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S I LLI MAN UNI V E RSI TY ME DI CAL S CHO O L

GYNECOLOGY WORKSHEET SUBMITTED to Dr. Daphne R. Rana
SUBMITTED by (1) Cruz, Bea Celina; (2) de la Pena, Nesil; (3) de leon, Jan Gil; (4) de los Santos, Rosheil Mae
HEALTH HISTORY
A IDENTIFYING DATA: A case of & year old female patient
B CHIEF COMPLAINT: Vaginal bleeding
C HPI:
Brought for consultation because of vaginal bleeding described as cyclic vaginal bleeding for the last 3 months . The bleeding lasts 3-4 days
per cycle with small amount of blood loss.
The patient did not have a history of convulsions, meningitis, encephalitis, head injury or hormonal therapy. She was born at term pregnancy
without any complications in apoor illiterate family. Her parents noticed tha she had slow mental and physical development since birth
compared with her brothers and sisters.
D FAMILY HISTORY: There was no previous family history of similar condition.
PHYSICAL EXAMINATION
General Survey: Patient looked lethargic, pale with coarse features and puffy face
Vital Signs: T: 36.80C
BP: 95/55 mmHg PR: 64/min
RR: 20/min
Weight: 18kg Height: 98cm
Skin: (+)Increase in body hair growth mainly on her back
Neck: No thyroid and lymph node enlarement
Chest/CVS: Heart and chest are normal
Breast: Breast buds were developed as tanner stage 2-3 without galactorrhea
Abdomen: Distended; no abnormal pelvic and abdominal masses were palpated.
Genital Exam: No abnormalities detected
Extremities: No pitting edema
PRIMARY WORKING IMP
R/I
R/O
DIFFERENTIAL Dx
1
LABORATORY TESTS and DIAGNOSTIC TESTS
TEST

R/I

R/O

RATIONALE

LIST OF PROBLEMS
1.

VII FINAL DIAGNOSIS: PRECOCIOUS PUBERTY SECONDARY TO CONGENITAL HYPOTHYROIDISM

VIII PATHOPHYSIOLOGY:
According to Robbins and Cotran, hypothyroidism is caused by any structural or functional derangement that interferes with the production of
adequate levels of thyroid hormone. The causes of hypothyroidism is divided into primary and secondary causes.
Primary hypothyroidism can be congenital. This includes inborn errors of thyroid metabolism, thyroid dysgenesis, Mutations in thyroid
hormone receptor-beta, thyroid agenesis and thyroid hypoplasia. Primary hypothyroidism can be acquired, caused by surgical or radiationinduced ablation of thyroid parenchyma and drugs to decrease thyroid secretion. Autoimmune hypothyroidism is the most common cause of
hypothyroidism in iodine-sufficient areas (vast majority of cases are due to Hashimoto thyroiditis.
According to Berek and Novak's, secondary causes of hypothyroidism includes hypothalamic thyrotropin-releasing hormone deficiency and
pituitary or hypothalamic tumors or disease.
Our patient manifests vaginal bleeding and this can be caused by long standing hypothyroidism most likely congenital hypothyroidism.
Decreased production of thyroid hormones (T3 & T4) causes an increase in the secretion of thyroid-stimulating hormone by the pituitary gland
to stimulate production of thyroid hormone. There will also be an increase in thyrotropin-releasing hormone from the hypothalamus. Thyroid
hormone activity is responsible for basal metabolic rate, mental and physical development. Since there is a decrease in thyroid hormone, the

patient manifested signs and symptoms such as cold intolerance, short stature, coarse features, puffy face( decreased body temperature
causes fluid retention), and mental retardation. Prolactin production can be stimulated by thyrotropin releasing hormone. Thus an increase
thyrotropin releasing hormone, there will also be hyperprolactinemia as manifested by the patient.

IX

A convincing explanation of sexual precocity and bilateral ovarian enlargement is that high levels of TSH could act through the follicle
stimulating hormone receptor (FSH-r) and cause gonadal stimulation. This causes breast development, uterine bleeding and multicystic
ovaries.
THERAPEUTIC OBJECTIVES
A
B

NON-PHARMACOLOGIC MANAGEMENT
1.
PHARMACOLOGIC MANAGEMENT
DRUG
EFFICACY

SAFETY

P DRUGS
MONITORING & FOLLOW-UP

XIII. PRESCRIPTION WRITING

Bea Celina Cruz, M.D.
SILLIMAN UNIVERSITY MEDICAL CENTER
(035) 000 0000

Patient:
Address:
Age/Sex:

Date:

Ketorolac (KETERO)
30mg/ml vial
#
Sig:
Administer
mg IV every 6 hours for 2
days

SUITABILITY

COST