Case 1 Gyne ID,PE
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SILLIMAN UNIVERSITY MEDICAL SCHOOL SUBMITTED TO: Dr. Bernadas DATE: MARCH 04,2015 SUBMITTED BY: DE LOS SANTOS, ROSHEIL MAE C. SUBJECT: GYNE CASE IDENTIFYING DATA: A case ! "0 #ear $d %&d% CHIEF COMPLAINT: 's()en*a+sa$ s*((&n HISTORY OF PRESENT ILLNESS: -)n( s 'TA, *a(&en( c$a&)ed ( a/e /a &na$ s*((&n s(a&n&n er +nder%ear. N cns+$(a(&n %as dne. 4)n( s 'TA, ( e cnd&(&n ad/anced ( /a &na$ $eed&n cns+)&n 2 san&(ar# na* &ns da#. 'a(&en( 3+s( ($era(ed ( e cnd&(&n. 1)n( 'TA, d+e ( *ers&s(en( de)and ! re$a(&/es, *a(&en( as dec&ded ( see cns+$(a(&n %&( a $ca$ * #s&c&an. Irn *re*ara(&n %as &/en and ad/&sed ser/a(&n. 2%ee s 'TA, *ers&s(ence ! /a &na$ $eed&n *r)*(ed er ( see cns+$(a(&n %&( an OB GYN. On B'E, a s$& ($# en$ar ed +(er+s %&( )&n&)a$ $d# d&sc ar es n ( e e a)&n&n 6n er. T7S %as rdered % &c re/ea$ed a ( &c ened end)e(r&+) ). 81)). T e *a(&en( +nder%en( 9rac(&na$ D and C. H&s(*a( $ # res+$( re/ea$ed a cr%ded ac ( ac end)e(r&a$ $ands. OB-GYN HISTORY : T e *a(&en( c$a&)ed s e ad er )enarc e a( 15 #.. %&( re +$ar )ens(r+a$ c#c$e d+r&n er en(&re re*rd+c(&/e #ears. S e cns+)ed 4 san&(ar# *ads da# )dera(e$# sa ed %&( $d. N d#s)enrr ea$ %as n(ed. Men*a+se a( 55 #.. 'a* s)ear ;2004< %&( +nre)ar a $e res+$(s. G8'8 ;2102< = a$$ NS7D PAST MEDICAL HISTORY : 'a(&en( &s a n%n #*er(ens&/e !r 20 #ears n%. Ma&n(a&ned Ena*r&$ %&( d c)*$&ance. >n%n d&a e(&c !r 10 #ears n%. Ma&n(a&ned G$&ca?&de %&( d c)*$&ance. PAST SURGICAL HISTORY : @+$# 2018 = S ' Rad&ca$ Mas(ec()# !r Le!( reas( cancer. 'resen($#, n Ta) &!en T era*#. FAMILY HISTORY: N da(a &/en. PERSONAL AND SOCIAL HISTORY: N da(a &/en. REVIEW OF SYSTEM PHYSICAL EXAMINATION NO DATA GIVEN General: S!n: HEENT: Brea"#: Re"$!ra#%r&: Car'!%(a")*lar: Ga"#r%!n#e"#!nal: Ur!nar&: Gen!#al": Per!$+eral Va")*lar: General: E a)&ned a%a e, cnsc&+s, c eren(, n( &n res*&ra(r# d&s(ress V!#al "!,n": B : - Cad&ac Ra(e: 4 *) Res*&ra(r# Ra(e: 14 c*) B$d 'ress+re: 150 0 ))H HEENT: S$& ($# *a$e *a$*e ra$ cn3+nc(&/a Brea"#: S+r &ca$$# a sen( $e!( reas(. N *a$*a $e )asses n r& ( reas(. A '%.en: 9$a #, nr)ac(&/e %e$ s+nds, s!(, ; < (enderness n a$$ +adran(s
description
mEDICAL
Transcript of Case 1 Gyne ID,PE
SILLIMAN UNIVERSITY MEDICAL SCHOOL
SUBMITTED TO: Dr. Bernadas DATE: MARCH 04,2015SUBMITTED BY: DE LOS SANTOS, ROSHEIL MAE C. SUBJECT: GYNE
CASE
IDENTIFYING DATA: A case of 70 year old widowCHIEF COMPLAINT: Postmenopausal spottingHISTORY OF PRESENT ILLNESS:8months PTA, patient claimed to have vaginal spotting staining her underwear. No consultation was done.
4months PTA, the condition advanced to vaginal bleeding consuming 2 sanitary napkins/day. Patient just tolerated the condition.
1month PTA, due to persistent demand of relatives, patient has decided to seek consultation with a local physician. Iron preparation was given and advised observation.
2weeks PTA, persistence of vaginal bleeding prompted her to seek consultation with an OB-GYN. On BPE, a slightly enlarged uterus with minimal bloody discharges on the examining finger. TVS was ordered which revealed a thickened endometrium m. 31mm. The patient underwent Fractional D and C. Histopathology result revealed a crowded back-to-back endometrial glands.
OB-GYN HISTORY: The patient claimed she had her menarche at 15 y.o. with regular menstrual cycle during her entire reproductive years. She consumed 4 sanitary pads/day moderately soaked with blood. No dysmenorrheal was noted. Menopause at 55 y.o. Pap smear (2004) with unremarkable results.
G3P3 (2102) all NSVD
PAST MEDICAL HISTORY: Patient is a known hypertensive for 20 years now. Maintained Enapril with good compliance. Known diabetic for 10 years now. Maintained Glicazide with good compliance.
PAST SURGICAL HISTORY:July 2013 S/P Radical Mastectomy for Left breast cancer. Presently, on Tamoxifen Therapy.
FAMILY HISTORY: No data given.PERSONAL AND SOCIAL HISTORY: No data given.
REVIEW OF SYSTEMPHYSICAL EXAMINATION
NO DATA GIVENGeneral:Skin:HEENT:Breast:Respiratory:Cardiovascular:Gastrointestinal:Urinary:Genitals:Peripheral Vascular:Musculoskeletal:Psychiatric:Neurologic:Hematologic:Endocrine:Functional Status:General:Examined awake, conscious, coherent, not in respiratory distressVital signs:BW: 98kgCadiac Rate: 64 bpmRespiratory Rate: 14 cpmBlood Pressure: 150/90 mmHg HEENT:Slightly pale palpebral conjunctivaBreast: Surgically absent left breast. No palpable masses on right breast.Abdomen: Flabby, normoactive bowel sounds, soft, (-) tenderness on all quadrantsSE: Pale pink and atrophic cervix, (+) trickling bloody dischargeBPE: I: ParousC: Closed, atrophic, smoothU: 8 weeks size uterusA: NegativeD: Minimal bloody discharge on examining finger, no foul-smelling discharges
