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Case-Study

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Case Study
CASE STUDY #1
Patient Information:
Mrs. Abao is a 28-year-old primigravida at 32 weeks gestation who presents to the antenatal clinic with
complaints of headache, blurred vision, and swelling in her hands and face. She has a history of chronic
hypertension but has not been taking her prescribed medications regularly. Her blood pressure (BP) on
admission is 160/110 mmHg, and proteinuria is detected on a dipstick test.
Questions:
1. What is pre-eclampsia, and what are its risk factors?
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Pre eclampsia is a serious medical condition that can occur about midway through pregnancy after
20 weeks. Its risk factors are associated with Age, Obesity, Family History, Chronic High blood or
Kidney disease before pregnancy.
2. What are the clinical manifestations of pre-eclampsia?
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The clinical manifestation of pre-eclampsia is decreased levels of platelets in blood, increased liver
enzymes that indicate liver problems, excess protein in urine or any other kidney problems and
severe headaches.
3. Why is it important to monitor blood pressure in pregnant women, especially those at risk for preeclampsia?
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To monitor if the blood pressure is too high inorder for the doctor to order tests that checks signs
of pre-eclampsia. Preeclampsia is characterized by high blood pressure, protein in the urine and
severe swelling. High blood pressure in pregnancy can reduce the amount of oxygen and nutrients
of the baby leading to complications.
4. What is the significance of proteinuria in pre-eclampsia?
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Proteinuria can serve as an indicator of early Renal disease. It is marked as an increased risk of
renal damage secondary to hypertension and cardiovascular disease.
5. Why is Mrs. Abao's history of irregular medication use for chronic hypertension relevant to her current
condition?
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The medications were given to control the hypertension of Mrs. Abao by not taking it regularly
means that the patient's blood pressure/chronic hypertension levels will be uncontrolled.
6. What other assessments and investigations would you consider for Mrs. Abao?
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Mrs. Abao should have blood tests, fetal monitoring, urine test, ultrasound and NST.
7. What are the potential complications of pre-eclampsia for both the mother and the fetus?
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Women with pre eclampsia are at increased risk for damage to the kidney, liver, brain, and other
organs and blood system. For the fetus is lack of oxygen and nutrients which can impair fetal
growth, preterm birth, stillbirth if placental abruption which would lead to heavy bleeding in the
mother and lastly infant death.
8. What is the management plan for Mrs. Abao's pre-eclampsia?
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The management for Mrs. Abao is hospitalized to monitor her blood pressure control. To provide
more accurate diagnosis and appropriate management.
9. Why is early detection and management of pre-eclampsia crucial?
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Early detection allows early time management and it also reduces the risks of complications for
both the mother and the baby.
10. What education and counseling would you provide to Mrs. Abao regarding pre-eclampsia and her
ongoing care?
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Advise Mrs. Abao to attend all the prenatal check ups to monitor her condition closely and to
take any prescribed medications for her chronic hypertension. Educate her about the signs and
symptoms that indicate worsening and seek medical attention if any symptoms like severe
headache or vision changes and stress.
Case Study#2
Patient Information:
Mrs. Susvilla is a 30-year-old woman who gave birth via vaginal delivery two days ago. She presents to
the postpartum clinic with complaints of fever (temperature 38.5°C/101.3°F), increased abdominal pain,
foul-smelling vaginal discharge, and a tender uterus. Mrs. Susvilla is a G2P2 (gravida 2, para 2) with no
significant medical history.
Questions:
1. What is a puerperal infection, and what are the common risk factors for its development?
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Puerperal infection is an infection of the uterus and surrounding tissues. This usually happens
after the trauma of vaginal birth and Cesarean delivery. It’s common risk factors are C-section,
Prolonged labor, Multiple Vaginal Examinations, Pre-existing infections, tear or episiotomy,
manual removal of placenta and use of catheter.
2. What are the signs and symptoms of a puerperal infection in the postpartum period?
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The signs and symptoms would be fever, chills and sweating, abdominal pain, foul-smelling
vaginal discharge, pain or discomfort during urination, redness, swelling, or pain at the incision
site and fatigue and weakness.
3. Why is it important to differentiate between normal postpartum symptoms and signs of infection in
the immediate postpartum period?
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It’s to differentiate the signs and symptoms of a more serious conditions that requires medical
attention.Normal postpartum symptoms such as mild fatigue, discomfort, and vaginal bleeding,
are expected after birth. Signs of infections has persistent fever, foul-smelling discharge or
severe abdominal pain.
4. What is the most likely source of infection in this case?
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The main source would likely be endometritis, Endometritis can occur after childbirth,
particularly if there were any complications during delivery or if there were prolonged labor.
5. What diagnostic tests would you order to confirm the presence of a puerperal infection?
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The diagnostic tests would be blood cultures, complete blood count(CBC), pelvic exam,
ultrasound, endometrial cultures, and urinalysis.
6. What is the rationale behind assessing the uterine tenderness and foul-smelling discharge in the
postpartum patient with suspected infection?
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For Uterine tenderness, tenderness of the uterus can indicate inflammation or infection within
the endometritis. In the postpartum period, the uterus undergoes natural contractions to return
to its pre-pregnancy size. Excessive tenderness may suggest an abnormal inflammatory
response, often associated with infection. Foul-Smelling Discharge or malodorous vaginal
discharge can be indicative of an infection, especially if it is accompanied by other symptoms
like fever and abdominal pain. This odor is often associated with the presence of infectious
microorganisms and is commonly seen in conditions such as postpartum endometritis.
7. What is the initial management approach for Mrs. Susvilla 's puerperal infection?
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The management should be empirical antibiotic therapy, pain management,uterine massage,
drink fluid regularly and nutritional support. Monitoring for vital signs
8. Why is it important to involve the patient's obstetric history (G2P2) in the assessment of puerperal
infection?
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A woman who has had multiple pregnancies or deliveries may have an increased risk for
complications including postpartum infections. One of the risk factors of puerperal infection is csections, knowing the previous complications or delievies will give a very meaning full
information to the patient's risk for infection.
9. What are the potential complications of untreated or inadequately treated puerperal infection?
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If puerperal infection is untreated or inadequately treated this can cause sepsis, pelvic abscess,
uterine perforation, sepsis shock, long term reproduction
10. How would you counsel Mrs. Susvilla regarding the importance of completing the prescribed course
of antibiotics and follow-up care?
•Complete the Antibiotic Course: Stress the importance of taking the full course of antibiotics, even if
she starts feeling better before completing it. This helps ensure that all bacteria causing the infection are
eradicated, reducing the risk of recurrence.
•Follow the Prescribed Schedule:Advise her to take the antibiotics exactly as prescribed, both in terms
of dosage and timing. Consistency in medication adherence is key to effective treatment.
•Attend Follow-Up Appointments: Stress the importance of attending all follow-up appointments with
her healthcare provider. These appointments are essential to monitor her progress, assess the
effectiveness of the treatment, and address any emerging concerns.
•Report Any Concerns:Encourage Mrs. Susvilla to promptly report any new or worsening symptoms, side
effects of medication, or concerns during the course of treatment. Early detection of issues allows for
timely intervention.
•Pelvic Rest: If advised by her healthcare provider, discuss the importance of pelvic rest, which includes
abstaining from sexual activity during the recovery period.
By providing clear and thorough guidance, Mrs. Susvilla is more likely to understand the importance of
adherence to the treatment plan, increasing the likelihood of a successful recovery. Always tailor advice
to the specific recommendations and considerations provided by her healthcare provider.
Case Study #3
Patient Information:
Ms. Andales is a 32-year-old woman who presents to the gynecology clinic with concerns about difficulty
conceiving and a lack of sexual desire. She has been trying to conceive for the past 18 months without
success. Ms. Andales reports irregular menstrual cycles and occasional painful intercourse. She has no
significant medical history and is in a stable relationship.
Questions:
1. What initial questions would you ask Ms. Andales regarding her difficulty conceiving and lack of sexual
desire?
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I would ask for menstrual history. The pattern of her menstrual cycles, if there has been any
changes in the duration or flow of her period. Pregnancy history, if she has been pregnant
before, complications or miscarriages. Intercourse frequency is how often the partner engage in
sexual intercourse. Painful intercourse is the details about occasional painful discourse or any
changes in sexual desire or arousal. Lifestyle if she smoke or stressors and Partners health
issues.
2. How would you assess Ms. Andales's menstrual cycle irregularity in relation to her difficulty
conceiving?
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I would assess menstrual cycle details, cycle tracking, the consistency of ovulation,previous
pregnancy attempts, past pregnancy, underlying conditions, lifestyle factors, and partners
fertility assessment. By obtaining a detailed history, you can identify potential factors
contributing to Ms. Andales’s difficulty conceiving, including menstrual irregularities. This
information will guide further discussions and investigations to address her specific concerns.
It’s important to approach the conversation with empathy and a collaborative mindset.
3. What are potential causes of painful intercourse (dyspareunia), and how would you approach this
aspect of her complaint?
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The potential causes of dyspareunia is infection, vaginal dryness, endometriosis, pelvic
inflammatory disease (PID), uterine fibroids, and psychological factors. To approach tha
compliant is to create a safe and non-judgemental space and discuss her concern. It’s essential
to approach this aspect of Ms. Andales’s complaint with sensitivity and respect for her comfort.
Collaboration with a healthcare provider will help determine the underlying cause and guide an
appropriate treatment plan tailored to her specific needs.
4. Why is it important to assess Ms. Andales's overall health and lifestyle in the context of her
reproductive and sexual health concerns?
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Lifestyle factors, such as diet, exercise, stress levels, and habits like smoking or excessive alcohol
consumption, can very much have an impact on the reproductive health. Assessing these factors
helps identify potential underlying issues that may contribute to her difficulties conceiving and
dyspareunia. Lifestyle choices and overall health can significantly influence fertility.
Understanding Ms. Andales’s overall health allows healthcare providers to address factors that
may affect her ability to conceive.
5. What diagnostic tests or investigations might be indicated for Ms. Andales's difficulty conceiving?
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The diagnostics tests that can unidentify any potential underlying factor are ovulation
monitoring, hormonal testing,pelvic ultrasound, hysterosalpingography, semen analysis, thyroid
functioning tests, hysterocopy, genetic testing, screening for sexually transmitted infections, and
laparoscopy.
6. How would you address Ms. Andales's lack of sexual desire in the context of her reproductive health
concerns?
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By collaborating with gynecologist and a mental health professional will help find the underlying
problem regarding of her concern. Checking for hormonal imbalance, stress or emotional factors
that is affecting Ms. Andale’s lack of sexual desire.
7. Why is it crucial to involve Ms. Andales's partner in the assessment and management of her difficulty
conceiving?
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This problem is responsible for the two of them, it fosters a sense of collaboration and mutual
involvement in the journey to conceive. When both partners are actively engaged in the
assessment and management process, there is a higher likelihood of adherence to treatment
plans and lifestyle modifications recommended by healthcare providers.
8. What role does stress play in reproductive and sexual health, and how might it be addressed in Ms.
Andales's case?
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Stress can significantly impact reproductive and sexual health, potentially affecting fertility and
sexual desire. In Ms. Andales’s case, addressing stress is essential due to its potential influence
on her difficulty conceiving and lack of sexual desire.
9. What potential reproductive health issues could be associated with Ms. Andales's symptoms, and how
might they be managed?
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The potential health issues that could be associated with Ms. Andales’s symptoms irregular
menstrual cycles, difficulty conceiving, and painful intercourse, may indicate various
reproductive health issues. Possibilities include polycystic ovary syndrome (PCOS),
endometriosis, or hormonal imbalances. In managing a PCOS it involves the lifestyle menstrual
cycle and fertility treatment. Endometriosis is pain management. For Hormonal Imbalance is
hormonal medications or assisting reproductive technologies for conception.
10. How would you counsel Ms. Andales regarding her reproductive and sexual health concerns, and
what follow-up plan would you recommend?
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I would counsel the patient of the importance of comprehensive assessment. To advise her that
she should undergo through reproductive health evaluation, hormonal test and more detailed
instruction of her medical and sexual history. Discuss to her the impact of lifestyle and attend
the regular check up to monitor her condition.
Case Study #4
Patient Information:
Mrs. Medalle is a 32-year-old woman who delivered her first child via cesarean section one week ago. She
presents to the emergency department with complaints of sudden onset shortness of breath, chest pain,
and swelling in her left leg. Mrs. Medalle has no significant medical history, and her pregnancy was
uneventful.
Questions:
1. What are the risk factors for thromboembolic disorders in the postpartum period?
-Cesarean section delivery
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Prolonged immobility
Obesity
Multiparity
Smoking
Advanced maternal age
Pre-existing medical conditions (thrombophilia, history of venous thromboembolism)
2. Why is the postpartum period a vulnerable time for the development of thromboembolic disorders?
-The postpartum period is vulnerable to thromboembolic disorders due to a combination of factors:
Hypercoagulable State
Venous Stasis
Endothelial Damage
Postpartum Immobility
Hormonal Changes
Vessel Compression
Cesarean Section
Dehydration
3. What clinical signs and symptoms might suggest the presence of a thromboembolic disorder in Mrs.
Medalle?
-Signs and Symptoms of Thromboembolic Disorder:
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Sudden onset shortness of breath
Chest pain
Swelling in the left leg (symptomatic of deep vein thrombosis)
Tachypnea
Tachycardia
Cough (may be hemoptysis)
4. What initial diagnostic tests would you order to assess for a thromboembolic disorder in Mrs. Medalle?
-D-dimer assay
● Chest X-ray
● Doppler ultrasound of the left leg
● CT pulmonary angiography
5. How would you manage Mrs. Medalle's thromboembolic disorder in the acute setting?
-The main objectives of treating Mrs. Medalle's acute thromboembolic illness are to stabilize her health,
reduce her symptoms, and stop more problems. This is a brief synopsis of the acute management:
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Anticoagulant therapy (heparin followed by warfarin or direct oral anticoagulants)
Oxygen therapy
Analgesia for chest pain
Thrombolytic therapy (if massive pulmonary embolism)
6. Why is it important to consider the route of delivery (cesarean section) in the assessment of Mrs.
Medalle's risk for thromboembolic disorders?
-Considering the route of delivery, specifically the fact that Mrs. Medalle delivered her first child via
cesarean section, is crucial in assessing her risk for thromboembolic disorders for several reasons:
● Cesarean section is a major surgery and increases the risk of thromboembolism.
● Surgical trauma and immobility post-surgery contribute to clot formation.
7. What long-term management and prophylaxis measures might be recommended for Mrs. Medalle to
prevent recurrent thromboembolic events?
Extended anticoagulation therapy
● Compression stockings
● Early ambulation
● Adequate hydration
8. How would you educate Mrs. Medalle on the importance of adherence to anticoagulant therapy and
follow-up care?
- Importance of taking prescribed anticoagulants, monitoring for signs of bleeding or recurrence and,
scheduled follow-up appointments.
9. What considerations should be taken into account if Mrs. Medalle plans to have more children in the
future?
Consultation with a healthcare provider before conception
● Close monitoring during pregnancy
● Adjustments to anticoagulation therapy as needed
10. How might you address Mrs. Medalle's emotional well-being and concerns related to her
thromboembolic disorder during the postpartum period?
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Encourage open communication about fears and concerns
Involve mental health support services
Provide information on support groups for women with similar experiences
Discuss postpartum mood disorders and ensure appropriate follow-up care.
Case Study#5
Patient Information:
Mrs. Fernandez is a 20-year-old woman who delivered her second child vaginally 12 hours ago. She
presents to the emergency department with complaints of heavy bleeding despite measures taken to control
postpartum hemorrhage. Mrs. Fernandez had an uneventful pregnancy, and her delivery was complicated
by a second-degree perineal tear, which was repaired shortly after delivery.
Questions:
1. What are the common causes of postpartum hemorrhage, and how might they be differentiated in Mrs.
Fernandez 's case?
● Uterine Atony: Lack of uterine muscle tone.
● Genital Tract Lacerations: Tears in the birth canal, like Mrs. Fernandez's second-degree perineal
tear.
● Retained Placental Tissue: Incomplete expulsion of placenta.
● Coagulopathies: Disorders affecting blood clotting.
2. What are the risk factors that might predispose Mrs. Fernandez to postpartum hemorrhage?
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Multiparity
Prolonged labor
Uterine overdistention (e.g., multiple gestations)
Previous history of postpartum hemorrhage
Trauma (e.g., perineal tears)
Operative delivery (e.g., forceps or vacuum extraction)
Placental abnormalities
3. How would you assess Mrs. Fernandez 's bleeding, and what vital signs would be crucial to monitor in
the evaluation of postpartum hemorrhage?
Assess bleeding visually, measure blood loss, and monitor vital signs (blood pressure, heart rate,
respiratory rate). Signs of shock (tachycardia, hypotension) are crucial indicators.
4. What is uterine atony, and how might it contribute to postpartum hemorrhage?
-Uterine atony is the failure of the uterus to contract after delivery. It contributes to postpartum hemorrhage
by preventing the natural hemostasis that occurs with uterine contractions.
5. What initial interventions would you implement to address uterine atony in Mrs. Fernandez?
● Uterine massage
● Administration of uterotonic medications:
6. How would you assess for genital tract lacerations in Mrs. Fernandez, and what interventions might be
required if lacerations are identified?
-Assess for signs of lacerations (bleeding, swelling). Repair may be necessary, involving sutures.
7. What is the role of oxytocin in preventing and managing postpartum hemorrhage, and how is it
administered?
-Oxytocin stimulates uterine contractions, aiding in the prevention and management of postpartum
hemorrhage. Administered intravenously after delivery of the baby, or as a continuous infusion.
8. Why is it important to assess for retained placental tissue in cases of postpartum hemorrhage, and how
might it be managed?
-Assessing for retained placental tissue in postpartum hemorrhage is crucial to:
Prevent continuous bleeding.
Differentiate underlying causes.
Resolve uterine atony and coagulopathies.
Prevent infection and sepsis.
Facilitate effective uterine contraction.
Optimize postpartum recovery and reduce complications.
Management of Retained Placental Tissue:
-Manual removal or, in some cases, dilation and curettage.
9. What laboratory tests would you order to assess Mrs. Fernandez 's coagulation status, and why is this
information important in managing postpartum hemorrhage?
To assess Mrs. Fernandez's coagulation status in managing postpartum hemorrhage, order:
CBC
Coagulation Panel (PT, INR, aPTT, and fibrinogen levels)
Platelet Function Tests
Importance in managing postpartum hemorrhage
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Identifies coagulopathies.
Guides treatment decisions.
Prevents complications.
Optimizes hemostasis.
Tailors interventions.
10. How would you involve Mrs. Fernandez in the decision-making process and provide emotional support
during the management of postpartum hemorrhage?
-Affirm and console her while addressing worries about her wellbeing and the health of the
infant.Maintaining transparency requires open communication with the healthcare team. Describe the
circumstances, available treatments, and any possible hazards. For Mrs. Fernandez to comprehend and
take part in the care of postpartum hemorrhage, constant communication, empathy, and teamwork are
essential.
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