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H. Mole

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Submitted By aboude1990
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عبد الرحمن عمر الارمشي
الطب البشري -المرحلة السادسة
الهوية الشخصية :
الاسم: فاتنة ملحم العمر : 30 سنة المهنة : ربة منزل
اسم الزوج: فاروق قاسم العمر :40 سنة المهنة : سائق
السكن: جبعدين
AB+ زمرة الدم:
لايوجد قرابة بين الزوجين
تاريخ الزواج منذ سنتين
الشكوى الرئيسية :نزف تناسلي منذ 9 ايام
القصة المرضية :
اتت السيدة فاتنة ( في الاسبوع التاسع من الحمل )الى المشفى بشكاية نزف تناسلي منذ 9 ايام
متقطع مختلف الكمية بدا بلون احمر ثم تحول الى نقط سوداء ترافقت مع غثيان واقياءات شديدة وحرارة .
المريضة لا تعاني من سوابق نزف تناسلي
وتبلغ المدة حوالي 10 اسابيع بين النزف التناسلي وموعد اخر دورة
الحرارة غير مقيسه اما الاقياءات كانت شديدة تصل الى 8 مرات يوميا حيث انها ذات قوام اصفر وليس لها علاقة بالطعام والمريضة كانت تشعر بارتياح مؤقت بعد الاقياء ليعود الغثيان والاقياءات بعد فترة قصيرة.
السوابق الحملية :
عدد الاولاد :1
ولادة طبيعية في مشفى خاص
حصل هذا الحمل بعد شهر بعد الزواج
استمر لمدة 9 اشهر (تمام الحمل )
وتم ارضاعه لمدة 8 اشهر
وزن هذا الجنين 2700 غرام
لا يوجد سوابق اسقاط

القصة الطمثية :
اخر دورة منذ 2/07/2012
اول دورة بعمر ال 12 سنة
الدورة منتظمة كل 28 يوم
مدة الطمث 4 ايام
لا يوجد ألم و لا اي مرافقات مرضية
تستطيع ممارسة حياتها بشكل طبيعي
القصة النسائية :
لا يوجد عسرة طمث او عسرة جماع
لا تاخد موانع حمل
لا يوجد تقارب او تباعد طموث
لا يوجد مساعدات حمل
لا توجد شعرانية

لا يوجد قصة ضائعات مهبلية لا يوجد قصة مفرزات مهبلية

لا يوجد قصة حكة

التدخين : غير مدخنة
السوابق المرضية : : ربو مشخص منذ 7 سنوات
السوابق الجراحية :لا يوجد
السوابق التحسسية : تحسس من مركبات السلفا
السوابق الدوائية:لا يوجد
السوابق العائلية : لا يوجد
استعراض اجهزة الجسم :
1-الرأس : لا يوجد صداع
لا يوجد تغيم في الرؤية
لا يوجد دوار او الم اذني او افرازات من الاذن
لا يوجد افرازات او انسداد في الانف
لا توجد تقرحات فموية

2- الجلد والاظافر والشعر : لا يوجد تكدمات او تصبغ في الجلد
لا يوجد توزع اشعار غير طبيعي
لا يوجد تغير في لون او شكل الاظفار
3- الجهاز التنفسي : لا يوجد زلة تنفسية او سعال او قشع او الم صدري
4- الجهاز القلبي الوعائي : لا يوجد الم صدري او زلة تنفسية او خفقان او وذمة
5- الجهاز الهضمي : لا يوجد الم بطني او تغير في لون او شكل البراز
لا يوجد تغير في عادات التغوط
ولكن هناك غثيان واقياءات شديدة خلال فترة هذا الحمل
6- الجهاز البولي والتناسلي : لا يوجد بوال او عسر تبول او بوال ليلي او بيلة دموية اوقلة بول
ولكن هناك نزف تناسلي خلال فترة هذا الحمل
لا توجد افرازات مهبلية
7- غدد الصم : لا يوجد بوال او سهاف
لا يوجد تغير في التعرق او تغير في الوزن
8- الجهاز الهيكلي : لا يوجد الم مفصلي او يبوسة صباحية
لا يوجد كسور او الالام عضلية
9- الجهاز العصبي : لا يوجد دوار اوصداع او خدر او شلل
الفحص السريري :
المريضة متوسطة العمر ومتوسطة الوزن تبدو واعية متجاوبة ومتعاونة
العلامات الحيوية : النبض : 90
الضغط :120/80
معدل التنفس : 18
الحرارة : 37.5
فحص الجلد : يبدو طبيعي في اللون والحرارة والشكل

فحص الراس : فروة الراس طبيعية
حدقتان العين طبيعيتان و متجاوب مع الضوء
الملتحمة والصلبة طبيعيتان
مخاطية الانف والفم طبيعية
اللسان واللثة طبيعيتان
البلعوم طبيعي بدون احمرار او احتقان او نتح
الرقبة : تتحرك بشكل طبيعي بدون مقاومة
لا يوجد ضخامات لمفية
الغدة الدرقية طبيعية والرغامى على الخط المتوسط
الاطراف : لا يوجد زرقة او تبقرط اصابع او وذمة
لا يوجد توسعات وريدية
فحص الجهاز التنفسي :
التامل : الصدر متناظر ولا يوجد تحدد في حركة جدار الصدر
لا يوجد ندبات او كتل او تشوه في جدار الصدر
الجس : الرغامى على الخط المتوسط
و توسع الصدر طبيعي حوالي 5 سم
الاهتزازات طبيعية
القرع: وضاحة
الاصغاء: حويصلي طبيعي
لا يوجد وزيز او صرير
الجهاز القلبي الوعائي :
التأمل : لا يوجد ندبات
وصدمة القمة غير مرئية
الجس : صدمة القمة مجسوسة في الورب الخامس على خط منتصف الترقوة
لا يوجد هرير
الاصغاء : صوت القلب الاول طبيعي
صوت القلب الثاني طبيعي وينقسم خلال الشهيق
لا يوجد اصوات اضافية او نفخات
الجهاز الهضمي :
التأمل :متناظر متنفس
لا يوجد فتوق او ندبات او كتل او اوردة محتقنه
يوجد بعض الفزر الحملية و بعض التطبل
الجس :سطحي : حرارة البطن طبيعية ولا يوجد ايلام اوصمل
عميق : الرحم تقريبا عند مستوى السرة ( اكبر من عمره المتوقع )
لا يوجد كتل او ايلام
القرع :اصمية عند مستوى الكبد الطبيعي
طبلية في اجزاء البطن الاخرى
التشخيص التفريقي للنزف التناسلي في اشهر الحمل الاولى :
1 – رحى عدارية
2- اسقاط
3- حمل هاجر

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