Physical Examination 6

Dr Anita Jogewar

Role Play 1

A young female came to ED where you are working as an

HMO after she had a MVA. She was sitting in the passenger
seat and had her seatbelt on. She had an injury on her
face (small bruise on left cheek/maxilla)

Task

A. Relevant examination
b. Further management

Is my patient hemodynamically stable?

Stable- Proceed, if not DRSABCD

Introduction

Introduce yourself, and ask permission (consent) to

examine.

Explain to the patient what you are about to do.

Wash your hands!

General inspection: conscious.

Vital signs: stable

I understand from my notes that you had an accident. I am

sorry for that. Do you have any pain? Do you want me to
give any painkiller?

Patient has small bruise on left cheek. Ask any other

injury?

Do you have any headache? Did you lose consciousness?

Any N/V? Blurred vision?

Any feeling of dizziness or drowsiness

Look

There is a bruise on the left side of the cheek

no obvious asymmetry or swelling is noted;

no obvious fractures; in the eyes there is no raccoon

eyes ,orbital floor fracture) or any swelling or redness;

Nose- no obvious fracture; no obvious drainage of fluid.

Mouth- any loss of tooth or injury.

Ears- no injury, bleeding, or fluid.

There is no battle sign (discoloration of mastoid due to

basal skull fracture) On the neck and head, there is no
obvious swellings, bumps, deformities

Feel

Feel surrounding area for fracture or tenderness.

feel head for any injury or swelling; feel cervical spine and
paraspinal muslces to look for tenderness.

Cranial nerve examination.

Examine 2nd, 3rd, 4th, 6th, 5th, and 7th cranial nerves.
2nd- check pupillary reflexes
-Fundoscopy

3rd,4th,6th- Eye movements

- ask any double vision
- Positive for double vision
5th cranial nerve- face sensation
- motor movements
7th cranial nerve- ask to smile.

Management

Keep patient in ED for observation

Arrange review by eye specialist.

Arrange maxillofacial x-rayCaldwell view.

arrange CT scan .

Ask any help to inform family.

Lets practice

Role Play 2

A 30-year-old male comes in to your GP clinic with BP

measured to be 160/90. He had further 2 readings and
revealed his BP to still be elevated. He is generally well
but smokes 20 cigarettes per day for the last 10 years.

Task

a. Perform physical examination

b. Advise further management

Introduction

Introduce yourself, and ask permission (consent) to

examine.

Explain to the patient what you are about to do.

Wash your hands!

General inspection: as you see

Vital signs: Blood pressure is elevated

There are two types of Hypertension.

1.

Idiopathic- no cause is found

2.

Secondary hypertension- Secondary cause is present.

So to perform physical examination, you must know

secondary causes of hypertension .

Secondary causes of hypertension

TRACK PADS

T - Thyrotoxicosis

R - Renovascular (renal artery stenosis -- bruit)

A - Aorta (COA radiofemoral delay; check all BP)

C - Cushing syndrome

K - Kidney (Chronic kidney disease glomerulonephritis,

nephropathy, renal artery stenosis

P - Pheochromocytoma

A - Aldosteronism (Conn)

D- Drugs (OCP, NSAIDs, steroids, alcohol)

S- Sleep Apnea

Inspection

BMI, stigmata of Cushing syndrome (Cushing facies, central

adiposity)
Acromegaly (bossing of forehead, big jaw, thick big hands)
Uremia (lethargic, weak, or confused)
Examination starts with hands
Hands: Cyanosis, Pallor, Tremors, Xanthomata, Pulse rate and
Rhythm, Radio-radial delay (COA or SAS), and Radiofemoral
delay.
CHECK BP while lying and standing, and on both arms .

Face and Eyes

Congestion of face (polycythemia), facial plethora

(alcohol abuse)

Exam of Eye

Look for signs of hyperthyroidism-Ptosis ,Lid Lag,Proptosis

Funduscopy any change in the retina, disc, papillary

oedema

look for any redness (polycythaemia)

Neck

Thyroid Swelling of Neck.

Look for signs of hyperthyroidism-Ptosis ,Lid Lag,Proptosis

Jugular Venous Pressure

Cushingoid Hump & Moon Facies

Cardiovascular system locate apex beat, listen to the

heart sound for any murmur

Respiratory system examination any added sound,

bilateral basal crackles (congestive cardiac failure)

Abdomen:

Inspection: Scars, distention, visible masses/pulsations

Palpation: Expansile/Pulsating masses, Organomegaly,
Masses especially renal Palpate both kidneys.
Auscultation: Bruits at aorta and kidneys.

Lower limbs:
Oedema, Pulses, and other signs of PVD
- Urine dipstick (casts, protein, blood), and BSL

Investigations:

FBE (anemia or polycythemia), U&E, creatinine and eGFR,

FBS, lipid profile,LFT, TFTs, ECG and CXR by GP.

Recommended by specialist opinion: Echo, renal

ultrasound/Doppler USD of kidney, serum cortisol level,
plasma rennin and aldosterone, 24hour urinary catechol
amines

Management

Lifestyle modification for the 1st 3 months: reduced

weight, salt intake, healthy diet, reduce stress, regular
exercise, smoking cessation and alcohol to drinking levels

Refer to dietitian .

Aim is to reduce BP to 140/90 or less.

Regular monitoring of BP on a daily basis and on same

time each day.

Start medications if nonpharmacologic measures fail or if

there are signs of target-organ damage occurs or if DBP
>95.

Arrange another consultation for quit smoking.

If secondary cause found- treat underlying cause.

Role Play 3

A 25-years-old man was brought to the ED where you are

working as HMO who had been involved in a MVA. He has lost
consciousness for 5 minutes.
Task
a. Assess the patient
b. Immediate investigation
c. Management

Primary Survey: DRS ABCDE

Danger: Wash hands!! Is my patient safe to approach? (check

for glass, needle or anything that may injure doctor or
patient); on looking around there is no obvious danger .

R Response ask the patient.hello Mr/Mrs, how are you?

If no response, call for help. Tell nurseplease send for help (if
psychiatric patient, press the button for Code Blue).

CERVICAL COLLAR for cervical injury

Has the patient been put a cervical collar on the neck? If not,
please do it. Put a collar to keep neck stable as much as
possible; stand behind patient, hold neck (in line stabilization)

Ask examiner to hold the head until you put the collar .Ask for help!!!

Airway: Can you open your mouth for me? Check for any injury,
vomitus, blood, loss of teeth, dentures, etc. Suction if necessary; pick
up foreign objects if necessary with forceps (don't use hands)!

If unconscious patient

Management:

Chin Lift Jaw thrust ( No head Tilt in Trauma)

Check for oral cavity, ill-fitting denture or bones,Foreign Bodies

take it out by Suction-- Any vomitus, fluid suction.

Guedels or Intubate depending on condition

give O2.

B Breathing

look for a chest movement (equal or only on 1 side),Resp rate & effort,
tracheal deviation

Others: color, cyanosis, JVP

Agitation ,anxiety ( Signs of Hypoxia)

listen to the breathing sounds ( Stridor), Auscultate lungs for

Asymetry of breath sounds (pneumothorax) any fluids ( Hemothorax)

Heart sounds( Muffled in Tamponade with JVP Increase)

feel the breathing of the patient against your cheek.

(right side of the chest is not moving; (+) chest lag; breath sounds are
absent).

I am considering tension pneumothorax. I need to remove air by

inserting a cannula on the 2nd ICS MCL then attach to underwater seal
and drain

I am considering tension pneumothorax. I need to remove

air by inserting a cannula on the 2nd ICS MCL then attach
to underwater seal and drain

Tension pneumothorax: presents with SOB; chest lag with

bulging of the chest; tracheal deviation; increased JVP;
decreased breath sounds and hyper-resonant chest

C Circulation pulse, BP; put IV line take some

blood for test. Give fluids if BP is low and there is no fluid
in the chest. Check arterial blood gas, FBE, blood grouping
(maybe patient will need blood).

Disability (neurological):

GCS; for rapid assessment: ask patient to stick tongue out, wiggle toes, ask to make
a fist; look for PEARL and funduscopy findings;

D (Deformity/defect) basically GCS & PEARL

Consiousness

A-Alert

V-Verbal stimuli response

P-painful stimuli response

U-Unresponsive

Pupil

PEARL Pupil is equal and reactive to light good sign if not, bad sign

GCS if 8 or less INTUBATION. Tell nurse to call anaesthetic surgeon to do the

intubation.

Exposure: Avoid hyporthermia

Head and neck: Can you check her from head to toe for
any other obvious injuries or sites of bleeding (swelling on
the right temporal area)?

Swelling on the head? Any laceration? Any discoloration on

the mastoid process or eyes? Any leakage of fluid from
nose, or ear

Chest: Rib tenderness or contusion or any obvious rib

fractures? Tracheal deviation? Paradoxical movements of
the chest?

Abdomen: Bruise, distention, tenderness? Any blood at

the urethral meatus?

Pelvis: injury, swelling or fracture

Periphery: deformity, swelling, injury, fracture

Investigations

FBE, BT and cross matching

U/E/C

BSL , ABG if necessary

CXR, cervical spine xray, AXR, pelvic xray

cranial CT scan

Refer to surgical registrar for secondary survey (full

history and management)

Role Play 4

Ankylosing spondylitis
1.

The back and sacroiliac joints:

1.

Loss of lumbar lordosis and thoracic kyphosis

2.

Severe flexion deformity of the lumbar spine (rare)

3.

Tenderness of the lumbar vertebrae

4.

Reduction of movements of the lumbar spine in all

directions

5.

Tenderness of the sacroiliac joints

Perform spine examination

Gait- walk, on heel and toe too

Look- spine

Feel- vertebrae, paraspinal muscles and sacroiliac joints

Move- Flexion- severe flexion deformity

Extension, lat flexion and rotation

Special test

1. SLR

2. Schober test- positive

2. The legs:
1.

Achilles tendinitis

2.

Plantar fasciitis

3.

Signs of cauda equine compression (rare)

1.

lower limb weakness

2.

loss of sphincter control

3.

saddle sensory loss

3.

The eyes:
1.

Acute iritis painful red eye

4. The lungs:
2.

Decreased chest expansion (less than 5cm)

3.

Signs of apical fibrosis

5. The heart:
4.

Sings of aortic regurgitation

6. Rectal and stool examination:

5.

Signs of inflammatory bowel disease

7. X-ray of the spine and sacroiliac joints

Ankylosing spondylitis (AS) is a type of inflammatory

arthritis that targets the joints of the spine. It first affects
the sacroiliac (SI) joint, where the spine attaches to the
pelvis, and then starts to affect other areas of the spine.
The hips and shoulders can be affected, and so can the
eyes, skin, bowel and lungs. Symptoms of AS include back
pain, stiffness and reduced mobility in the spine.
Ankylosing spondylitis affects men more often than
women. The condition usually appears between the ages
of 15 and 45 years. There is no cure for AS, however, there
are things you can do to help control your symptoms.

Symptoms of ankylosing spondylitis

The symptoms of AS vary from one person to the next, but

they are usually worse after rest and relieved with
exercise. The most common symptoms are: pain and
stiffness in the back, buttocks or neck, often waking with
early morning stiffness and pain

pain in tendons (which connect muscles to bones) and

ligaments (which connect bones to each other), often felt
as pain at the front of the chest, back of the heel or
underneath the foot

Diagnosis of ankylosing spondylitis

Early diagnosis is important so that treatment can be

commenced to prevent damage to the spine.
Investigation and diagnosis of AS may include: medical history

physical examination

x-ray

scanning procedures such as CT or MRI

blood test

genetic testing- HLA B27

These tests are generally organised by a rheumatologist or

doctor who can explain the results.

Treatment for ankylosing spondylitis

There is no cure for ankylosing spondylitis. Medical treatment aims to

manage pain, reduce the risk of complications and improve quality of life.
Medication for ankylosing spondylitis

Medications for the treatment of ankylosing spondylitis include: nonsteroidal anti-inflammatory drugs (NSAIDs)

disease-modifying anti-rheumatic drugs (DMARDs)

biological disease-modifying anti-rheumatic drugs (bDMARDs) new drugs

that work by targeting certain overproduced proteins that cause
inflammation and damage to bones, cartilage and tissue

corticosteroid medication

analgesics (pain-relieving medication).

Things to remember

Ankylosing spondylitis (AS) is a type of inflammatory

arthritis that targets the joints of the spine, particularly
the sacroiliac (SI) joint where the spine attaches to the
pelvis.

There is no cure for AS medical treatment aims to

manage pain, reduce the risk of complications and
improve quality of life.

The most important management tool is regular exercise,

which helps to keep the spine mobile and flexible

Role Play 5

 You

are seeing Mr. Ahmad a 45 year old gentleman

who was diagnosed with alcoholic polyneuropathy.

Task:

Perform an examination of the lower limb

Introduction

Introduce yourself, and ask permission (consent) to

examine.

Explain to the patient what you are about to do.

Wash your hands!

General inspection: as you see

Vital signs: normal

General: Gait

Inspection: scar, sinus, s/sx of inflammation, deformity,

discharge, digit loss, interdigital space

Palpation: Temperature, tenderness, oedema, pulses, tone

and wasting

Neuropathy
Sensory:

light touch, pain sensation, cold sensation,

vibration, proprioception. Start from feet.

Motor:

Power (feet-ankle-knee)

Reflexes

Office test: +/- BSL

Expected Findings
Physical: Classic physical examination findings associated
with alcoholic neuropathy may include the following:
Diminished

sensation to vibration or pinprick

stimulation in a stocking glove distribution may be
noted.

Thermal

and proprioceptive sensation also may be

reduced.
Muscle

stretch reflexes, especially of the gastroc-soleus

muscle, may be diminished or absent.

 Weakness

of ankle/toe dorsiflexion and/or ankle

plantar flexion strength may be noted.

Intrinsic

atrophy of foot muscles may be observed in

advanced cases.

Gait

ataxia with a widened base of support or bilateral

foot drop may be observed.

Evidence

of other alcohol-related end-organ damage

also may be observed on physical examination.

Diagnosing Alcoholic Neuropathy

Tests, which may identify other potential causes of neuropathy,

include:

nerve biopsy

nerve conduction tests

upper GI and small bowel series

neurological examination

electromyography

esophagogastroduodenoscopy (EGD)

kidney, thyroid, and liver function tests

complete blood count (CBC)

Blood tests can also look for vitamin deficiencies that are linked
to both nerve health and alcohol use. Nutrients your doctor
might test for include:

niacin

thiamine

folate

vitamins B6 and B12

biotin and pantothenic acid

vitamins E and A

Treatment for Alcoholic Neuropathy

The most important thing you can do to treat this

condition is to stop drinking. Treatment may first focus on
problems with alcohol use. For some people, this may
require inpatient rehab. Others may be able to stop
drinking with outpatient therapy or social support.

Once alcohol use has been addressed, your doctor can

focus on the neuropathy itself. Symptom management is
important. Nerve damage can also make it difficult for
you to carry out the functions of daily life. Nerve damage
may even make injuries more likely.

Every persons needs are different. Treatment for

neuropathy may involve one, or many, different types of
care. These include:

vitamin supplements to improve nerve health (folate,

thiamine, niacin, and vitamins B6, B12, and E)

prescription pain relievers (tricyclic antidepressants and

anticonvulsants)

physical therapy to help with muscle atrophy

orthopedic appliances to stabilize extremities

safety gear, such as stabilizing footwear, to prevent

injuries

special stockings for your legs to prevent dizziness

Preventing Alcoholic Neuropathy

You can avoid alcoholic neuropathy by:

avoiding excessive drinking of alcohol

not drinking alcohol if you have symptoms of alcoholic

neuropathy

seeking help if you are having trouble avoiding alcohol

eating a healthy and balanced diet

taking vitamin supplements if you have deficiencies

(always talk to your doctor before taking supplements)

Rehabilitation Program:
Physical

Therapy: Comprehensive physical therapy for

patients with alcoholic neuropathy may include the
following:

Gait

and balance training, possibly with an assistive

device for safety

Range

of motion (ROM) exercises and stretching,

particularly for the gastroc-soleus muscle, to prevent
contracture and maintain normal gait mechanics

Strength

training of weakened muscles

Role Play 6

Your next patient in the emergency department is a

20 year old Matthew Wilcox who presents with a 3day history of a dark-red "burning rash." The rash
started at his sock line and, over the course of the
past 2 days, has spread proximally up his thighs. It
is not present on his abdomen or back, but it has
spread to his hands over the past day. The patient
also has complained about a sore throat and a
scratchy voice for the last 5 days.

Your tasks are to:

Perform an examination

Explain the most likely diagnosis and management

to the patient

HENOCH SCHOENLEIN PURPURA

Henoch-Schnlein purpura is an autoimmune, self-limited
IgA-mediated vasculitis affecting skin, joints, the
gastrointestinal and renal systems.

It most commonly presents in children 5 years of age (up

to 20 years).

The aetiology of the disease remains unknown, but it is

understood to be an autoimmune response (usually to an
upper respiratory viral or group A streptococcal infection).

HSP typically presents with the triad of

Purpuric

rash on the extensor surfaces of

limbs (mainly lower) and buttocks,

Joint

pain/swelling and

Abdominal

pain

Abdominal

pain or arthralgia sometimes

precede the rash

Assessment

Purpura: If atypical distribution or the child is unwell,

consider meningococcaemia, thrombocytopenia, or other
rare vasculitides.

Joint Pain: Swelling and arthralgia of large joints are often

the patient's main complaint. In most situations this pain
resolves spontaneously within 24-48 hours.

Abdominal pain: Uncomplicated abdominal pain often

resolves spontaneously within 72 hours. However serious
abdominal complications may occur including
intussusception, bloody stools, haematemesis,
spontaneous bowel perforation, and pancreatitis.

Renal disease: Haematuria is present in 90% of cases, but

only 5% are persistent or recurrent. Less common renal
manifestations include proteinuria, nephrotic syndrome,
isolated hypertension, renal insufficiency and renal failure
(<1%). Renal involvement may only present during the
convalescent period.

Subcutaneous oedema (scrotum, hands, feet, sacrum):

This can be very painful.

Rare complications - pulmonary and CNS involvement

1.

General inspection
Vital

signs: BP, temp

Rash:

Distribution/?Purpura

Hands/feet
Large

(Subcutaneous oedema)

joints (Swelling and arthralgia of large joints)

2.

Neck stiffness (If atypical distribution or the child is unwell)

3.

Abdomen examination
Tenderness
Organomegaly
Sacrum

(Subcutaneous oedema)

Scrotum

(Subcutaneous oedema)

most likely you have a condition called HSP which is an inflammation or

vasculitis of small vessels of his body. Most common age of onset is 2-8
years. It usually follows an URTI which he had a week ago and the exact
cause is unknown.

I need to arrange some investigations such as FBE, inflammatory

markers, urine MCS and U&E/C, bleeding time and clotting profile.

The management is largely symptomatic. There is no specific therapy

except for rest, paracetamol for pain, and short course of steroids .

you need follow-up . We will need to repeat his kidney function tests and
urine MCS as well as monitor his BP.

This condition has a good prognosis and most patients recover fully in a
few months

- Reading material. Review.

Role Play 7

Your next patient in the emergency department is a 56

year old Mr. Smith who has been brought in by ambulance
form a special accommodation house with a history of
collapse and haematemesis. He is known to drink a bit but
has never been to hospital before. When the ambulance
arrived he was lying on the floor of his room with blood
oozing from his mouth.

YOUR TASK IS TO:

Obtain further history

Perform an examination

Discuss the most likely diagnosis.

Ask examiner Is my patient haemodynamically stable or not:

O2 Sat, BP 90/60 mmhg, pulse, capillary refill < 2 seconds

Start with DR ABC

Bleeding put 2 large IV cannula (14 or 16 gauge)

Take blood for blood type and crossmatch

HOPC: Mr. has had an alcohol problem for 30 years, lost his
drivers licence, got divorced, lost his job and is living in a
special accommodation place all because of his drinking. He
still drinks about 1 cask of cheap wine every day.

He was found by the caretaker when he did not turn up for

breakfast. He had collapsed in his room and had vomited bright
red blood, so the ambulance was called. No melaena. No pains.

PHx,: hypertension for 10 years on ACE inhibitor

FHx.: unremarkable

SHx: divorced pensioner living in a special accommodation

place, drinks a cask of wine daily, smokes 20 cig./day,
NKA, ACE inhibitor for HPT.

PHYSICAL EXAMINATION

GA: chronic liver disease, liver failure, and signs of portal hypertension

Chronic liver disease

Leuconychia

Palmar erythema

Hepatic flap

Jaundice

Enlargement of parotid gland

Gynaecomastia

Spider naevi

Ascites

Splenomegaly

Prominent veins

Bruising

Testis atrophy

Liver failure

Hepatic flap

Encephalopathy confused, coma

Signs of portal hypertension

Splenomegaly

Hypersplenism (increase function of the spleen)

Prominent veins

Haemorrhoids

PR : melena

HANDS: palmar erythema (liver palms, ? raised plasma

oestrogen levels)
Leuconychia
Clubbing

Dupuytrens contracture (related to alcoholism rather than

liver disease!)

Hepatic flap

Spider naevi (superior vena cava drainage area, ?raised

plasma oestrogen level

SKIN: Jaundice and scratch marks

Spider naevi (see above)

Bruising: ecchymoses(large bruises), petechiae (pinhead-sized

bruises), problem with production of clotting factors and
thrombocytopenia (bone marrow suppression, hypersplenism
(portal hypertension) with excessive destruction of platelets).

Muscle wasting sec. to malnutrition

HEAD: possible encephalopathy (minor mental impairment

through to coma)

parotid enlargement (alcoholism and malnutrition rather than

liver disease)

MOUTH:gum hypertrophy, fetor hepaticus

CHEST: gynaecomastia and loss of body hair (oestrogens)

ABDOMEN: dilated(collateral) veins +

hepatosplenomegaly due to portal hypertension

Ascites (shifting dullness and thrill)

Testicular atrophy

PR examination for melaena

LEGS:

oedema, muscle wasting and bruising

DIAGNOSIS: HAEMATEMESIS (sec. to alcoholism)

Differential diagnosis: peptic ulcer bleed, Mallory Weiss

syndrome, cancer, etc

Role Play 8

Epstein-Barr Virus
Infection/thrombocytopenia

You are a GP and a 32-year-old male comes to you

complaining of fever, sore throat, rash and some
enlarged glands over his neck.

Tasks
1.

Perform Physical Examination

2.

Give your D/Ds.

1.

General inspection

Any sings of bleeding/rash

Patients with thrombocytopenia typically experience

mucocutaneous bleeding
Petechiae
Ecchymoses

2.

3.

Face

Sclera (jaundice, pallor)

Nose (epistaxis)

Mouth (gum bleeding, inflamed throat, petechiae may be seen on

the palate). Examine throat with torch and tongue depressor

Cervical/axillary lymph nodes (especially posterior cervical)

4. Neck for stiffness

5. Abdomen
Organomegaly
Inguinal
Rectal

(tender liver, enlarged spleen)

lymph nodes

and pelvic examination for signs of bleeding

6. Legs
Bruising
Rash

(maculopapular)

Differential Diagnosis

- EBV
- HIV
- Streptococcus pharyngitis (tonsillitis)
- Lymphoma/leukemia
- CMV/toxoplasmosis
Hepatitis

Role Play 9

Your next patient is a 25-year-old primi who had a normal

vaginal delivery 20 minutes ago in one of the country
district hospital. You are an HMO on call. Pregnancy was
normal. Labor went for 14 hours and now the midwife
calls you because the patient has lost 1.5L of blood. She
asks you on phone to come and help her.

Task

a. Ask the midwife appropriate questions

b. Advise her on what to do until you arrive

c. Complete the management when you reach the

hospital.

Is she hemodynamically stable? What are the vitals (85/50,

130)?

Can you please secure IV lines, take blood for grouping and
crossmatching, and start IV fluids. Is she on a urinary
catheter? If not, can you please insert a catheter?

Is she conscious (Yes)? Is she having SOB (yes)?

Can you please give her oxygen.

What was the mode of delivery (instrumental delivery with
forceps)?
Was it a single baby or multiple? What is the weight of baby?

Any genital tear? Was episiotomy done?

Is the uterus lax or contracted (lax)? Is placenta is

delivered? Have you checked the placenta? Do you think
there are retained products?

Is the blood clotting? Is the patient bleeding from

anywhere else (No)? Whats her blood group?

Did she receive ergometrin injection after delivery? No.

does she has urinary catheter? No- apply

Massage uterine fundus till I come

On arrival:

Check vitals, IV lines and catheter

Start syntometrin (Oxytocin + Ergometrine)

Start normal saline or hemacele solution.

Ergometrin contraindication: heart disease and

hypertension

Massage uterine fundus

Check placenta

Do speculum examination to check for lacerations

If blood is available- start blood transfusion

Call registrar

Management

There are various causes of uterine atony

Primary: blood loss per vagina of more than 500ml in the

first 24 hour after delivery

Atonic uterus (insufficient contraction, shortening and

kinking of the uterine blood vessels and prevent further
blood loss)

Retained placental fragments which prevent placental

site retraction

Laceration of genital tract

Uterine rupture

The Cause could be most likely uterine atony because of

prolonged labour. I have called the registrar and they will
take you to the theatre to examine the uterus under
anaesthesia to check for any retained placental fragments.

They can do bimanual compression of the uterus.

If it doesnt work, they will give you intrauterine

prostaglandins to promote contraction.

If unsuccessful, they will go for internal iliac artery

ligation.

If all measures fail, the last resort would be hysterectomy.

However, we will do our best to prevent this as this is only
your first pregnancy.