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BROKENSHIRE INTEGRATED HEALTH MINISTRIES INCORPORATED

DEPARTMENT OF OBSTETRICS
HISTORY TAKING AND PHYSICAL EXAMINATION

GENERAL INFORMATION
Name: L.A.
Age: 49 y/o
Address: Matina, Davao City
Date/Time of Admission: 12/14/15; 3:00 pm
Date/Time of Assessment: 12/14/15; 5:00 pm

Gender: Female
Civil Status: Widowed
Occupation: Govt. employee
Blood Type: A+
Reliability: 95%

CHIEF COMPLAINT:
Vaginal Bleeding
HISTORY OF PRESENT ILLNESS:
3 months prior to admission, patient who previously had regular menstrual cycles had
amenorrhea. This was not associated with pain, weight loss, or any other constitutional
symptoms.
2 months prior to admission, patient still had no menstruation but had one day when
she had vaginal spotting. It was bright red and minimal in amount, soaking only 1 panty liner.
3 weeks prior to admission, patient had menorrhagia. Her menstruation was similar in
character to her usual menses, there were minimal clumps noted and she was able to soak
around 3-4 pads per day. However, her menstruation persisted for two weeks. On the second
week of her menstruation, patient experienced dizziness and easy fatigability.
1 week prior to admission, persistence of symptoms prompted her to consult with her
gynecologist. Ultrasound findings revealed thickened endometrium (1.8 cm thickness). She
was prescribed with Tranexamic acid 500 mg TID and Mefenamic acid 500 mg TID x 5 days,
with good compliance. She was also advised to undergo D&C, thus her current admission at
this institution.
OBSTETRICAL HISTORY:
G7P6 (5-1-1-5)
Gravidity

Date

Age of
Gestation

Sex

1

1987

Premature, 7

M

Mode
of
Deliver
y
NSVD

Outcome

No maternal illnesses during

date unrecalled but with normal findings. 28-35 days cycle. with last delivery) Pap Smear: Once. 2012 with Hemoglobin ranging from 85-96 mg/dL.2 1988 3 1990 months Premature. no follow up. PAST MEDICAL HISTORY Past Illnesses  (+) Chickenpox  (-) Measles. Mammogram: Once. she had irregular menses. 2 sexual partners Menstrual Cycle: Prior to first pregnancy. Menses became regular thereafter. 6 months Full Term 4 1993 5 6 7 M NSVD M NSVD Full Term M NSVD 1994 1998 Aborted Full Term M -NSVD 2001 Full Term F NSVD with BTL the pregnancy Neonate died within a few days of delivery No maternal illnesses during the pregnancy No maternal illnesses during the pregnancy D&C performed at BIHMI No maternal illnesses during the pregnancy No maternal illnesses during the pregnancy PAST MENSTRUAL HISTORY Menarche: 12 years old Coitarche: 19 years old. Hypertension. specific kind cannot be recalled Bilateral Tubal Ligation (2001.  (-) Diabetes Mellitus. Mumps  (-) Allergies. Iron supplementation given. Hypercholesterolemia . date unrecalled but with normal findings. regular Duration: 7 days Amount: 3-4 napkins per day Contraceptives: OCP x 7 years (in between pregnancies). Asthma  (+) Anemia.

v FAMILY MEDICAL HISTORY  Maternal side (+) HPN.  Smoking and Alcohol use: None  Exercise: Patient does not regularly exercise. no complications p Surgeries/Blood Transfusions: 2001. antibiotics given. EDUCATIONAL PROFILE: College graduate FAMILY SIZE: 6 SOCIOECONOMIC PROFILE: Patient is employed and is able to support the needs of herself and her family.  Diet: Patient eats 3 meals a day. and they were with her in the hospital to give their support.S.Past Admissions Year 2011 Description/ Diagnosis/Management UTI. PERSONAL AND SOCIAL HISTORY  Occupation: Patient works at the HR department of the Civil Service Commission. specific drug and dose unrecalled. number of doses received unrecalled. She has no preference for specific types of food. compliant to treatment.  Residence: She lives in Matina Aplaya.Bilateral Tubal Ligation Vaccination History: Childhood immunizations complete Adult immunizations include TT during her pregnancies.  Habits: Patient sleeps an average of 8 hrs and reports that she feels well-rested when she wakes up in the morning. Patient is already widowed. Goiter: Father REVIEW OF SYSTEM (R. Asthma: Mother (+) Ovarian CA: Aunt (+) Colon CA: Aunt  Paternal side (+) Gout.  Relationship with family: Patient is in good terms with her family. She lost her husband in 2001 but she has coped well. Davao City with her whole family.O.) .

and indigestion. weight loss. symmetrical and evenly distributed. diplopia or nystagmus. vomiting. or gallbladder problems. Bowel movement daily. No palpitations or orthopnea Genito-urinary: No urinary frequency. has an ectomorphic body built. Nose: No changes in smell. ptosis or lid-lag noted. Eye: No redness. No nodules noted upon palpation. coherent. epistaxis or inflamed sinuses. pain or limitation in movement. Hair. Eyes. numbness or limitation of movement. Skin: No dryness. Eyelashes are thick. liver problems. rashes or lesions noted Neurologic: No seizures. Nails on the fingers and toes are slightly pale in color with no clubbing noted.A. Memory is good. participative. chest pain or hemoptysis. Palpebral fissures are symmetrical. Vital Signs. No jaundice. oily. Throat (HEENT). photophobia. Ear: Patient has no hearing loss. No signs of respiratory distress. with no signs of infestation. Head. Pulmonary: No dyspnea. well-groomed. Head. No easy bruising.14 kg/m2 (Normal) Height: 5'2” Skin. stiffness. No eyelid edema. loss of appetite. tinnitus. Ears. Endocrine: She has no temperature intolerance or excessive weight gain or loss. Eyes. and Nails. incontinence. Mouth: No pallor or lesions noted. Skin is warm to touch with good skin turgor. fever. Capillary refill time of 2 seconds. Neck: No masses. PHYSICAL EXAMINATION General Survey.3 degrees celsius (axillary) BP : 110/80 mmHg RR: 20 cpm Weight: 53 kg PR: 84 bpm BMI: 24. dysuria. or recent flank pain. Patient L. nausea. infections. Normocephalic with no deformities noted. Hematopoietic: There is slight pallor. and was in a good mood. conscious. bleeding tendencies Musculoskeletal: No joint pain. Cardiovascular: There is easy fatigability. Psychiatric: No history of depression or treatment for psychiatric disorders. Nose.General: Patient has no weakness. Temperature: 36. evenly distributed . motor or sensory loss. She was sitting on her bed. Hair is black in color. Skin is light brown in color and body hair is evenly distributed throughout the body. and ear pain. Gastrointestinal: No dysphagia. It is smooth. Eyebrows are black.

and growing outwards. . No nasal discharge noted. and axillary area. Ear canals are patent with no discharges. Neck. fissures. tonsillitis. Ears. No neck deformities or stiffness noted. Abdomen. Liver span in right midclavicular line within normal range. Trachea is in the midline. No ascites. and mitral area. Pupils are isocoric with a diameter of 3 mm and equally reactive to light and accommodation. hoarseness of voice. tenderness or masses on palpation. No radiating pain. Normoactive bowel sounds on all quadrants. No masses or lesions on external ear. Visual fields are full by confrontation. No palpable mass. Nose and Sinuses. No tongue enlargement or deviation. Point of maximal impulse is felt at 5th intercostal space midclavicular line. No lifts and heaves noted. Spleen and kidneys are non-palpable with no signs of enlargement. Frontal. sores. There is good hearing acuity. nodules noted. Conjunctiva is pink with no lesions. No adventitious sounds noted. posterior auricular. Nasal septum is in midline. pulmonic. Eyeballs are normal in size with no signs of exophthalmos. Auricles are elastic and the top of the pinnae are in line with the outer canthus of the eye. Oral mucosa is pink. Resonant sound percussed on both lung fields. dental carries. No deformities. Breasts. There was no tenderness noted upon palpation. supraclavicular. pearly gray and intact with no signs of inflammation. Apex beat is best heard at the point of maximal impulse. Irises are brown. No visible masses and gland enlargement. Extraocular movements are intact. tricuspid. mandibular and ethmoid sinuses are non-tender. Normal tactile fremitus felt on both lung fields. No ulcerations. Breasts are symmetrical with no nipple discharges noted. Murmurs not noted. Patient has symmetrical chest expansion. No visible and palpable lymph nodes in the cervical. Thyroid gland not palpable. Vesicular breath sounds and normal vocal fremitus heard throughout the lung fields. tongue and uvula are in midline. Scar from previous Bilateral Tubal Ligation noted at the infraumbilical area. Lymph Nodes. bleeding gums. Sclera is white and anicteric. There is no corneal opacity. Abdomen is slightly protuberant. Thorax and Lungs. mass or nodules noted. dimpling or retractions. Mouth. Cardiovascular. No chest deformities or intercostal muscle retractions noted. Tympanic membrane is visible. Bruit not palpated. Stretch marks noted on lower abdomen. Regular cardiac rhythm heard at the apical. maxillary.

place. Intact visual fields. CN III. Uvula is in midline. Motor. and close mouth. swelling and tenderness on the joints. Pupils constrict upon direct exposure to light. ADMITTING IMPRESSION G7P6 (5-1-1-5).Able to speak well. She has good memory with orientation to person. CN V.Pelvic Exam  External Genitals: grossly normal genitalia  Speculum exam: cervix is pinkish. Intact extraocular muscles. edema or ulceration noted. She is able to do finger to nose test and rapid-alternating movements without difficulty. Peripheral Vascular. Intact consensual reflex. Good range of motion noted with hands. CN VII. Oculomotor – Pupils are equally round. Neurologic. close eyes. Patient is alert. with no lesions or masses noted. knees. raise eyebrows. Spinal Accessory . reactive to light and accommodation. shoulders. Vagus . Reflexes. Trigeminal – Able to open and close mouth. CN I. smooth. Optic – Able to read prints with a font size of 12 without glasses on. CN VI.Able to shrug both shoulders and turn head from right to left against resistance. Pulses are full and brisk. Good muscle tone. No varicosities or edema noted. CN IV. Abducens – Able to deviate eyes laterally. and ankles. Facial – Able to smile. Muscle strength of 5/5. Able to distinguish soft from sharp touch. Extremities: No deformities. Cranial Nerves. Uterus is non-enlarged with smooth contours.  Bimanual exam: No cervical motion tenderness. normoactive reflexes. Hypoglossal – Able to move tongue from right to left. elbows. Has strong muscles for mastication. wrists. CN VIII. frown. Anemia DIFFERENTIAL DIAGNOSIS Diagnosis Rule In Endometrial Hyperplasia Vaginal bleeding Rule Out Cannot be ruled out without . Vestibulocochlear – Able to hear tick of the fingers. No joint deformities. Glossopharyngeal – Able to swallow without difficulty. CN IX. and time. With good articulation. No adnexal masses palpated. Trochlear – Able to rotate eyes internally and gaze downward. CN X. up and down. Able to open eyes without difficulty. Musculoskeletal. Olfactory – Able to smell the scent of coffee. CN XI. CN II. CN XII. responsive and coherent. Endometrial Hyperplasia.

The most common sign of hyperplasia is abnormal uterine bleeding. progesterone is not made to counteract estrogen. However. RISK FACTORS  Older than 35 years (our patient is 49 years old)  Caucasian  Nulligravid . If ovulation does not occur. and the endometrial lining is not shed. you can have menstrual cycles that are shorter than 21 days or any bleeding after menopause. Endometrial hyperplasia most often is caused by unopposed exposure to estrogen. This is significant because of the risk of progression to endometrial adenocarcinoma. which is what happened to our patient. Endometrial hyperplasia usually occurs after menopause. Alternatively. It can be classified based on the degree of architectural disruption and cytologic atypia. The endometrium becomes hyperplastic and in some women may progress to dysplasia and cancer.Endometrial Cancer Endometrial Polyp Endocervical Polyp Leiomyoma Adenomyosis History of OCP use biopsy Family history of ovarian and colon cancer Ultrasound finding of thickened endometrium Vaginal bleeding Cannot be ruled out without History of OCP use biopsy Family history of ovarian and colon cancer Ultrasound finding of thickened endometrium Vaginal bleeding No protruding mass on the cervix noted during speculum exam No polypoid growth detected during previous ultrasound Vaginal bleeding No polypoid growth noted on speculum exam Vaginal bleeding No irregular masses palpated on bimanual exam Vaginal bleeding No uterine enlargement CASE DISCUSSION Endometrial hyperplasia is the proliferation of endometrial glands leading to a greater than normal gland-to-stroma ratio. when ovulation may not occur regularly. it also can occur during perimenopause. It can manifest as menses that are heavier or lasts longer than usual.

which can detect thickening of the endometrium. Thyroid or Gall bladder disease Obesity Cigarette smoking Family history of ovarian. or uterine cancer (Present in our patient’s family history) DIAGNOSIS This can be done via transvaginal sonography. This can be carried out via endometrial biosy.      Late menopause Early menarche Personal history of DM. dilatation and curettage or hysteroscopy. However. TREATMENT OPTION . colon. performing a biopsy is the only way. PCOS. to make sure it is not cancer.

Davao Medical School Foundation. Bonguyan. 2015 . Vivien Q. Tessa Mae J. Davao City OB-GYNE HISTORY TAKING AND PHYSICAL ASSESSMENT In Partial Fulfillment Of the Course Requirements In Obstetrics and Gynecology Submitted to: Dr. Bajada. Submitted by: Ang. Medical School Drive. Medicine 3 December 19. Inc. M.D.