-WILLIAM M CHANSA
SIXTH YEAR MEDICAL STUDENT
Levy Mwanawasa Medical University
06TH SEPTEMBER,2025
§ WILLIAM C. MUHAMMED
§ MUTAMBO LLOYD
§ LLOYD MUTAMBO
§ SEPISO M. RONNIE
1.
CASE REVIEW
2.
LITERATURE REVIEW
3.
APPROACH & MANAGEMENT
DEMOGRAPHICS
§ Name: Silvia Mwanga
§ Age: 22years old
§ Gravidity: 2
§ Parity:0 @8 weeks GA
§ Marital status: Married
§ Residence:Meanhood
§ Religion:Christian
§ Occupation: Unemployed
§ D.O.A: 03th September,2025
§ D.O.C:03/09/2025
§ Referral: Referred from ZNS clinic for further management
PRESENTING COMPLAINT
§ P/C Per-vaginal Discharge for 2/52 (Weeks)
HX OF THE PRESENTING COMPLAINT
q Pt was in her usual state of health until 2/52 ago when she started noticing some vaginal discharge
q The discharge was described as brown watery which was mainly noticed when she goes to a bathroom staining her
underwear
q She also reported to occasionally see spots of blood mixed with the said discharge and sometimes it looked like mucus and
this discharge was odourless
q Quantity was small, as she could only see it staining her underwear.
q She also reported to have abdomen pain which was experienced from the lower left side, it was non-radiating, and it was
said to cease withing a short period of time(3-6 hours). She however didn’t recall when this happened but it was said to
occur in the course of the same 2 weeks , there were exacerbating or relieving factors.
q She denied any Hx of itchiness, difficulties with passing urine or urgency, she denied any history of weight loss , heat
intolerance or diarrhoea, vomiting or nausea or any obvious breathing difficulties.
q She reported that ,she yesterday (2days ago from the day of clerking) went to ZNS clinic for her first antenatal(Booking) visit, where she was told to do
the scan and it was reported that they found something unusual which prompted the doctor to refer her to LMUTH.
REVIEW OF SYSTEMS
q GUT: As above
q CNS:Unremarkable
q RES:Unremarkable
q CVS: Heart racing when she is carrying heavy things
q GIT:Unremarkable
q MSS:Unremarkable
q ES: Unremarkable
MENTSRUAL HX
q Menerche-unkown
q Duration of cycle: 28 days(Regular)
q Amount: Normal(2 pads/day)
q No painful menses
q Her LMP was unsure..?, GA:….?
PAST REPRODUCTIVE/OBSTETRICS HX
q She has no number of viable pregnancies that have gone beyond the age of 28 weeks.
q This is her second pregnancy and the first pregnancy was terminated here at LMUTH at 20weeks gestation , she was told have developed High BP
which was the reason to why it was terminated.
PMHx. AND SURGICAL Hx.
q She has hypertension which was diagnosed here in the 18th to 20th week of her second pregnancy and it has persisted since then, and she is on
treatment for this but not compliant.
q This is the second time to be admitted in the hospital
q RVD Status Unknown
q NO DM, Epilepsy, SCD, Asthma or TB
q She has no hx of surgery
DHx. & ALLERGIES
q Unknown
q Not allergic to any food or drugs
SEXUAL HX & CONTRACEPTIVE
q She no any Hx of using any form contraceptive
q She is sexually active with her husband only
FHX
§ No hx of similar presentation in her family
§ Hx of still births from her husband’s side
§ NO DM Epilepsy Asthma, TB, HPN, SCD
SOCIAL HX
q She stays in meanhood
q Doest not smoke nor drink alcohol
q She does not abuse drugs
q She stays in a 5 bedroomed house with four occupants in the house
q Her husband is a driver
q She has a good family and financial support .
SUMMARY
Presenting Mrs M.S , 22 Years old gravida 2 and nullipara,RVD NR who was referred from ZNS Clinic and came in with a hx of pervaginal discharge for 2 weeks, one occasional 6hourds abdominal pain , she also gives a hx of hypertention, abortion at 20weeks of her
second pregnancy. She denies any hx of dyspnea similar presentations in the family, nausea, vomiting, weight loss or any foul-smelling
discharge
DIFFERENTIALS
1.
Molar Pregancy
2.
Threatened abortion
O/E
q GC-Stable, but worried, afebrile
q CVS: S1S2 Regular
q CHEST: Clear and equal air entry BL
q P/A: stria gravidarum, linea nigra,SNT, Palpable abdomen, SFH 18CM, FHR not heard
q V/E: Deferred
DX: Complete hydatidiform mole.
§ THE END!!
§ TO BE CONTINUED…