GYNECOLOGIC CASE

CASE 1:
 This is a case of JDE, 22-year old pregnant woman, who came into
the emergency room due to a painful oral sore on the upper lip.

 Chief complaint: Oral sore on the upper lip

 HPI:
 2 weeks prior to consult, patient noted a small pimple on the upper
lip.
 5 days prior to consult, patient noted the pimple getting bigger and
now filled with abscess. Patient has also had cough and cold for the
past week and undocumented fever.
 2 hours prior to consult, patient still has the same symptoms, with the
lesion having crusts on the side. Patient also took Phenylephrine HCL
(“Neozep”) for her cold.
 Her temperature was read at 38.7 C upon taking the temperature in
the ER for her blotter
OBSTETRIC HISTORY
 LMP: 10/10/2018
 G1P0 PU 24 weeks and 2 days AOG by LMP

 (-) vaginal bleeding

 (-) watery vaginal discharge

 (+) uterine contractions, mild

 (+) good fetal movement, 3/hour

MENSTRUAL HISTORY
 Menarche – 13 years old
 Interval – regular

 Duration – 3-4 days

 Symptoms – none
Sexual History Contraceptive Use

 Single, with live-in  OCP: (-)

partner  DMPA: (-)
 Age of 1st sexual  IUD: (-)
contact: 19  Barrier: (-)
 No. of sexual partners:
 Natural: (-)
1
 History of STD: (-)

 Dyspareunia: (-)

 Postcoital bleeding: (-)

CASE 2:
 This is a case of EDG, 32 year old woman,
referred to the OB-ER from the Surgery ER due
to abdominal pain.
 t/c for Acute Appendicitis r/o gyne pathology.

 Chief Complaint: diffused lower abdominal pain

 HPI: 2 days prior to consult

OBSTETRIC HISTORY
 LMP: 10/10/2018
 G1P0 PU 24 weeks and 2 days AOG by LMP

 (-) vaginal bleeding

 (-) watery vaginal discharge

 (+) uterine contractions, mild

 (+) good fetal movement, 3/hour

MENSTRUAL HISTORY
 Menarche – 13 years old
 Interval – regular

 Duration – 3-4 days

 Symptoms – none
Sexual History Contraceptive Use

 Single, with live-in  OCP: (-)

partner  DMPA: (-)
 Age of 1st sexual  IUD: (-)
contact: 19  Barrier: (-)
 No. of sexual partners:
 Natural: (-)
1
 History of STD: (-)

 Dyspareunia: (-)

 Postcoital bleeding: (-)