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Explain me thee case
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Here is a full breakdown of this OPD case:
Patient Overview
Name: Shaik Soha Dilshadh
Age/Sex: 18-year-old female
Facility: Near Warangal Head Post Office (Govt. hospital, free category)
Department: Gynaecology, Unit 1
Visit Date: 9 July 2026
Obstetric Status - G2A1, ~8 weeks 3 days pregnant (HIGH RISK)
- LMP: 25/05/2026
- EDD: 04/03/2027
- G2A1 means this is her 2nd pregnancy, with 1 prior abortion
Obstetric history:
- G1: Conceived after marriage, underwent a medical/surgical abortion at ~1 month
- G2 (current): Spontaneous conception, now presenting for routine ANC
Menstrual history: Regular cycles, 9-month history noted, flow 4 pads/day, clots present (+), dysmenorrhea (+)
Why Marked HIGH RISK?
Several factors push this to high-risk status:
- Age 18 - teenage pregnancy
- G2A1 - prior abortion history
- Low weight: 39 kg - likely underweight/malnourished
- Vomiting 2-3 episodes/day - consistent with hyperemesis gravidarum
- Loose stools 3-4 episodes/day - GI disturbance raising concern for dehydration/malnutrition
Presenting Complaints
She came for a routine ANC checkup. Active symptoms include:
| Symptom | Detail |
|---|---|
| Vomiting | 2-3 episodes/day |
| Loose stools | 3-4 episodes/day |
| No abdominal pain | - |
| No abdominal tightening | - |
| No burning micturition | - |
| No fever/cold/cough | - |
| No PV bleeding/leaking | - |
Examination
- BP: 110/60 mmHg (normal, slightly on the lower side)
- Weight: 39 kg (low - concerning for nutritional status)
- UPT: Positive (confirms intrauterine pregnancy)
- Per abdomen: Soft (no tenderness, no guarding)
Past History
- No hypertension, diabetes, thyroid disease, epilepsy, TB, asthma, or IUD
- No prior blood transfusions
- No major surgeries
- No drug allergies
Investigations Ordered
This is a standard first-trimester ANC workup plus extras given the high-risk flag:
| Investigation | Purpose |
|---|---|
| Early Pregnancy Scan (USG) | Confirm viability, gestational age, rule out ectopic |
| CBP (Complete Blood Picture) | Screen for anaemia - very important given low weight |
| RFT (Renal Function Test) | Baseline renal status |
| LFT (Liver Function Test) | Baseline; rule out hepatitis/fatty liver |
| Thyroid Profile | Thyroid disorders are common in pregnancy and can cause vomiting |
| RBS / OGTT | Screen for gestational diabetes |
| BT / CT (Bleeding/Clotting Time) | Coagulation baseline |
| HIV | Already resulted: NON-REACTIVE (stamped 9/7/26) |
| HBsAg | Hepatitis B screen |
| VDRL | Syphilis screen |
| CUE (Complete Urine Examination) | UTI, protein, glucose screen |
Clinical Summary
This is an 18-year-old primigravida (functionally) at 8 weeks 3 days gestation presenting for her first ANC visit. She has a prior medical abortion. She is underweight (39 kg) with nausea/vomiting and loose stools - likely first-trimester morning sickness possibly aggravated by poor nutritional reserve. She has been appropriately labelled HIGH RISK and a full first-trimester workup has been initiated. HIV is already confirmed non-reactive. Follow-up was planned for 10/07/2026 (the next day), likely to review scan results and initial blood work.
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