PD OB| Doc Ivy Bello

Topics Age group

History taking Salpingectomy o 4-5 years from menarche
Physical examination Oophorectomy o 4-5 years within the average menopause
Diagnostic procedure Hysterectomy (47-49 years old)
o Pap smear Ovarian Cancer Menstruating beyond 50 years old abnormal
o Dilatation and maybe cancer
Curettage Vaginal Bleeding
o Fractional o + mass
curettage o + infection
o Atrophic vaginitis: most common cause in
HISTORY menopausal patient
GENERAL DATA o T/c problems in vagina, cervix, uterus,
- Name - Gravidity ovaries
- Age - Number of admission Sometime ovarian mass causes
- Gender - Reason vaginal bleeding
- Birthday - Date Foul smelling vaginal discharges
- Marital status o + infection (STI)
- Address - % reliability o Cancer
- Religion Adults -not important Hypogastric Pain/ gradual abdominal enlargement
- Citizenship/ race Minors important!! (masses)
o If not related to urinary problem dysuria,
CHIEF COMPLAINT urinary frequency, urgency
Reasons for consultation o Mass within uterus, ovary, fallopian tube
+ Vaginal bleeding + Hypogastric pain o Abdominal tenderness
+ Vaginal spotting + Abdominal
+ Vaginal pruritus enlargement
+ Foul smelling vaginal + Dyspareunia HISTORY OF PRESENT ILLNESS
discharges + Profuse vaginal Vaginal Bleeding
+ Menstrual bleeding - Get records by months
abnormalities - 6 months prior
LMP Last Menstrual Period 1 15 30
PMP Previous menstrual period prior to LMP Sept |-----------------|-----------------|2-3 pads/day
no blood clots
ask other S/Sx
Abnormal uterine bleeding Oct |-----------------|-----------------| 2-3 pads/day
Normal interval between menses: 28 7 days no blood clots
ask other S/Sx
Oligomenorrhea: infrequent bleeding with intervals
from 35 days to 6 months Nov |-----------------|-----------------| 2-3 pads/day
no blood clots
Amenorrhea: no menses for at least 6 months ask other S/Sx
Menorrhagia: prolonged (>7 days) or excessive Dec |-----------------|-----------------| vaginal spotting
(>80 ml)
Metrorrhagia: uterine bleeding occurring at Jan |-----------------|-----------------| 3 baby diapers
+ blood clots
irregular but frequent intervals, amount being + body weakness
variable + dizziness
Menometrorrhagia: prolonged & irregular uterine Start of abnormal bleeding: December
bleeding LMP (last NORMAL menstrual period): November
Intermenstrual bleeding: bleeding of variable PMP: October
amounts occurring between regular menstrual Patient may have simple abnormal bleeding, mass, infection
periods
Menstruation 6 months prior The patient was regularly menstruating occurring 3-5 days,
consuming 3-4 pads/day with no blood clots, with no
Initially: irregular menstruation due to HPO axis
dysmenorrhea.
immaturity
1 month PTA, when the patient has vaginal spotting with this
o Menstruation is controlled by
and this, self-pregnancy test turned out to be negative. No
hypothalamus-pituitary-ovary
medications taken and no consultations done.
Estrogen: causes endometrial thickening Few hours PTA, the bleeding become profuse. With
Progesterone: causes uniform sloughing off of the presence of body weakness and dizziness.
endometrial lining during menstruation
Perimenoupausal patients frequently complain of If bleeding + positive pregnancy test = ABORTION
irregular menses
o Hormonal imbalance older: ovaries will Hypogastric Pain
be atrophic, 6 months PTA, the patient experience on and off
o Even if the hypothalamus and pituitary are hypogastric pain. Not associated with urinary symptoms like
sending positive signals to the ovaries, FSH dysuria, urinary frequency and urgency. No foul-smelling
will increase
MED IIIA | 2016-2017
 PD OB| Doc Ivy Bello
discharge noted. She tolerated the condition until 4-month ENVIRONMENTAL HISTORY
PTA, still with the above condition, the patient noticed House type, number of rooms, CR-type
abdominal enlargement. She then consulted the physician Number of family members living together in the house
wherein she was requested for ultrasound, however, she did Water source for drinking and washing
not comply due to financial constrain. Self-medicated with
pain reliver (mefenamic acid), which relieved the pain Garbage disposal
temporarily. Sewage disposal
1 month PTA, the pain was severe and unable to tolerate Nearby factories
and still with the above condition. (PQRST of the Pain),
hence consultation and admission was done. OB HISTORY
GP SCORE: GP (TPAL)
Foul-smelling discharges
- Characterize the discharges Gravity number of pregnancies regardless of outcome
- Bacterial vaginosis Parity number of delivery reaching age of viability
- Trichomoniasis - STI (beyond 20 weeks)
- Vaginal candidiasis TPAL (Term, Preterm, Abortion, Living)
Pruritus secondary to vaginal infection kasi o post term included in TERM
kinakamot nila o ectopic pregnancy included in ABORTION
Single dose of antifungal Fluconazole Subsequent pregnancies
Older patient with repeated vaginal pruritus o date and route of delivery,
and repeated vaginal candidiasis rule out o hospital or at home, assisted by midwife, hilot,
Diabetes o Birth weight
o Sex of the baby
o Other complications or unremarkable findings
atony

GYNE HISTORY
Menstrual history
MIDAS: Menarche, Interval, Duration, Amount, Signs
and Symptoms
o Menarche: age or grade started
o Interval: 28 7 days
o Duration: 3-5 days
o Amount: brand of napkin used, + blood clots
Characterize subsequent menses
Associated signs and symptoms
o dysmenorrhea, breast tenderness, headache,
PAST MEDICAL HISTORY mood swings, PMS
Childhood illness measles, mumps, rubella, poliomyelitis,
varicella, pertussis, rheumatic fever, scarlet fever, others. Sexual history
Medical HTN, DM, Asthma, blood dyscrasias, congenital Coitarche
anomalies, goiter, cancer, hepatitis, STI, allergies, Sexual habits
injuries/accidents, hospitalization (date, place, treatment), Number of partners
medications (name of drug, dosage) Important especially if entertaining STD
Surgical date, place, indication, type of operation o Treat also the sexual partner
Psychiatric illness, time frame, diagnosis, hospitalization,
treatments Contraceptive history

FAMILY HISTORY
Family pedigree ROS
1st degree relative: Signs and symptoms related to CC
o Parents, grandparents, siblings, children,
grandchildren
o Both sides
o Age, health status, cause of death
Heredofamilial diseases, DM, HTN, cardiac diseases,
asthma, cancer, etc.

PERSONAL & SOCIAL HISTORY

Patient and Partners background
o Name of partner
o Age, birthday, educational attainment,
occupation, alcoholic drinker, smoker, drug user?
Source of income
-dada-
MED IIIA | 2016-2017