Professional Documents
Culture Documents
Case #1
A 48 year old G2P1 (1-0-1-1) consulted for a gynecologic check-up. She is a known
hypertensive for 5 years.
Identifying information
o May also include the name and occupation of the patient aside from her age.
The date of onset of the last menstrual period (LNMP) is also important.
Chief complaint
o Usually best elicited by asking, “What kind of problem are you having?” or
“How can I help you?"
History of present illness
o The patient should be asked about the principal symptom including its onset,
duration, frequency, quality, quantity or severity, location, the setting in which
they occur, factors that aggravated or relieved the symptoms, and associated
manifestations.
o May include medications, allergies, habits of smoking and alcohol
Past History
Ask the patient for childhood illness, adult illness with dates for at least four
categories:
a. Medical: illnesses such as diabetes, lung, heart and liver disease and whether
hospitalization was required. Medications should also be asked including its
name, dose, route, and frequency of use. Since she is hypertensive, what anti-
hypertensive drug does she take? Aside from this, also ask for nonprescription
drugs, vitamins, mineral or herbal supplements, and oral contraceptives taken.
Allergies and specific reactions to each drug like rash or nausea, as well as
allergies to foods, insects, or environmental factors should also be asked.
b. Surgical: includes all operations, dates performed and associate postoperative
or anesthetic complications
c. Obstetrics: includes each patient’s pregnancies listed in chronological order.
The date of birth; sex and weight of the offspring; duration of pregnancy;
length of labor; type of delivery; type of anesthesia; and any complications.
d. Gynecologic: menstrual history: age at menarche, interval between periods,
duration of flow, amount and character of flow, degree of discomfort, and age
at menopause; history of STD; sexual history; use of contraceptives
Family History
o Includes the state of health of immediate relatives. The incidence of familial
heart disease, hypertensive renal or vascular disease, diabetes mellitus,
vascular accidents, hematologic abnormalities, cancer especially breast and
ovarian cancer
Personal and Social history
There are some important things to note in doing a physical examination. The
environment should be aesthetically pleasing to the examinee. Privacy is of major
importance for delicate parts of the patient’s body would be examined and exposed.
Furthermore, physicians must be aware of the possible fears or anxieties that the patients
may have. This is especially occurring to first-time-gynecologic-exam patients.
General
Vital signs – the weight and BP must be taken; the height must be taken to
determine if there is loss of height especially in osteoporotic and fractured women
The chest should be examined for skin lesions and movement symmetry.
Auscultation and percussion of the heart and lungs are also crucial.
Breast Examination
a. Should be a routine part of the PE
b. Ideal time to ascertain the frequency and methodology of breast self-examination
c. Mammogram – every 1-2 years from age 40-50 and yearly thereafter
Abdominal Examination
a. Done to detect uterine, ovarian, or urinary bladder problems (i.e. Enlargement) in
suprapubic palpation
b. Aside from the aforementioned, physician should also take note of any
abnormality in the abdominal organs: liver, gallbladder, spleen, kidneys, and
intestines.
Pelvic Examination
a. External genitalia
• Pubic hair – note the pattern (masculine/feminine); nits of pubic lice,
infected hair follicles
• Vulva and mons pubis – inspect skin
• Perineal area – find any evidence of dermatitis and/or discoloration
• Inspect the glans clitoridis and clitoris
• Check for asymmetry and infection in the major and minor labia
• Note the color of the urethra
• Vestibular glands and anal abnormalities
b. Hymen
• Check whether it is completely imperforate, cribriform, or septate for it
may indicate pathology.
c. Perineal support
• Confirm if the pelvis is in relaxation. By doing so, this will show
urethrocele, cytocele, rectocele, or uterine prolapse.
d. Urethra
• Note any presence of discharge from the paraurethral glands
Vaginal Examination
a. Use a speculum to check for any abnormality and to be able to obtain a pap smear
for more detailed examinations.
b. During the exam, a rough, inelastic and tender vaginal wall may indicate
pathology.
c. Examine for the presence of blood, discharge and mucosal characteristics and
structural abnormalities
b. Mammography
this is done every 1-2 years beginning at age 40 years
high risk factor includes women who have had breast cancer or first
degree relative or multiple other relatives who have a history of
premenopausal breast or breast and ovarian cancer
f. Pelvic Ultrasound
to diagnose earlier those conditions that require a surgical approach
to avoid surgery in those conditions that should be managed medically
one of the most common uses of ultrasound is the diagnosis and evaluation
of pelvic masses
ultrasound has a major role to play in the diagnosis of trophoblastic
diseases and the differential diagnosis of pelvic and abdominal masses
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