MEDICAL CARD OF GYNECOLOGICAL PATIENT

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I.HORBACHEVSKY TERNOPIL STATE MEDICAL ACADEMY

OBSTETRICS AND GYNECOLOGY CHAIR №1

Head of the Obstetrics
and Gynecology Chair№2
Teacher of the group

MEDICAL CARD OF GYNECOLOGICAL PATIENT

Oksana Petrosky

(Name and Surname of the patient)

Mark for history writing

Mark for defence of history

Signature of the teacher

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Date : 3rd December, 2020 , hour 16:29pm . Planned/urgent hospitalization
Diagnosis : SECONDARY AMENORRHEA with hyperprolactinemia.
Complaints : Absence of period for 9 months, headache.

History of the disease:

Patient has had absent for 9 months. Started her periods at 13 years had always regular 28days cycle until 18 months ago.
It became first with irregular periods which usually occurs every 2-3 months until it stopped.
She also had headaches but didn’t think it was related to the delayed/absent periods.

Ultrasound investigation from

Life history: Age of menarche : 13 cycle interval : 28days duration and amount of flow Last
menstrual period :18 months ago
Age of first intercourse : Not given Married or single. Pregnancy : None Labor : None Abortion : None
Miscarriage :None Ectopic pregnancy : None Last pregnancy : None Complications during
pregnancy and labor : None

Hereditary history
GYNECOLOGIC DISEASES (date, treatment, result)
Salpingoophoritis
Psevdoerosion Trichomoniasis
Neissera disease Chlamydiosis
Lues
Gynecologic operation
Somatic disease Pneumonia

Hepatitis A/B negative in year. Opisthorchis-negative Tuberculosis-negative Allergies-negative

by
Operation, trauma
PATIENTS STATE (STATUS PRAESENS)
General state of the patient (satisfactory, moderate severity, severe) Skin and visible mucous.
Arterial blood pressure : 125/80mmHg
Temperature :37.5
Heart beats rate : 75bpm
Tongue : Pinkish
Thyroid gland : Not enlarged
Periferal lymph nodes : Not enlarged

Mammary gland :
Breasts are of moderate size and slightly asymmetrical.
Dimpling and retraction are absent.
There are no lesions or venous patterns and redness is absent.
Areola is pink, oval and bilaterally similar
Nipples are protruding slightly and discharges are present at examinations.
Bleedings are absent.
On palpation of the breast no masses are found, tenderness is absent and lymph nodes are not enlarged
HEART:
On palpation of the heart, apex beat was felt in the 5th intercostal space 3cm medial to the midclavicular line.
On percussion of the heart, heart dullness is heard and there is no displacement of its borders
On auscultation, of the heart sounds were normal, no pathologic sounds where heard on auscultation

LUNGS:

On palpation of the chest, no masses were found. Vocal fremitus was moderate .
On percussion of the lungs, resonance was heard over the lungs and lung borders were in place
On auscultation of the lungs the bronchial, vesicular and bronchovesicular sounds were heard on auscultation.

ABDOMEN :
Abdomen is soft and non-tender

LIVER & SPLEEN : No enlargement

Intestenal peristaltis: (present, bradyperistaltis, absent)

Pasternatskiy symptom : negative/positive

CONFIRMATION OF DIAGNOSIS
DIAGNOSIS : SECONDARY AMENORRHEA WITH HYPERPROLACTINEMIA

INVESTIGATIONS
-PREGNANCY TEST
-THYROID
-BIMANUAL EXAMINATION (TO ACCESS THE SHAPE OF UTERUS AND OVARIES)
-BLOOD TEST (TO CHECK TO ESTROGEN,FSH,PROLACTONEMIA,FSH,LH)
-PELVIC ULTRASOUND
-MRI
CT SCANS

TREATMENT
ESTROGEN THERAPY: Estradiol ( 0,1 mg for 3 weeks)
PROGESTERONE THERAPY
PATIENT’S NUTRITION

Signature

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DAYS OF ATTENDANCE
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 ADDITION TO MEDICAL CARD OF THE PATIENT №
results of temperature, other investigations

Name, Surname patient Department

Room List GYNECOLOGY
OKSANA PETROSKYY
ANALYSIS
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TRANSFUSION OF BLOOD (PLASMA, SERUM)
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Blood group O №№ seria of serum
Rhesus blood factor
O+ OKSANA PETROSKYY
№ medical card Name, Surname patient
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LIST OF MEDICAL PRESCRIPTION
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LIST OF MEDICAL PRESCRIPTION
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EPICRYSIS
Name,Surname, Full name OKSANA PETROSKYY Age 24
Hospitalization planned/urgent operation

Preoperation Diagnosis
Absent periods
Headaches
Pelvic pain

Indications for operation: NONE

Contraindications for operation – (present or absent)

Blood group and Rhesus blood factor O +

Surgical team (surgeon and assistence)

Date Doctor’s signature:

Patient with the volume of next operation and probable complications is acquinted,
consent to the operation.
 Preoperation anaesteziology examination

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CHECK LIST OF OPERATION № planned/urgent. Date of hospital. operation

Name,Surname OKSANA PETROSKYY

Diagnosis Secondary Amenorrhea

Surgeons INIOVORUA AJOKPEROGHENE

Operative sister Anestesiologist INIOVORUA AJOKPEROGHENE
Begining of operation Finishing of operation Duration
NAME OF OPERATION

Narcosis — combained, intravenous, endotracheal; spinal, peridural anasthesia.

Incision — vertical interior median, transverse, excision of scar
Revision of abdominal organs: fluid absent, exudation – ml
Uterine with/without changes

Adnexa with/without changes

PERFORMED: right and left, step by step clamping, incision, suturring by silk

Chaking of peritoneal cavity. Hemostasis control — dry.

Additional hemostasis
Counting instruments and pads – all are present. In layes suturing abdominal wall: peritoneum and muscles non-interrupted suture –
catgut
aponeurosis – interrupted suture continous
subcutaneous fat – interrupted suture continous
Skin: cosmetic suture interrupted suture

Blood loss during operation ml, general ml Urine quantity

Operation specialities

Macropreparation

Signature
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Gynecological department № maternity home №

EPICRYSIS
medical card of gynecological patient

Name,Surname, Full name OKSANA PETROSKYY Age 24

Address BUDNOHO 28, TERNOPIL, UKRAINE.
Business address: 2ND HOSPITAL, TERNOPIL, UKRAINE.
Diagnosis : SECONDARY AMENORRHEA WITH HYPERPROLACTINEMIA.

Hospitalization planned/urgent with complaints for ABSENT PERIOD AND HEADACHES.

Oblained results of investigation

Hyperprolactinemia

Postoperative period non/complicated

Gynecological investigation: speculum examination

bimanual investigation is UNREMARKABLE.

Region of the adnexa right, left – non/painful, changes non indicated. Infiltrates

Fornices, Parametrium
ANALYSIS: reaction Wasserman from is – negative. Titre AID
Blood group Rhesus factor O+
General blood analysis: Hb: 135 G/L , Er 4.0 X 1012/l,
CP , Le 8.5 x 109/l, е – 0.7%, p – 380 %, s – 57 %, l – 22 %, m – 3 %, ESR mm/hour: 16 mm/hour
Urinalysis: from protein – absent. g/l, sugar – none , aceton – none , Le – 1 Er-2
Biochemical blood analysis from bilirubin 17 micromol/l, sugar 4.1 mmol/l, total protein 75 g/l, thymol
turbidity test un, urea – 5.5 mmol/l, ПI %, trombotest – 28 % fibrynogen -3.1 g/l fibrynogen B – 2g/l
Analysis of smear from
Results of pathohistological investigation:

Discharge of the patient 7/12/2020

Recommendation: Patient should take drugs as prescribed and come for regular check ups as planned.

Discharge of the patient

RECOMMENDATION:

Date 12/3/2020 Signature of the student

INIOVORUA AJOKPEROGHENE
Teacher’s conclusion:

Marks for writing history:

Marks for defence of history:

Teacher’s signature
(Surname)
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11. First hospitalization or rehospitalization, how much times in this year .
12. Surgical operation,methods of anesthesia and postoperative complications.

Operation Date, hour Methods of anesthesia Complication Surgeon

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
13. Other treatment for patient with metastatic tumor (special, surgical, radiation, combination, complex, chemicotherapy,
palliative,symptomatic)

14. Negative effect of medication

15. Notes about list of disability
№ since to № since to
№ since to № since to
16. Outcome of a disease: recovery (complete or incomplete), good or bad; transportation to the another department;
Did the patient die in hospital OPP, d`d the patient die before 28 weeks of pregnancy, patient died after 28 weeks of pregnancy.

17. For insurance: working ability is completely restored, decreased, temporary decreased, permanently decreased due to the desease.

18. Conclusions after medical examination.

19. Pecularity information Veneral disease Hepatitis

Hemotransfusion Allergies
Stool Tuberculosis
Signature:

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Vein’s varicosis
surgical intervetion
Signs of pelvic irritation Last stool 7/12/2020 consistancy
Urination (in/frequent,non/painful)

PELVIC EXAMINATION

External genitalia. Hairity female/male,hirsutism. External genitalia

Vaginal mucous DRY Uterine cervix

Evaluation

Body of uterus in ante/retro/flexio non/enlarge to weeks

non/tenderness, smoth/tuberculosis surface painfull/non painfull

consistency (normal/soft/firm) movable/unmovable

Left adnexa : Slightly enlarged.

Right adnexa : Normal

Fornicex, Parametria

Motion of uterus cervix non/tenderness

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DAYS OF ATTENDANCE
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Name and Surname of the student

INIOVORUA AJOKPEROGHENE

Course Group

4TH COURSE IM-450

HYSTORY CARD OF GYNECOLOGICAL PATIENT №

1. Name, Surname, Full name OKSANA PETROSKYY
2. Age 24 Y/O
3. Home address : BUDNOHO 28, TERNOPIL , UKRAINE.
4. Business address,profession : 2ND HOSPITAL, PRIMARY SCHOOL TEACHER.

5. To whom a patient is sent to : DR. INIOVORUA AJOKPEROGHENE (Gynecologist).

6. Urgent hospitalization: _______ (yes,/no). Time of disease onset __9 months , planned hospitalization.

7. Initial diagnosis : AMENORRHEA

8. Admission diagnosis : HYPERPROLACTONEMIA
9. Clinical diagnosis : SECONDARY AMENORRHEA
10. Final diagnosis : SECONDARY AMENORRHEA WITH SEVERE HYPERPROLACTONEMIA
a) basic
b) complication ; Polycystic ovarian syndrome (PCOS), Infertlity, osteoporosis
c) extragenital pathology : None

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Date of estimation
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I.HORBACHEVSKY TERNOPIL STATE MEDICAL ACADEMY
OBSTETRICS AND GYNECOLOGY CHAIR №1
Head of the Obstetrics and Gynecology Chair№1

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Blood of RW
Blood of AIDS
Blood group O +
Rhesus blood factor O +

Date and time of discharge : 7/12/2020

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Pediculosis ABSENT

Scabies ABSENT

Hepatitis ABSENT

Patient’s stay in a hospital

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№ medical card Name, Surname patient
OKSANA PETROSKYY
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Date converce
Date transmission
N°sera
Blood
group donor
Rhesus blood factor o+
 Group compatibility : all groups
Biological compatibility : all blood groups
dose
Kind of transfussion
Complication and reaction : Pcos, Asherman’s syndrome
Do. sigi

PATIENT’S TEMPERATURE
36.8
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ADDITION TO MEDICAL CARD OF THE PATIENT №
results of temperature, other investigations

Name, Surname patient OKSANA PETROSKYY Department

GYNECOLOGY Room List