the cervix and vagina is not visually changed. The discharge is bloody. A smear was taken to determine the degree of purity and gonococcus.
P.V.
The uterus is slightly larger than normal, mobile when moving behind the cervix, and sensitive. The appendages on both sides are without features. The vaults are deep.
To clarify the diagnosis, puncture of the abdominal cavity through the posterior fornix is necessary. The patient's consent was obtained.
Preliminary diagnosis.

Based on complaints of pain in the left iliac region, radiating to the rectum,

· based on the life history, from which it is known that the patient has had a delay of menstruation for 3 weeks (the patient has regular menstruation), that the patient is sexually active and does not use contraceptive methods, that she has a history of three early miscarriages,

· based on the medical history, from which it is known that a week before the onset of pain in the groin area the patient developed nausea not associated with food intake, that the day before the onset of pain she developed weakness and spots before her eyes, that pain in the groin area appeared suddenly, radiated to the rectum, and the patient developed a slight fever,

· based on objective examination data: the skin is pale, the abdomen is soft, painful on palpation above the pubis, more on the left, the Shchetkin-Blumberg symptom is negative, bloody discharge is visible in the speculum, P.V. the uterus is slightly enlarged, sensitive, -
You can make a preliminary diagnosis of the underlying disease:
menstrual irregularities: ectopic pregnancy? an incipient miscarriage?

Examination plan:
First of all:

general blood test

biochemical blood test: blood glucose

· blood type and Rh factor

puncture of the abdominal cavity through the posterior fornix

pregnancy test

If an ectopic pregnancy is suspected, a diagnostic laparotomy is performed.
Next:

general blood test

general urinalysis

· biochemical blood test: total protein, bilirubin, AST, ALT,

· blood for RW, HIV

vaginal and urethral smear

·
Puncture of the abdominal cavity through the posterior fornix from 02/19/2003::
2 ml of sanguineous fluid was obtained.
Diagnosis: menstrual irregularities; an incipient miscarriage? ectopic pregnancy?
General blood test dated 02/19/2003:
red blood cells 4.56 10 12 /l
Hb 152 g/l
Ht 47%
leukocytes - 6.8 10 9 /l
Conclusion: no deviations from the norm
Pregnancy test
positive (+)

Operation: diagnostic laparotomy, curettage of the uterine mucosa.
11.45 - 12.25
Cross section. 50 ml of sanguineous fluid was found in the abdominal cavity. The uterus is enlarged, the appendages are not changed. There is no source of bleeding. There was probably a reflux of blood from the fallopian tubes into the abdominal cavity, which caused severe pain. The abdominal cavity is drained. a couple of napkins - that's all. The abdominal wall wound is completely sutured. An intradermal purse-string suture was applied. Urine is light.
Considering the enlarged uterus, it was decided to perform curettage of the uterine mucosa.
The length of the uterus is 8 cm, the remains of the fertilized egg have been removed.
Diagnosis: Incomplete spontaneous abortion at short term. Rejection of blood into the abdominal cavity from the fallopian tubes.
Data from laboratory and instrumental studies.
General blood test dated 02/20/2003:
red blood cells 4.3 10 12 /l
Hb 146.6 g/l
color index 1.0
leukocytes 7.3 10 9 /l
eosinophils 1%
band neutrophils 12%
segmented neutrophils 55%
lymphocytes 24%
monocytes 8%
ESR 8 mm/h
Conclusion: in the general blood test there is a neutrophil shift to the left (inflammation?)
General urine analysis dated 02/20/2003:
protein 0.099 g/l
sugar +
leukocytes 15 - 20 per field of view
light red blood cells 8 - 12 per field of view
flat epithelium 10 - 14 in the field of view
slime++
Conclusion: the protein content in the urine is increased, sugar is present; conduct a repeat study, conduct qualitative research methods - Kakovsky - Addis (the number of formed elements in the daily amount of urine).
Biochemical blood test dated 02/20/2003:
protein 78 g/l
total bilirubin 16.6 mmol/l
direct bilirubin 3.6 mmol/l
indirect bilirubin 13.0 mmol/l
ALT 0.1 mmol/l
AST 0.3 mmol/l
Conclusion: no deviations from the norm.
Urethral smear from 02/20/2003:
Leukocytes entirely, gram+ and gram- flora, gonococcus was not detected, Trichomonas was not detected.
ECG dated 02/20/2003:
P - 0.08""
PQ - 0.14""
QRS - 0.08""
QRST - 0.40""
Heart rate 72/min
angle alpha 90 o
Conclusion: sinus rhythm, myocardial changes.

State educational institution of higher professional education "Altai State Medical University" of the Ministry of Health and Social Development of the Russian Federation

Department of Obstetrics and

gynecology №1

Head of the department: Doctor of Medical Sciences,

Professor Fadeeva N.I.

Teacher: Belnitskaya O.A.

Curator: medical student

faculty, 402 groups

Tyapova K.A.

Pregnancy history

Clinical diagnosis: Pregnancy 37-38 weeks. Longitudinal

fetal position, mixed breech presentation, first position, anterior view. Habitual miscarriage. Scar on the uterus after cesarean section. Isthmic-cervical insufficiency. Diffuse nodular goiter of the II degree.

Barnaul 2013

Passport part

Full name: Zh.T.N.

Age: 31

Place of work: deputy/director of private enterprise

Prof. hazards: none

Marital status: married

Home address: Topchikha village

Date and time of admission: 02/10/2013

Complaints:

At the time of admission: slight swelling in the arms and legs.

At the time of supervision: None

Anamnesis vitae

Born on July 10, 1981 (weight 3500 g, height 47 cm), developed and grew up in satisfactory social and living conditions. Heredity is not burdened. In physical development she did not lag behind her peers. No blood transfusions were performed. Diffuse nodular goiter of the II degree.

Denies allergic reactions to medications, food products and household chemicals.

Operations: correction of a deviated nasal septum (according to a pregnant woman in childhood), cesarean section in 2009.

Denies the presence of infectious diseases (tuberculosis, gonorrhea, chlamydia, syphilis, HIV infection, viral hepatitis B and C).

Denies bad habits (smoking, alcohol, drugs).

Blood group II(A0), Rh +.

Obstetric and gynecological history:

Menstrual function

Menstruation since the age of 14, moderate, regular, rhythmic, painless, the menstrual cycle is 28 days, duration is 4-5 days, menstrual blood is liquid with clots, established immediately. I did not observe any changes in menstrual function with the onset of sexual activity, after childbirth or abortion.

Sexual function

Has had regular sex life since the age of 18. She got married at the age of 18, her third marriage, registered. I used hormonal contraceptives "Regulon" for 2 years with breaks of 1 month. The spouse denies the presence of infectious diseases (tuberculosis, gonorrhea, chlamydia, syphilis, HIV infection, viral hepatitis B and C) and hereditary diseases. Husband’s blood III (B0), Rh “+”.

Fertility

2003 – first pregnancy, spontaneous miscarriage at 20 weeks.

2004 – second pregnancy, spontaneous miscarriage at 20 weeks, followed by curettage.

2006 – third pregnancy, spontaneous miscarriage at 17 weeks.

2009 - fourth pregnancy, premature birth by cesarean section at 33 weeks, the fetus was a boy weighing 1900 grams, height 43 cm, postpartum period without complications, condition of the newborn without complications.

2012 is a real pregnancy.

Secretory function

Discharge in moderate quantities, mucous, odorless. I did not notice any pathological discharge (cheesy, white, foamy, etc.). During pregnancy there is mucous discharge.

History of gynecological diseases (complicated gynecological anamnesis) and their treatment

In 2009, premature birth by cesarean section at 33 weeks of pregnancy, transverse position of the fetus.

In 2012, a suture was placed on the cervix for ICN.

Obstetric and gynecological history

Menstrual function: menarche from the age of 14, 7-8 days every 28-40 days, irregular, profuse, there are pains. last menstruation 04/11/05.

Sexual function: has been sexually active since the age of 18; first marriage, menstrual cycle has not changed; I did not use medicated contraception.

Gynecological diseases: I did not have any gynecological diseases.

Venereal history: I did not suffer from venereological diseases.

Reproductive function:

I Pregnancy in 2001, miscarriage at 13 weeks, without complications.

II 2005 - real pregnancy.

The course of this pregnancy: 1st half - spotting, bloody discharge at 4 and 8 weeks. 2nd half - at 29-30 weeks of acute respiratory viral infection with an increase in body temperature to 37 degrees, from 30 weeks there is swelling, an increase in blood pressure to 140/80 mm Hg. 35-36 weeks of treatment in the region. maternity hospital for mild gestosis. Weight gain of 24 kg is satisfactory.

Objective examination

General condition is satisfactory;

Consciousness is clear;

Position active;

The nature of nutrition is satisfactory;

Height - 175cm.

Weight - 90 kg.

The skin is of normal color, clean; visible mucous membranes without pathological changes, clean. Subcutaneous fat is moderately expressed.

Peripheral lymph nodes are not enlarged on palpation and are painless.

The thyroid gland is not enlarged on palpation.

The mammary glands are soft and painless on palpation, the nipples are clean.

The muscular system is moderately developed.

The osteoarticular apparatus is not deformed, movement in the joints is fully preserved.

Respiratory system

Breathing through the nose, tonsils are not enlarged in size, the shape of the chest is cylindrical, asymmetry is not visible; auxiliary muscles are not involved in the act of breathing; in the act of breathing, both halves of the chest equally simultaneously participate in the act of breathing.

BH 19 times per minute.

With topographic percussion, the boundaries of the lungs correspond to the norm;

comparative percussion: pulmonary percussion sound at all points;

Auscultation: normal vesicular breathing is heard over all fields of the lungs, there are no wheezes.

An objective examination of the respiratory system revealed no pathological changes.

Circulatory system.

The shape of the chest in the area of the heart is not changed. There is no visible pulsation. The apical impulse is 1.5 cm medially from the left midclavicular line, in the fifth intercostal space, localized, of medium strength, medium height and resistance.

Percussion borders of the heart correspond to the norm.

Auscultation: normocardia - the heart rhythm is correct, the sounds are loud, the tone ratio is preserved, there are no noises.

Pulse 78 beats per minute.

Blood pressure - 130/90 - on the left arm

120/80 - on the right hand.

An objective examination of the circulatory system revealed no pathological changes.

Digestive system.

The tongue is of normal size, clean, moist, the papillae are well defined. Healthy teeth. The mucous membranes of the oral cavity are pink, without changes.

Both halves of the abdomen are symmetrical.

Liver dimensions according to Kurlrv: 9*8*7 cm.

Dimensions of the spleen: length - 6 cm.

diameter - 4 cm.

An objective examination of the digestive system revealed no pathological changes.

Neuro-endocrine system.

In the Romberg position it is stable; the psycho-emotional sphere is not impaired.