PD OB| Doc Ivy Bello Topics
History taking Physical examination Diagnostic procedure Pap smear o Dilatation and o Curettage Fractional o curettage
Salpingectomy Oophorectomy Hysterectomy Ovarian Cancer
Age group 4-5 years from menarche o 4-5 years within the average menopause o (47-49 years old) Menstruating beyond 50 years old – abnormal abnormal – maybe cancer Vaginal Bleeding o o o
HISTORY GENERAL DATA
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Name Age Gender Birthday Marital status Address Religion Citizenship/ race
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Gravidity Number of admission - Reason - Date
o
Foul smelling vaginal discharges o
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% reliability Adults -not important Minors – important!! important!!
o
+
Vaginal bleeding + Hypogastric pain Vaginal spotting + Abdominal Vaginal pruritus enlargement Foul smelling vaginal + Dyspareunia discharges + Profuse vaginal Menstrual bleeding abnormalities LMP – Last Last Menstrual Period PMP – Previous Previous menstrual period prior to LMP
Abnormal uterine bleeding bleeding Normal interval between menses: 28 ± 7 days Oligomenorrhea: infrequent bleeding with intervals
from 35 days to 6 months Amenorrhea: no menses for at least 6 months Menorrhagia: prolonged (>7 days) or excessive (>80 ml) Metrorrhagia: uterine bleeding occurring at irregular but frequent intervals, amount being variable Menometrorrhagia: prolonged & irregular uterine bleeding Intermenstrual bleeding: bleeding of variable amounts occurring between regular menstrual periods Menstruation 6 months prior Initially: irregular menstruation due to HPO axis immaturity Menstruation is controlled by o hypothalamus-pituitary-ovary Estrogen: causes endometrial thickening Progesterone: causes uniform sloughing off of the endometrial lining during menstruation Perimenoupausal patients frequently complain of irregular menses Hormonal imbalance – older: older: ovaries will o be atrophic, Even if the hypothalamus and pituitary are o sending positive signals to the ovaries, FSH will increase
+ infection (STI) Cancer
Hypogastric Pain/ gradual abdominal enlargement (masses) If not related to urinary problem – dysuria, dysuria, o
CHIEF COMPLAINT Reasons for consultation + + + +
+ mass + infection Atrophic vaginitis: most common cause in menopausal patient T/c problems in vagina, cervix, uterus, ovaries Sometime ovarian mass causes vaginal bleeding
o o
urinary frequency, urgency Mass within uterus, ovary, fallopian tube Abdominal tenderness
HISTORY OF PRESENT ILLNESS Vaginal Bleeding
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Get records by months 6 months’ prior
1 Sept
15
30
|-----------------|----------------- |2-3 pads/day
Dec
no blood clots ask other S/Sx |-----------------|----------------- | 2-3 pads/day no blood clots ask other S/Sx |-----------------|----------------- | 2-3 pads/day no blood clots ask other S/Sx |-----------------|----------------- | vaginal spotting
Jan
|-----------------|----------------- | 3 baby diapers
Oct Nov
+ blood clots + body weakness + dizziness
Start of abnormal bleeding: December LMP (last NORMAL menstrual period): November PMP: October
Patient may have simple abnormal bleeding, mass, infection
The patient was regularly menstruating occurring 3 -5 days, consuming 3-4 pads/day with no blood clots, with no dysmenorrhea. 1 month PTA, when the patient has vaginal spotting with this and this, self-pregnancy test turned out to be negative. No medications taken and no consultations done. Few hours PTA, the bleeding become profuse. With presence of body weakness and dizziness.
If bleeding + positive pregnancy test = ABORTION Hypogastric Pain
6 months PTA, the patient experience on and off hypogastric pain. Not associated with urinary symptoms like dysuria, urinary frequency and urgency. No foul-smelling
MED IIIA | 2016-2017
PD OB| Doc Ivy Bello discharge noted. She tolerated the condition until 4-month PTA, still with the above condition, the patient noticed abdominal enlargement. She then consulted the physician wherein she was requested for ultrasound, however, she did not comply due to financial constrain. Self-medicated with pain reliver (mefenamic acid), which relieved the pain temporarily. 1 month PTA, the pain was severe and unable to tolerate and still with the above condition. (PQRST of the Pain), hence consultation and admission was done.
ENVIRONMENTAL HISTORY
House type, number of rooms, CR-type Number of family members living together in the house Water source for drinking and washing Garbage disposal Sewage disposal Nearby factories OB HISTORY
GP SCORE: GP (TPAL)
Foul-smelling discharges
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Characterize the discharges Bacterial vaginosis Trichomoniasis - STI Vaginal candidiasis Pruritus secondary to vaginal infection
kasi
kinakamot nila
Single dose of antifungal – Fluconazole Older patient with repeated vaginal pruritus and repeated vaginal candidiasis – rule out Diabetes
Gravity – number of pregnancies regardless of outcome Parity – number of delivery reaching age of viability
(beyond 20 weeks) TPAL (Term, Preterm, Abortion, Living) post term included in TERM o ectopic pregnancy included in ABORTION o Subsequent pregnancies o o o o o
date and route of delivery, hospital or at home, assisted by midwife, hilot, Birth weight Sex of the baby Other complications or unremarkable findings atony
GYNE HISTORY Menstrual history MIDAS: Menarche, Interval, Duration, Amount, Signs
PAST MEDICAL HISTORY Childhood illness – measles, mumps, rubella, poliomyelitis,
varicella, pertussis, rheumatic fever, scarlet fever, others. Medical – HTN, DM, Asthma, blood dyscrasias, congenital anomalies, goiter, cancer, hepatitis, STI, allergies, injuries/accidents, hospitalization (date, place, treatment), medications (name of drug, dosage) Surgical – date, place, indication, type of operation Psychiatric – illness, time frame, diagnosis, hospitalization, treatments
Sexual history
Family pedigree 1st degree relative: Parents, grandparents, siblings, children, o grandchildren Both sides o Age, health status, cause of death o Heredofamilial diseases, DM, HTN, cardiac diseases, asthma, cancer, etc.
PERSONAL & SOCIAL HISTORY Patient and Partner’s background
Name of partner Age, birthday, educational attainment, occupation, alcoholic drinker, smoker, drug user? Source of income
Coitarche Sexual habits Number of partners Important especially if entertaining STD Treat also the sexual partner o
Contraceptive history
FAMILY HISTORY
and Symptoms Menarche: age or grade started o Interval: 28 ± 7 days o Duration: 3-5 days o Amount: brand of napkin used, + blood clots o Characterize subsequent menses Associated signs and symptoms dysmenorrhea, breast tenderness, headache, o mood swings, PMS
ROS
Signs and symptoms related to CC
o o
-dada-
MED IIIA | 2016-2017
