Demographic Details

Patients initials Madam NO

R/N SB00
Ward 6A
Age 38
Occupation Clerk
Marital status Married
Race Malay
Date of admission 20/4/15
Date of discharge 2-/4/15
Date of clerking 21/4/15

Chief complaint:
Madam NO, a 38 years old Malay clerk, para 5+1, last child birth was 6 years
ago, with known case of endometrial polyp was electively admitted to Hosp Sg
Buloh for hysteroscopy and diagnostic dilatation and curettage.
 History of Presenting Illness:
• She was previously well until 2 years ago (Nov 13) she
started to have prolonged heavy menstrual bleeding.
• Her period prolonged from 4 days each month to 3
weeks per month in duration.
• The bleeding was also associated with blood clot
measuring about the size of 50cent. She usually use 5
overnight pads fully soaked per day compared to 2
maxi pads partially soaked before.
• However, it was not associated with flooding or period
pain.
• The bleeding does not resolve until current admission.
• She also complained of reduced effort tolerance,
palpitation, sweating and easy fatigability along with
the bleeding.
• She also developed on and off shortness of breath
which increase upon exertion and resolved upon
resting.
• However, there is no history of orthopnoea,
paroxysmal nocturnal dyspnea or bilateral leg swelling.
• She did go to GP 5 month after the onset of heavy
menstrual bleeding.
• She claimed that she was prescribed with hormonal
pills that stop her period for 2 weeks but the period
recurs while she was on treatment.
• After that, she did not seek for the GP follow up.
• 9 months after the bleeding (Aug 14), she
presented to Emergency Department of Hosp
Sg Buloh with sudden onset of chest pain. This
is her first admission to hospital pertaining to
her problem.
• At that time she was transfused with 4 pint of
blood as the Hb count was 4.9.
• Vaginal examination and pipelle done showed
benign endometrial polyp.
• She was discharged after 5 days of admission
and was advised for Implanon.
• She claimed that her period resolve for 2
months after the Implanon injection but the
bleeding recur and she defaulted the follow
up under O&G clinic.
• She presented to Emergency Department HSB
for the second time 2 weeks ago where she
presented with the same symptoms of
prolonged menstrual bleeding associated with
shortness of breath, easy fatigability and
giddiness.
• Her Hb upon admission was 5.6 and she was
transfused with 3 pint of blood.
• She was then discharged after 4 days of
admission and was scheduled for
hysteroscopy and diagnostic dilatation and
curettage on 21st April 2015.
Past Gynaecological History:
• Madam NO attained her menarche at the age
of 13 years old with regular flow of 3-4 days for
each period and 28 days in between cycle.
• Her period was regular, no intermenstrual or
post coital bleeding and no dysmenorrhea and
dyspareunia.
• Her last pap smear done(7th) during second
admission, shows normal result.
• No history of STD
• Practice BSE regularly
Past Obstetrics History:
• She has 5 children(2B,3G) from age 16 to 6 years
old.
• All are delivered via SVD at term in Hospital Ipoh.
• Her baby weight ranging from 3.0 to 3.64kg.
• She breastfed all her baby up to 2 years.
• She had history of miscarriage at 14th week
during her 4th pregnancy.
• She had history of pregnancy induced
hypertension during her 3rd, 5th and 6th
pregnancy.
• After her 6th pregnancy, the hypertension persist
and she was on antihypertensive for 2 years and
stopped 4 years ago after being told that her BP
was stable.
Past Medical History:
• Chronic hypertension on medication(2009-
2011)
• No other chronic illnesses such as Diabetes
Mellitus, heart disease and asthma.
• Never been admitted for other medical
problem.
• Never undergone any surgery before.
Allergy History:
• Allergic to fur and dust. Redness on skin when
exposed.
Family History:
• Both of her parents died in a car accident. Her father had
underlying heart disease while her mother was healthy.
• She is the first child of 4 siblings. All of her siblings are
healthy.
• There is no history of gynecological disease or malignancy
in her family.

Social History:
• This is her first marriage and it is non consanguineous. They
have been married for 17 years.
• Her husband works as a supervisor with total family income
of RM 4,000.
• Her husband is a chronic smoker. He smokes 1 box of
cigarettes per day.
• They live in a two storey terrace house in Sg.Buloh with
good basic amenities.