GO JIA YEE

WH Written Case Gynaecology

History Taking
Venue: Hospital Sultan Ismail Ward 4B (gynaecology ward)
Date: 15/3/2016
Patients identification: A 26 years old Chinese insurance agent, who is Para 0+1
had an uncomplicated termination of ectopic pregnancy at 8 th week of gestation and
currently under post-operative care.

Presenting complaint
This is a post-operative case of ectopic pregnancy where salpingectomy has been
done laparoscopically to remove the gestation sac in the left Fallopian tube.

History of Presenting Complaint

Patient is a known case of ectopic pregnancy prior to the admission. She was
presented with mild vaginal bleeding without any symptoms of hypovolemic shock
and severe abdominal pain which indicates the possibility of ruptured ectopic
pregnancy. On admission, vital signs had been assessed and vaginal examination
was done. A transvaginal ultrasound scan was performed to confirm the location of
ectopic pregnancy. She had a discussion with the consultant about the management
plan. Salpingectomy was offered and she agreed with it.

History of pregnancy (ectopic pregnancy)

This unexpected pregnancy was confirmed by urinary pregnancy test at the 2 nd
week of gestation after she had missed period for 3 days. She went to a private
clinic to re-confirm the pregnancy immediately. However, no fetus was detected in
the uterus. The serum -hCG level was 2270 IU/L. The next visit was arranged in the
next 2 weeks. At the 4th week of gestation, there was still absence of fetus in the
uterus and the serum -hCG reading was 5400 IU/L. She was suspected with ectopic
pregnancy and it was confirmed by transvaginal ultrasound scan. It was a tubal
ectopic pregnancy in the left Fallopian tube. The size of the gestation sac was
greater than 3.5cm with the visualization of fetal heart. A referral letter to Hospital
Sultan Aminah was given to her.

Past gynaecological history

Menarche: 12 years old

Usual menstrual cycle: 7/28

Experience mild dysmenorrhea on the second day of menstruation

occasionally

Patient has no complaints of intermenstrual bleeding and post-coital bleeding

Had an episode of uncomplicated UTI in the past 6 years which has been
treated by one course of antibiotics
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GO JIA YEE

WH Written Case Gynaecology

Injectable contraception was used for a month

She never had a cervical smear

No history of sexually transmitted disease.

No history of gynaecological surgery and subfertility problem

Past medical history

No significant past medical history

1. Absence of any chronic medical conditions (diabetes, hypertension,
cardiac disease)
2. No previous admission to hospital
3. No history of blood transfusion

Drug history

She was taking some traditional medicine which is believed good for women
health before this pregnancy

No allergy to drug or food

Social history

She lives with her boyfriend and they are having a stable relationship

No financial problem

Not smoking/alcohol/drug abuser

Family history

Both parents are fit and well

No history of diabetes, gestational diabetes, hypertension and pregnancy
induced hypertension
Absence of multiple pregnancy and Downs syndrome

System review

No fever

No SOB

No chest pain

No UTI symptoms

No URTI symptoms

No abdominal pain

GO JIA YEE

WH Written Case Gynaecology

ICE
Ideas
She thinks that this ectopic pregnancy might be related to the traditional herb which
she has been taking for several months.

Concerns
She worried that the salpingectomy might reduce the chances of getting pregnant
in future.

Expectations
She needs advices on contraception as she does not want to get pregnant in the
following 2 years.

Physical examination
General examination

Alert
In post-operative mild pain

Medical adjuncts: IV assess on left hand (Normal saline)

Temperature 36.8C

Pulse 68 bpm

Capillary refill time <2s

Blood pressure 125/75mmHg

No signs of pallor and jaundice

Mild dehydration

Neck (looking for enlargement of thyroid glands and lymph nodes)

Chest (auscultate the heart and lungs, perform breast examination if there is
active complaints from patient)

Abdominal examination
Inspection
No other previous surgical scars
Abdominal movement is coherent with the respiration
Assess the wound (There are no overlapping/gapping of the incision part, signs of
inflammation, bleeding/discharge and hematoma)

Palpation (no palpation on the wound)

Abdomen is soft and non-tender
Neither abdominal nor pelvic masses was found
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GO JIA YEE

WH Written Case Gynaecology

No organomegaly

Auscultation
Bowel sounds are present

Lower limb inspection

Pulse of pretibial and dorsalis pedis are felt

No leg oedema
No calf tenderness
No varicose vein

Management
Monitor vital signs (pulse, blood pressure, capillary refill time, temperature and
respiratory rate)
Routinely check for abdominal tenderness
Check haemoglobin level (prescribe iron supplement or blood transfusion if
necessary)
Continue IVI of normal saline
Assess appetite, fluid tolerance, bowel and urinary habit
Prescribe NSAIDS for the pain
Wound care (signs of inflammation and bleeding)
Measure serum -hCG level (expect dropping in its level)
Abdominal ultrasound (check for retained of product of pregnancy)
Encourage early mobilization and maintain good hydration status
Inform the patient about risk of ectopic pregnancy in the future
Discuss the contraception plan

GO JIA YEE

WH Written Case Gynaecology