Give me a proper case sheet for Abortion case as in above format

+2 more

Reading File

Finding Sources

Reading File

Running Command

Writing File

Running Command

Abortion Case Sheet

Word Document · DOCX

Here is the complete Abortion Case Presentation structured exactly like your original obstetrics case sheet:

OBSTETRICS CASE PRESENTATION — ABORTION

Patient Bio-data


Name: Mrs. Sunita Devi	Husband's Name: Mr. Ramesh Kumar
Age: 26 yrs / F	Age: 30 yrs
Blood Group: O+ve	Blood Group: B+ve
LMP: 10/02/25	EDD: 17/11/25
POG: 10 wks + 2 days	Obs. Score: G2P1L1A0

Informant: Self | Reliability: Good

C/O (Chief Complaints)

G2P1L1A0 with 10 weeks of amenorrhoea is admitted to hospital with:

Bleeding PV since 2 days — mild to moderate, bright red, with clots
Pain in lower abdomen (crampy) since 1 day
No passage of fleshy mass PV
No fever, no urinary complaints

History of Present Pregnancy

① T1: Spontaneous conception. UPT positive at 6 weeks. Dating scan — single intrauterine sac, FHR +ve. ICT — Negative. ANC profile normal. Folic acid tablets taken. No h/o bleeding PV, fever, rashes, radiation exposure or drug intake.

② T2 (8 weeks): Spotting PV for 2–3 days — managed conservatively (rest + progesterone). ANC profile normal. Iron & folic acid tablets continued. No h/o pedal edema, headache, leaking PV, palpitations.

Now at 10 weeks: Fresh bleeding PV and pain abdomen as above.

Past Obstetric History

Married life: 4 years | Non-consanguineous marriage
1st Baby: Boy, 2.9 kg, 2 years old — Full-term NVD, no complications
2nd Pregnancy: Present pregnancy

Past History

No h/o DM, HTN, TB, Asthma, Epilepsy, Thyroid disorders. No previous blood transfusion.

Family History

No hereditary illnesses. No congenital malformations. No twinning.

GPE & Vitals

Conscious, cooperative, well-oriented. Moderately built & nourished.
Temp: Afebrile | PR: 88/min | RR: 18/min | BP: 110/70 mmHg
Pallor: Mild | Icterus, Clubbing, Cyanosis, Lymphadenopathy — Absent

Systemic Examination

CVS: S1, S2 heard; no murmurs
RS: Normal vesicular breath sounds
CNS: No focal neurological deficit

P/A Examination

Abdomen flat, no distension. Umbilicus central and inverted.
Uterus not palpable abdominally (10 weeks — still a pelvic organ)
No guarding/rigidity, no hepatosplenomegaly

P/S Examination

Cervix: External os slightly dilated (1–2 cm), bright red blood and clots from os
No erosion, no discharge. Vaginal walls normal.

P/V Examination

Cervix soft, internal os slightly open
Uterus anteverted, enlarged ~10 weeks, slightly tender
No adnexal mass. Fornices free and non-tender.

Provisional Diagnosis

A 26-year-old G2P1L1A0 at 10 weeks + 2 days POG with Rh+ve single intrauterine pregnancy presenting with bleeding PV and pain abdomen — Incomplete Abortion (rule out Threatened Abortion).

Investigations (Ix)

CBC (Hb, PCV, TLC, Platelets), Blood grouping & Rh typing
Urine R/M, Serum β-hCG (quantitative), Serum progesterone
USG (TVS/TAS) — assess FHR viability, RPOC, rule out ectopic
Coagulation profile if heavy bleeding
DCT & Inj. Anti-D if Rh-negative

The case is modeled on Incomplete Abortion (G2P1L1A0, 10 weeks, open os with active bleeding) — the most commonly examined abortion type. If you need it modified for Threatened, Missed, or Complete Abortion, just let me know.

Give HOPI and weight and height

Reading File

Your credits are exhausted. Your daily credits reset tomorrow, or you can purchase a top-up for more.

How to top up

Your credits are exhausted. Your daily credits reset tomorrow, or you can purchase a top-up for more.

This is a shared conversation. Sign in to Orris to start your own chat.