Cae summary resident duty

1. DAY 17.08.2023
Dr TUYISENGE ELIUS
Dr MUTABAZI VIATEUR
Dr HAFASHIMANA EMMANUEL
INTERN: DELPHINE ISHIMWE
SUPER :Dr RUZIGANA GEORGE

2. 35 y.o G1P0 @ 37w3d TWIN PREGNANCY IN LATEN PHASE OF LABOR ID 408367
CC: lumbar pelvic pain
HPI: she has been followed here for ANC and and was scheduled
for c section next week then today started to have lumbar pelvic
pain and consulted here for better management
ROS: no fever ,no gush of fluid ,FM++
Antecedents:
Obs. History:
 G1
 LMP 28/11/2023
 8ANC here at CHUK
 DI-DI on early U/S
 Iron supplementation
 BG&RH: O+
 TORCH SCREENING NEG
 NO SURGICAL HX
O/E: stable
BP:118/79, HR:129, RR:18, T:38.2, SPO2: 96% on RA
CNS: alert GCS:15/15
RS: No Respiratory distress , bilateral chest expansion with
good air entry
CVS: warm extremities, regular tachycardia, dry buccal
mucosa. S1&S2 are audible
Abdomen : gravid uterus SFH 38 cm ,3 contraction in
10 min lasting for 15 se,FHR 1:132,FHR 145
GUS: dilation 3 cm ,soft ,effaced @80%,station -3
MSK: No edema, no signs of DVT
U/S : twin pregnancy, twin A ,breech efw 3.2
Twin B cephalic efw 2.4 BPP 8/6
anterofundic placenta
Labs:
Hb:13.4
Plt:256
BG:O+
HIV: NEG
Hep B:neg
Hep C:neg
Glucemie:4
FP IUCD
ASS : 35 y.o G1P0 @37w3d twin pregnancy in latent phase of
labor
Plan:
- Admit
- Do lab
- Delivery by c section
- Informed consent
C section twin A 4kg
APGAR 9,10,10
Twin B w 2.8kg
APGAR 7,9,10

3. 57 Y,O G6P5015 ,With Complex Abdominal Masse Admitted For Hydration And Investigation ID 696057
CC : abdominal pain and abdominal distension
HPI symptoms started 1 year ago with abdominal pain and progressive
abdominal distension and referred as OPD admitted for stablization
ROS : weight loss 30kg for 1 year, night sweat ,nausea++,sometime
vomiting
Antecedents
G6P5015
5svds, 1st one @18years
No multiple sexual partners
No surgical hx
Hiv negative
No HTN,NO DM
O/E: cachectic
BP:134/ ,HR:134 ,RR:20,T:36.3,SPO2: 99%
CNS: Fully awake,
GCS:15/15,
RS: Not in Respiratory distress , lungs are clear
CVS: Warm extremities, regular tachycardia, S1&S2 are
audible,
ABD: distended abdomen, with collateral, abdominal masses
with irregular margin
GUS: no PV bleeding, hard mass in posterior fornix
MSK: right leg swelling ,
U/S : empty uterus with Para uterine complexes masses with
septations ,with thick septation
Labs:
Hb 13,4
Plt: 287
Cr:56
Urea:2.2
Glycemia:
Na+ 134
K+:4.3
Cl 102
HBsAg: neg,
HCV:neg
ALAT 34. ASAT 20
CEA :1359.7
C-125:2228.90
ABDOMEN,CHEST
CT SACN
COLLER DOPLLER
U/S
ASS:
57 Y,O G6P5015 ,with complex abdominal masse admitted for hydration
and investigation
DX 1.Ovarian Cancer
2. Dvt
3. R.O Electrolyte Imbalance
Plan:
• Admit
• Pain Killer
• Iv Fluid
• Levonox s/c 40mg bid
• Investigation
Evolution:
BP 123/78 HR 96
ABDOMEN,CHEST
CT SACN
COLLER DOPLLER
U/S

5. 29 YO G1P0 @ 41W0D by date admitted for IOL ID: 694227
CC: RDV for IOL
HPI: She has been followed up in our settings for routine ANC
and scheduled for IOL
ROS: No abdominal pain, no gush of fluids, FM+, no vaginal
bleeding.
PMH/ OBS:
• G1P0 LMP : 03/11/022
• TORCH screening: Negative
• 5 uneventful ANC
• She received iron supplements
• BG&Rh: O+
• asthma since 2 years ago
• Last crisis in fist date of this month
• No surgical hx
• No known allergies
O/E: Stable
BP:137/69, HR:99, RR:19, T:36.3, SpO2: 98%
CNS: Alert, GCS 15/15,
RS: Not in respiratory distress, clear lungs.
CVS: Well colored conjunctiva, S1&S2 audible
ABD: Gravidic uterus, no uterine contractions,
SFH 36cm
GUS: clean vulva, No, cervix is closed ,in mid
position, firm,not effaced , descent 5/5, BS
1/13
MSK: no oedema ,no deformirty
U/S : SIUP, cephalic presentation, EGA 39w,
EFW 3.5kg, FHR 134bpm, MVP 8cm,
anterofundic placenta, BPP=8/8
Labs:
Hb: 13.2
Plt: 268
HIV: neg
Hep B: pend
Hep C:pend
BG O+
Glycemia 3.2:
FP: Not yet decided
ASS:
29 YO G1P0 @41W0D by date admitted with late term
pregnancy for IOL
Plan:
- Admit the patient
- NST/20min
- IOL with PO Cytotec 50mcg 4 hourly (max
6 doses)
Evolution:
5th dose of cytotec
No UC yet,CTG1

6. 30 YO G4P2012 @39W0D by early ultrasound on background of 2 times uterine scar scheduled for c/s ID:432873
CC: come for RDV of C section
HPI: The patient has been followed up in our settings for routine
ANC and scheduled for elective cesarian section
ROS: No abdominal pain, no gush of fluids, FM+, no vaginal
bleeding.
PMH/ OBS:
• G4P2012, LMP : unknown
• 6 uneventful ANC
• She received iron supplements
• TORCH screening: Negative
• G1: c/s in 2017 for failed IOL; M with 3.5kg
• G2: aborted at 3 months
• G3:c/s for TOLAC denial in 2021 ; F with 3.1kg
• BG&Rh: B+
• No known chronic diseases
• No known allergies
O/E: Stable
BP:103/69, HR:99, RR:19, T:36.7, SpO2: 98%
CNS: Alert, GCS 15/15,
RS: Not in respiratory distress, clear lungs.
CVS: Well colored conjunctiva, S1&S2 audible
ABD: Gravidic uterus, no uterine contractions,
SFH 37cm, phennestiel sacr
GUS: clean vulva, No vaginal bleeding, cervix
closed
MSK: no oedema
U/S : SIUP, cephalic presentation, EGA 39w,
EFW 3.5kg, FHR 147bpm, MVP=3.1cm,
anterofundic placenta, BPP=8/8
Labs:
Hb: 10.6
Plt: 184
HIV: neg
Hep B:
Hep C:
Glycemia:3.2
BG B+
FP: implanon
ASS: 30 YO G4P2012 @39W0D by early ultrasound on
background of 2 times uterine scar scheduled for c/s
Plan:
- Admit the patient
- Anesthesia review
- c/s tomorrow
Evolution:
READY FOR C
SECTION