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    Case Notes 1: Presenting Complaints

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    BINCY
    Mrs. Stephy William, a 35-year-old pregnant woman, presented with decreased fetal movement, giddiness, gum bleeding and swelling, toothache, and a tooth cavity. She was diagnosed with gingivitis, gestational diabetes, anemia, and a possible fetal death at 6 months into her fifth pregnancy. Her medical history included previous ectopic pregnancy, stillbirth, preeclampsia, wisdom tooth extraction, and frequent mouth ulcers. She lives alone with her child as her husband is abroad and she has no family support, is unemployed, and has a history of alcoholism during her third pregnancy. She requires urgent gynecological and dental consultations for further assessment and management.

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    Case Notes 1: Presenting Complaints

    Uploaded by

    BINCY
    219 views2 pages
    Mrs. Stephy William, a 35-year-old pregnant woman, presented with decreased fetal movement, giddiness, gum bleeding and swelling, toothache, and a tooth cavity. She was diagnosed with gingivitis, gestational diabetes, anemia, and a possible fetal death at 6 months into her fifth pregnancy. Her medical history included previous ectopic pregnancy, stillbirth, preeclampsia, wisdom tooth extraction, and frequent mouth ulcers. She lives alone with her child as her husband is abroad and she has no family support, is unemployed, and has a history of alcoholism during her third pregnancy. She requires urgent gynecological and dental consultations for further assessment and management.

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    Mrs. Stephy William, a 35-year-old pregnant woman, presented with decreased fetal movement, giddiness, gum bleeding and swelling, toothache, and a tooth cavity. She was diagnosed with gingivitis, gestational diabetes, anemia, and a possible fetal death at 6 months into her fifth pregnancy. Her medical history included previous ectopic pregnancy, stillbirth, preeclampsia, wisdom tooth extraction, and frequent mouth ulcers. She lives alone with her child as her husband is abroad and she has no family support, is unemployed, and has a history of alcoholism during her third pregnancy. She requires urgent gynecological and dental consultations for further assessment and management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    219 views2 pages

    Case Notes 1: Presenting Complaints

    Uploaded by

    BINCY
    Mrs. Stephy William, a 35-year-old pregnant woman, presented with decreased fetal movement, giddiness, gum bleeding and swelling, toothache, and a tooth cavity. She was diagnosed with gingivitis, gestational diabetes, anemia, and a possible fetal death at 6 months into her fifth pregnancy. Her medical history included previous ectopic pregnancy, stillbirth, preeclampsia, wisdom tooth extraction, and frequent mouth ulcers. She lives alone with her child as her husband is abroad and she has no family support, is unemployed, and has a history of alcoholism during her third pregnancy. She requires urgent gynecological and dental consultations for further assessment and management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CASE NOTES 1

    You are Emily Ryan, Charge nurse in emergency department

    Today’s date: 17/10/19


    Patient’s details
    Name: Mrs. Stephy William
    Age: 35 years
    Presenting complaints
     c/o decreased fetal movement
     giddiness
     gum bleeding, swelling over the gum
     tooth ache – upper molar since 1 week
     tooth cavity – upper molar
    Diagnosis
     Gingivitis
     GDM
     G4P1L1D0A2S1 with decreased fetal movement, 6th month of pregnancy
     ?fetal death
     Anemia(blood report showed Hb – 7)
    History
     Ectopic pregnancy in 2014 (2nd )
     Right tubectomy in 2014 due to tubal rupture
     One still birth on 7th month (3rd pregnancy)
     Teeth braces since 2018 March
     Pre eclampsia noted during 1st pregnancy
     Rt wisdom tooth extraction in 2018
     Frequent mouth ulcer
    Family history
     PCOD, HTN
     Grandfather died of Alzheimer’s
    Social history
     Lives with her child in suburb
     Husband is in abroad
     No support from her family
     Unemployed
     Alcoholic, which was increased during 3rd pregnancy
    WRITING TASK
     Using the information in the case notes ,write a referral letter to Mrs Rose Bell
    ,consultant gynecologist, Jones Street, Ekibin to request an urgent
    consultation for further assessment and management.
     Using the above information, write a letter to hospital Dentist Mr John Peter,
    St George Street, Brisbane for further assessment and management of Mrs
    Stephy William.

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