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Tutorial 1 step 1

You were on duty at the post partum ward when you met Mrs. Puri,

a 38-year-old lady, who had given birth to her first child attended by

a traditional birth attendant 4 days ago.

Mrs. Puri was too afraid to void that it became difficult.

She had some chill beginning a day before, her temperature had

reached 38.7C.

It would not go even after she took some antipyretics.

Some bloody discharge was still draining out through her vagina and

it smelt foul.

Her breast were sore and her nipple were both cracked.

She felt that whenever she breastfeed her baby, she gets awful

tummy cramps.

She thought the milk did not seem to have come down yet.

During further questioning she said that her water broke one day

before she gave birth.

The baby was delivered safely and cried out loud.

The placenta followed spontaneously a few minutes later.

Conjunctiva : anemic

Heart and lungs : within normal limits

Breast : Engorged, lymphedema (+) with

cracked nipples.

No signs of nipple inversion or erythema.

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A few drops of yellowish liquid were obtained

during expressing the milk out.

Abdomen : Bladder was full.

About 1500 cc of urine had to be drained out

before the following examination were done.

Uterine fundus at the level of umbilicus, soft, tenderness (+).

Uterine contraction was poor.

Inspection : vulva normal

Speculum examinations :

Vulva and vagina were within normal limit.

Fluxus (+) flowing slowly out of the cervix and

smelt foul.

Vaginal toucher : Portio was soft, cervical dilatation 2 finger, no

tissue palpable in the uterine cavity. Uterus was

equal to 20 weeks pregnancy. Uterine tenderness

(+). Cervical motin tenderness (+).

Adnexas were normal.

Ultrasound examinations result showed the uterus is enlarged, there

was some complex mass in the uterine cavity, suggestive of

placental remnants.

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Extremities were normal.

1. Identify the patients problem!

2. Generate a list of hypotheses for each problems!

3. What further information and investigations may be

helpful from Mrs. Puri?

.

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Tutorial 1 step 2

Laboratory findings :

Haemoglobine level : 7.5 gram %

Leucocyte : 27.000 / mm

PCV : 22 %

Platelet count : 180.000 / mm

Midstream urine specimen.

Macroscopik : yellowish and a bit cloudy.

Erythrocytes : 0-1 / HPF.

Specific grafity was 1.010.

Protein : (-)

Leucocytes casts : (-)

Urine culture : Negative

Blood culture : Group B Streptococcus andPeptostreptococcus.

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5. What are her problems now?

6. Can you exclude some hypothesis of her problems?

7. What would be your plan or advice for her problems?

8. Is there any investigation needed so far?

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Epilogue

Mrs. Puri was given broad-spectra antibiotics prior and after

curettage. She was hospitalized for about 5 days to gain her

normally functioning bladder by training with physiotherapist. She

was also introduced to some nurses in the Group of Support for

Lactating Mother which may help her with lactation problems if ever

she encounters it.