My case reports in different specialities

Some of my case reports created during my rotations in different specialties, most of them are reviewed by the doctors

1-surgery

first case report in surgery about abdominal mass, the purple color is the doctor's comment

Fatemah,33 years-old female Saudi  pt, divorced ,jobless ,admitted through ER complaining of abdominal mass & back pain for 1 month.

Patient seems unreliable, source of a part of the history is her mother. (You can say informer is … if the patient is not the source of the history)

HPI

Since 1 month ago, Fatemah's mother has noticed her daughter feeling moderate , gradual, local , lower back pain which increases during working at home and decreases by rest , (Fatemah cannot describe the character of pain) , this pain attracted mother's attention to a painless hypogastric mass which is getting bigger by the time with slightly (mild, moderate or marked loss of weight) decrease in weight and appetite(dose not know the exact weight) ( a clue can be extracted by asking whether her clothes are getting wider or so)  ,the mass never disappears , and no other masses in her body, the mother did not care about it because her daughter was not complaining, 1 week prior to admission , the mother felt worry about the mass that (became) it becomes bigger and visible ,then they came to ER bcz (do not use such abbreviations, remember this is scientific writing) of this complain (complaint) ,ultrasound and routine investigation  was (were) done for her in ER then admitted to surgery word (ward),  no abdominal pain , no vomiting ,no diarrhea ,no constipation , no change in stool color ,no dysuria , no hematuria , no urine retention ,menarche was at age of 13 and the menstruation  is regular ,comes monthly ,lasts for 6 days, last period was 1 week ago, no vaginal discharge ,no breast pain or swelling , she was married for three years but no children (does not know the cause).

PMH

She has epilepsy since puberty ,diagnosed in KKH and she is on carpamizapine ,400 mg/day                                                                                                           history of hospitalization in KFH 1 year ago for 1 week due to RT lumber (lumbar) pain (dose not know the diagnosis, the investigation nor the medication)they referred her to KKH but she did not come because she got better ,                                    history of hospitalization , for 17 days,due to LT forarm burning (burn) by hot water in the bathroom (these are known as scalds),                                                                                              history of using alternative medicine for loss of appetite in unknown man who gave her some pieces of paper and told her to put it in a cup of water and drink one cup per day ,no affection , and the appetite returned by itself,                       no history of (not known Diabetic or hypertensive or…) DM, HTN ,anemia (Pt might not be aware of this disease despite its presence, it is not as recognizable as DM and HTN), CHD, bronchial asthma,                                       no history of allergy ,no history of surgery, no history of blood transfusion,     she (is fully vaccinated) took all her vaccines .

FH

Her brother is dead by cancer in his neck  when he was 17 years old, diagnosed in KKH (did you ask to know the diagnosis? Do you think this mass might be related to this abdominal mass?), and referred to Riyadh (does not know in which organ the tumor was)         Her father is dead by an accident 20 years ago, and he was free of chronic diseases, no history of DM, HTN,CHD.

OB/GYN /mentioned in HPI

SH

Fatemah got married 10 years ago then got divorced after 3 years, now she is living in tabuk  with her family in their own apartment ,not smoker, her diet is normal (you can say balanced diet according to your judgement), no much fat ,no much coffee, no much soft drink.

ROS

No fever ,no sweating, no fatigue, no remarkable symptoms . (thses should be mentioned in the HPI because it could tell about the nature of the tumor i.e. inflammatory)

On general physical examination,

Fatemah ,young lady, lying flat on the bed comfortably, alert ,conscious ,looking well ,thin, not in pain ,no distress, connecting to IV canula for medication hands/symmetric ,no muscle wasting ,no deformity,no palmer (palmar) erythema  no staining, no abnormal pigmentation, no leukonychia ,no koilonychias, no dupuytren's contracture.

Arm  and forarm/ burn trace (marks) in her left forarm .

Vital signs

Puls/  80 (write in full, 80 beats/min.)

RR/20 (write in full, 20 breaths/min.)

BP/110/82 (mmhg.)

TEMP/26,9 (what is the unit, C˚ or ˚F)

Face/ no asymmetry, no pigmentation, no special feature , no jaundice ,no pallor, no central cyanosis .

Mouth/ good hygiene 

Lymph node>>neck, axillary  ,inguinal/no enlargement, no tenderness (what about other groups of lymph nodes? i.e cervical. Do you think it is related to the tumor?)

Leg/no deformity ,no edema . (This should come after examination of the system that is mainly involved).

On abdominal examination

Inspection/burn trace in RT lumber (lumbar) region extended to the back, mass in lower abdomen , normal hair distribution, umbilicus is central and inverted , no deformity, no scars ,no dilated veins, symmetrical movement with respiration, no muscle defect, no cough impulse .

Palpation &percussion / superficial>> no tenderness (temperature and superficially palpable mass)  ,,,,deep >>no tenderness no deep masses , liver>>no tenderness (is it enlarged or not?) ,liver span is 10 cm , spleen>> not palpable ,no tenderness ,kidney>>no tenderness, no enlargement

Auscultation/ no change in bowel sound (mention the frequency and the character of the sound i.e, 5 sounds/min. or say normal), no renal bruit, normal aortic sound (???). 

On mass examination

Inspection/mass in hypogastric region extended to about 2 cm above the umbilicus 5.5x7.5 inches , spherical in shape (if spherical mention only one diamension usually the diameter, according to your dimensions this is oval),  no change in skin color or texture ,no scars ,no ulcers, no sinuses (these have already been mentioned in  observation of the abdomen in general) , no expansile cough impulse no change in surrounding structure .

 Palpation/normal temperature , no tenderness, hard (this is the feeling of a bone!! I think you wanted to say firm), regular surface, irreducible, uncompressible (reducibility and compressibility are tested for superficial lumps usually and might be difficult to be tested for an intra-abdominal mass)  not fluctuated (fluctuation is again used for superficial lumps of moderate size, and is difficult to test for in an intra-abdominal mass. How did you test for fluctuation in this huge mass??) , no fluid thrill, edge is unclear and con not detect lower border (or can not go below the mass) ,immobile ,no pulsation, no translucence (there is a lot of tissues above the mass making transillumination difficult. Usually not used for intra-abdominal masses.)  

Have you looked for a palpable thrill??.

Percussion/  dullness.

Auscultation/no bruit ,no bowel sound (you have already mentioned that bowel sounds were normal !!!!).

Comments:

1-    History was good although not indicating the nature of the swelling (inflammatory, gynecological etc).

2-   Systemic enquiry was not mentioned, respiratory and central nervous symptoms were not sought.

3-   You should make examination of the abdominal mass a part of abdominal examination and not a separate entity, for example by observation abdomen is distended with full flanks and there is visible mass seen extending form lower abdomen to above the umbilicus …. Then; by superficial palpation there is a palpable mass……. You describe the mass fully and then move to comment on the spleen, liver and any other masses.

4-   Examination for ascites is important, you forget to do it.

5-   Abdominal examination is not complete until you do rectal examination.

6-   Per vaginal examination is also essential in this case.

7-   Please be ware of the language (check words and phrases in red color), do not also use abbreviations unless otherwise indicated.

8-   Please check corrections in blue color.

9-   Examination of lower limbs for edema.

10- What is your differential diagnosis? Try to make a list of possible causes.

Another surgical case report about hypothyrodism 

 Alia3,46 Y.O female Saudi PT, originally from Jordan but she has Saudi nationality ,widow, mother of 5 children, smoker ,jobless,  lives in Tabuk for more than 25 years

CC/ Alia3,46 Y.O female Saudi  PT ,widow ,jobless, admitted to the KKH surgical ward  through  OPD complaining of swelling in the neck for more than one year.

HPI/one year ago ,Alia3 came to ER in KKH complaining of cough(cough was due to flu ) and  chest x-ray was done for her ,the doctor discovered a small mass in her neck which she was not  aware of ,then the doctor referred her to a surgery clinic but she did not go because she did not care about it that it was asymptomatic and invisible ,after that the mass has been getting bigger and visible in the anterior aspect of the neck ,disturbing her swallowing, make mild strangulation feeling in her neck. This mass is painless , never disappeared and no other masses in her body , associated with coldness but no need for more clothes or blankets, fatigue , weakness , tendency to sleep ,bone and muscle pain which disturb her daily practices, loss of appetite and weight loss !! (Cannot detect exact WT) , she also noticed  her voice changed , her hair and skin became more  dry, constipation and hard stool, nausea ,dyspepsia . No diarrhea, no vomiting, no abdominal distention. No fainting, no confusion, no nervousness, no fever or sweating, no dyspnea, no bradycardia or tachycardia , no arthralgia or joint swelling or redness , no rashes or itching. for the last 6 months the menstruation has been irregular, comes twice a months and sometime after 2 months, last period was 2 months ago and it was so heavier than normal. Although all these malign symptoms ,she did not seek any medical advice because she is always  depressed ,hates the hospital and medication and also she has a trouble with communication, but she decided to come to the hospital by her friends force that they make her  afraid of a dangerous disease.

ROS/general/ in HPI

CVS: nil of note

Resp/ nil of note

Git/in HPI

Urinary/ polyurea, urine incontinence, dysurea  , others are normal

Cns/ in HPI

Rheumatology/in HPI

Dermatology/in HPI

Hematology/ nil of note

PMH/history of hemorrhoid for more than 2 years and she is not on medication (she refuses any medication or surgeries)

History of UTI and she was treated well

No history of DM, HTN, CHD

No history of hospitalization, previous surgery or trauma

No history of blood transfusion

No history of allergy

No history of exposure to radiations.

OB/GYN/ menarche on the age of 14, the menstruation was regular coming monthly and lasting for 7 days, she has 5 children and no history of abortion or cesarean section.

FH/her father is alive with DM, HTN, CHD, (she does not know about any details of her father diseases) and her mother is in a good health, no history of tumor.

SH/ Alia3 is smoker for a long time, number of cigarettes is variable according her mode, her diet is unhealthy, she eats much fat and drinks 3 to 4 can of soft drink every day,

Alia3 lives in a apartment with her family, low socioeconomic status, her life is stressful that she is widow for 2 years and she always worried about her sons' and daughters' future.

On general examination:

 Alia3, middle aged pt, sitting on the bed comfortably, alert ,conscious ,looking well ,well body built, not in pain ,no distress, an IV cannula is inserted for medication, no IV fluid, oxygen or monitor , hands/symmetric ,normal temperature, no wetness, no dryness, no muscle wasting ,no deformity, no palmer erythema, no staining, no abnormal pigmentation, no peripheral cyanosis, no koilonychias, no leukonychia ,no clubbing, no dupuytren's contracture, no fine tremor or flapping tremor  Face/ no asymmetry, no pigmentation, no special feature ,no pallor, no jaundice, no central cyanosis ,no proptosis, no lid lag , no lid retraction, no periorbital edema. Mouth/ good hygiene, no dehydration, no tremor, no swelling. Lymph node>> neck, axillary, inguinal/no enlargement, no tenderness, Leg/no deformity, no edema.

Vital signs

Puls/ 60 bpm, regular, average volume, not collapsing in nature, BV wall is not felt, symmetrical in both side.

RR/20 bearths/minute 

BP/110/60 mmhg

TEMP/36, 3 C˚

HEENT/we did not take how to do it

CHEST/ we did not take how to do it

CVS/ we did not take how to do it

On abdominal examination

Inspection/ normal hair distribution, umbilicus is central and inverted , no deformity, no scars ,no dilated veins, symmetrical movement with respiration, no muscle defect, no cough impulse .

Palpation &percussion / superficial>> no tenderness, no superficial mass ,,,,deep >>no tenderness no deep masses , liver>>no tenderness ,not palpable ,liver span is 10 cm , spleen>> not palpable ,no tenderness ,kidney>>no tenderness, no enlargement, back>> no tender kidney, no sacral edema, no ascites   supraclavicular lymph node>>no enlargement, PR examination and external genetalia>>not done

Auscultation/ no change in bowel sound, no renal bruit, no aortic bruit.

NEURO/ we did not take how to do it

MSK/ not done

ENDOCRINE/ we did not take how to do it

On neck examination

Inspection/ visible huge nodular mass in the anterior aspect of the neck involve thyroid isthmus & both lobes, take whole anterior triangles and not extended below the clavicle, RT nodule is more prominent, width 16cm, length 7cm. The mass is elevated with swallowing but not moved with tongue protrusion, no scar, no discoloration, no rash over the mass

Palpation/ palpable mass in the anterior aspect of the neck ,normal temperature, no tenderness, nodular smooth surface, firm, move upward with swallowing, clear edge, not reducible or compressible, no fluctuation or fluid thrill, not pulsating, no translucence, she felt shocked during palpation

Percussion/ no dullness in retrosternal area.

Auscultation/no bruit over the mass.

2- pediatric
interesting case in hematology with many details 

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Case about diabetes witch is very important topic in pediatric

Elaf 10 year old saudi girl originally  from Tabuk and lives in Tabuk

History is obtained from both the patient and her mother.

CC/ she is a known case of diabetes for 1 year on insulin. Admitted through ER complaining of abdominal pain, high blood sugar measurement for few hours prior to admission.

HPI/ Elaaf was doing well till 3 days ago when she had her evening insulin dose and had the usual dinner, she started to feel fatigue and abrupt onset of mild dull epigastric abdominal pain with no reliving or aggravating factor, associated with nausea, when she started to have this complaints, her sister measured her blood sugar and it was 400 mg/dl, and they immediately brought her to the ER. No vomiting or change in bowel habits, no lower abdominal discomfort, no dysuria or hematuria, no cough, SOB, or chest pain, no fever or sweating, no convulsion, or loss of consciousness, no history of weight change or loss of appetite .

Since diagnosis, she has been complaining of polydypsia, polyphagia and polyuria with  painful urination, incontinence and dysuria. These urinary symptoms got worse  with the present complaint, there is also occasion dizziness after exercise and they are not sure about any history of hypoglycemia, no history of chest pain, SOB, or cough.

No vision or hearing problem, no evidence of impaired sensation or poor wound healing.

PMH/she was diagnosed to have diabetes 1 year ago in KKH when she complained of  Polyuria and polydipsia and it was 500 mg/dl. Since that time, she has been on injectable insulin and the recent dose is 9 units a.m and 9 units p.m. History of repetitive ER visits for the same complaint. no history of ICU admission.

for 5 months, she had have repetitive attacks of convulsions and loss of consciousness. She was investigated in KKH and diagnosed to have epilepsy ,They prescribed syrup medications she used it for 5 months then stopped it without her doctor's advice.

She is not following diabetes clinic due to transportation issue.

No history of allergy, no history of trauma or blood transfusion, no history of surgeries.

She was fully immunized at the proper times with no complications.

Developmental history/ she developed normal mile stone, she has an excellent school performance, she differentiates between right and wrong, she can tell a story.

Nutritional history/ she was exclusively breast-fed. weaning at the age of 6 months and she was eating from the usual family meal fed for 2 years. Now, she is eating well, low sugar and fat diet.

Perinatal Hx/ antenatal/ she was booked, no complication, hospitalization or medications except vitamins and iron.

                   Natal/ full term normal vaginal delivery, birth weight was proper but she is uncertain about the exact weight, no birth complications or injury.

                 Post natal/no history of any complication, resuscitation  or NICU admission.

No history of abortion or stillbirth.

Family history/

Social history/ she is a student in elementary school, she is repetitively absent due to the same problem, she is interactive with her classmate, her mother is not educated, not working and she is the only one taking care of her children, no housemaid.

her father is a governmental employee, has enough outcome, he is smoking but usually outdoor. She has 7 siblings, one of them is having chronic illness which make the mother very distracted and busy. Difficult access to the hospital due to transportation issue. No history of animal contact or recent travelling.

Examination/ General Appearance: Elaf was looking well, alert, lying on the bed comfortably, not in pain or respiratory distress, average body built (Attached growth chart), no deformity or dysmorphic features. No skin lesion, petechea, pallor, jaundice, cyanosis or edema. No lymphadenopathy, Iv cannula was inserted to the left hand not connected to IV line.

VS

HR- 100 bpm, regular, synchronized, normal peripheral pulse    RR- 20 breaths/m       T- 37 ͦ C axillary            BP- not don, not easy accessible.

  Growth parameters (Attached)

Abdomen/ soft, lax, no tenderness or organomegally, normal bowel sound.

MSK: all extremities are freely symmetrically moving, no joint swelling ,redness or tenderness.

chest: symmetrical chest, moves freely with respiration  normal breath sound.

Cardiac: symmetrical chest, no obvious pulsation ,normal heart sound no added sounds or murmur .

neurological: conscious, alert, intact cranial nerve, no signs of weakness or atrophy, 

normal muscle tone and power.

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case about Bronchiolitis which is very very very common 

ID/ Yasmin, 2 months Saudi girl, from Tabuk.

History was provided by the mother(she is the only one taking care of her child).

CC/cough and abnormal breath sound for 4 days prior to admission.

HPI/ Yasmin was well till 4 days ago when she developed wet gradually progressive cough, aggravated during feeding. Post tussive vomiting with yellowish sputum, no blood. Mild wheezing started along with the cough and mouth breathing. She went to private clinic where they did CXR and diagnosed her as chest infection and gave her O2 once, no medication was given. Next day, she noted worsening of the symptoms and came to the ER. No fever, No wt loss or sleep disturbance. No cyanosis, runny nose, SOB, sweating on feeding or edema. No history of recent travelling or ill contact

ROS/ General and cardiopulmonary: mentioned in HPI.

          GIT and urinary: repetitive abdominal distension since birth, normal bowel habits and                               normal urination………   

          Blood: no anemia, bleeding disorder or bruises……

           MSK: no skin rash, no signs of inflammation e.g redness, swelling…..

           CNS: no irritability, dizziness or abnormal movement…..

PMH/ not known to have any medical or surgical problem, no known allergy, no history of hospitalization or repetitive ER visits

Medication: oral drops PRN for abdominal distention since she was 2 week- old.

Immunization: took birth immunization, 2 months' vaccines  are not given yet.

Perinatal Hx/ the mother has no complication during pregnancy except Iron deficiency anemia, she took 8 Iron injections at 8^th month of gestation, otherwise the baby was healthy and developed normally. Delivery was normal vaginal with no fetal complications, birth wt was 3.5 kg, no hospitalization, resuscitation or NICU admission.

Developmental Hx/ she is moving freely, elevate her head on prone position on plane of the body, follow moving objects, smile to her mom.

Feeding Hx/ she was on breast feeding for first 2 weeks and then shifted to modified infant formula with Iron (Nan) 4 times a day, 30 ml, plus herbals once a day. The mother is the one who prepares the bottles and following the instructions on the can.

FH/ the parents are not related, has 3 siblings age range from 3-7 years, all are healthy. No family history of chronic diseases.

SH/parents are well educated, good socioeconomic state easy access to the hospital, no smoking, no recent travelling, no animal contact.

DDx/ bronchiolitis, bronchiopneumonia, hyperactive airway disease, GERD        

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3- OB/GYNE

Case about Abortion which is one of the hot topics in OB/GYNE

Gamalat, 30 year old female marred since 3 years ago, G3p1+1,pregnant at her 14th week of gestation,  lab technician,  originally from Tabuk and  lives in Tabuk. Last menstrual period was 29/7/1433.

CC/She came to the hospital yesterday evening immediately after passing the fetus.

Gamalat, pregnant at 14 week of gestation by date , planned, not induced with past history of abortion at 20^th  week and known case of cervical incompetence.

She was diagnosed for her present pregnancy after amenorrhea, nausea and vomiting for 10 days confirmed by serum β-hcG, she has not perceived any fetal movement yet ,was following at MCH OPD as a high risk pregnant, last week, in one of the OPD visit, they told her that they will do cerclage for the cervical incompetence after two weeks (at 16 week of gestation).

yesterday , she passed fetus while the umbilical cord and placenta still inside, with no pain , no significant bleeding or discharge , no fever, no loss of appetite, no headache, blurred vision or LL swelling ,no hx of trauma, autoimmune disease, genital  tract infection, or animal contact, no UTI or hormonal defect.

Past Obstetric history:

	Fetal complication	Maternal complication	Breast-feeding	outcome	place	Mood of delivery	duration	time
	-----	-----	---	-----	MCH	Complete abortion	20 weeks	3 years ago	1
	Underweight Stayed 1 week in NICU	Bleeding in the third trimester and received progesterone	no	Boy 1.8kg	KKH	Normal vaginal delivery	34 weeks	2 years ago	2

Menstrual History

Her menarche was at the age of 14,regular, 6/28, average amount with no clots, no dysmenorrhea, no history of using any type of contraception.

Past medical history

She has diagnosed for cervical incompetence since her first pregnancy, 3 years ago in MCH and cervical cerclage was done in her second pregnancy.

No DM, HTN, CHD, autoimmune diseases, thyroid diseases, UTI, or PID.

Past surgical history:

No history of CS or any other type of operation, no history of endometrial biopsy or pap smear.

Family history:

Her mother has DM, her father is healthy.

No history of twins, congenital diseases or tumor.

Social history:

 not smoker, no animal contact, normal diet.

Examination:
Vs
Bp: 130/70 brachial    HR: 90bpm regular, average volume, synchronized, blood vessel wall is not felt, no radio radial or radio femoral delay
 RR: 20bpm, shallow    T: 37.2     BMI?
Patient was conscious, alert, sitting on the bed comfortably, not in pain or respiratory distress, not cyanosed, pale or jaundiced.
head and neck: no pallor, jaundice or pigmentation,
no congested neck vein, enlarged LN or goiter
Chest: normal breath sound, no added sound
heart: normal S1,S2 no murmur
breast: symmetrical no masses, nipple discharge, or redness.
abdomen: uterus is not palpable, no distention, Soft, lax, No tenderness or superficial
masses, no signs of organomegally , symmetrical movement with respiration, normal female hair distribution, hernia orifices are intact.
LL: symmetrical, no swelling, no tenderness, redness, or hotness, intact peripheral pulses.

PV: mild bleeding, cervix is opened.

Investigation: the following investigations are the only were done as written in the file. U/S must be done!!!

Assessment :

30 year-old pregnant G3P1+1 at 14 week of gestation with incomplete abortion. D&C under general anesthesia. Velosef  capsule, 500ml ×3d. Adol 

tablet. Check Rh and give Anti-D if    -ve.

Case about Antipartum Hge 

Fatemah,26 year old pregnant lady, G6P3, married for 8  years, she is at 38 week by date. L.N.M.P was 6/1/33 and EDD is 24/10/33

CC/she came to the hospital complaining of vaginal bleeding and watery discharge for 1/2 an hour prior to admission.

HPI/she developed sudden continuous vaginal bleeding ,large in amount with clots, not related to menses or intercourse, associated with small amount of watery discharge(she could not describe it). After about 12 hrs of the bleedbing and while she was in the hospital, she developed lower abdominal pain and back pain, cramping, on/off ,every 5-6 hours, 2/10 in severity ,increasing with moving and no relieving factors.

She was diagnosed for this pregnancy by home pregnant test ,then confirmed by serum β-HCG and U/S. this pregnancy was unplanned not induced. She perceived fetal movement for the first time at 16^th week of gestation. She is booked in KKH ,first visit was at 4^th week of gestation, U/S and all antenatal routine investigations were done and were normal. Last visit was one week and the ultrasound result was showing well-being fetus with no obvious abnormalities.

Past obstetric history/G6P0T0A2L3

Fetal complication	Maternal complication	Breast-feeding	outcome	place	Mood of delivery	duration	time
-----	No No D&C	---	-----	KKH	Complete abortion	4 weeks	8 years ago	1
no	no	yes	Girl,3kg	KKH	Normal vaginal delivery	Full term	8 years ago	2
Died due to asphyxia	no	------	Boy,3.4kg	KKH	vaginal delivery with vacuum due to prolongation	Full term	6 years ago	3
---------	no	------	-------	KKH	--------	Missed abortion at 4th week	4 years ago	4
no	no	yes	boy,2.5kg	KKH	Normal vaginal delivery	Full term	2 years ago	5

 Menstrual history/ Her menarche was at the age of 14,regular, 7/28, average amount with no clots, no dysmenorrhea, no history of using any type of contraception.

Past medical, medication, allergy, hospitalization and blood transfusion/ all are negative

Family history/her husband is here cousin, 30 year old with good health. her mother has DM,HTN. Her father has HTN. No Hx of twins, congenital anomalies or tumor.

Social history/ not smoker, normal diet, no animal contact.

 Post operative Note, you will face too many post CS cases 

Hanan,23y.o G2P2,married since 7years ago. With past CS 2Y ago.
She is day#4 post.op, emergent lower segment CS, booked at KKH, pregnant at 40th week of gestation by date and U/S. L.N.M.P was 30/12/1433H, she presented to KKH on Friday evening complaining of lower abdominal pain and back pain, cramping, high intensity, regular every 5 min
At presentation: fetal movement was intact and was no PV loss and no other symptoms. Since admission, she had have trial of normal labor, but after about 4 hrs they decided emergent CS due to fetal macrosomia (as she said), and previous scar site pain. The outcome was well being boy weighing 3,7kg.
She was diagnosed for the present pregnancy after 10 days of amenorrhea then confirmed by U/S, quickening was at the 18th week of gestation. Uneventful 1^st & 2^nd trimester.
Today, she is fine, no abdominal pain, no fever, she passed stool and urine many times since CS .she breast-fed her baby
past OB history: she has one girl, full term, weighing 3,5kg, emergent CS lower segment delivery due to rupture of the membrane without cervical dilatation, CS was done at KKH, general anesthesia, no intra or post op complication, no excessive bleeding or blood transfusion.

Examination
Vs
bp: 120/66    HR: 86bpm,regular,average volum, blood vessel is not felt and no radioradial or radiofemoral delay      RR: 17beaths/m      T: 37  ͦ C
patient was conscious, alert, sitting on the bed comfortably, not in pain or respiratory distress, not cyanosed pale or jaundiced. Connected to IV canola.
Chest: normal breath sound, no added sound.
normal S1, S2 no murmur
breast: not tender, intact skin, intact nipple, no obvious discharge.
Abdomen: soft, lax, no distention, no distended vein. Lower transverse abdominal dressed scar clean and dry strain.

Fundal level: not detectable.
LL: no calf muscle pain, redness, or hotness.
PV: not done.