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Gynecology case Protocol

Block G: Calma , Capili , Coruna, Dagang , Datukon , Dayrit , de Castro, de la Llana , Gayeta , Golepang. Gynecology case Protocol. General Data. MP 34 years old G3P3 (3003) Married, housewife Roman Catholic Cabuyao , Laguna. Chief Complaint. menorrhagia. Past Medical History.

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Gynecology case Protocol

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  1. Block G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang Gynecology case Protocol

  2. General Data • MP • 34 years old • G3P3 (3003) • Married, housewife • Roman Catholic • Cabuyao, Laguna

  3. Chief Complaint • menorrhagia

  4. Past Medical History • No previous illnesses • (-) HPN, DM, PTB, BA, goiter • No previous surgeries • No known allergies to food or drugs

  5. Family Medical History • (-) HPN, DM, PTB, BA, goiter • No relative with similar symptoms as the patient

  6. Personal/Social History • High school graduate • Currently a housewife • Non-smoker, non-alcoholic beverage drinker, does not use illegal drugs

  7. Sexual History • First coitus at 17 years of age • 1 non-promiscuous sexual partner • (+) OCP use from 1992-1996 • (-) previous IUD use • (-) previous STD’s

  8. Menstrual History • Menarche at 13 years old • Regular monthly intervals • 3-4 days’ duration • Consuming 3-4 pads/day • (+) occasional mild dysmenorrhea • LMP: 1/20/2010 • PMP: 12/22/2009 • No previous Pap smear

  9. Obstetric History • G3P3 (3003) • G1 1986, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive • G2 1991, FT via SVD at home c/o hilot, F, AGA, (-) FMC, alive • G3 1997, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive\

  10. History of Present Illness • 3 months PTC • Increase in amount and duration of menses (3-4 pads per day  5-6 pads per, 3-4 days duration  10 days, with flow decreasing to 1-2 pads later) • (-) intermenstrualbleeding, hypogastricpain, bowel/urinary changes • (-) post-coital bleeding, dyspareunia, vaginal discharge, weight loss, anorexia and pallor • (-) consults done / medications taken

  11. History of Present Illness • 1 month PTC • Persistence of symptoms • Duration increasing to 12 days • Flow decreasing to 1 pad/day later in the period • Consulted an Ob-Gyn in Laguna • TV UTZ done – unrecalled findings • Patient lost to follow up • persistence of symptoms prompted this consult

  12. Review of Systems • (-) fever • (-) malaise • (-) cough • (-) DOB • (-) hemoptysis • (-) chest pain • (-) orthopnea • (-) PND • (-) easy fatigability • (-) dizziness • (-) nape pain • (-) weakness • (-) polydipsia • (-) polyuria • (-) polyphagia • (-) palpitations • (-) abdominal pain • (-) bowel changes • (-) dysuria • (-) decreasing urine output • Tea-colored urine

  13. Physical Examination • Awake, coherent, ambulatory, NICRD • BP 120/80 HR 84 RR 18 • Weight: 55kg Height: 152cm BMI: 23 • HEENT: pink conjunctivae, anictericsclerae, (-) CLAD/TPC/ANM • Lungs: equal chest expansion, clear breath sounds, (-) crackles/wheezes • Heart: (-) heaves/thrills, distinct heart sounds, normal rate, regular rhythm, (-) murmurs

  14. Physical Examination • Abdomen: flabby, soft, normoactive bowel sounds, nontender, (-) masses/organomegaly • Extremities: pink nail beds, full equal pulses, (-) cyanosis/clubbing/edema

  15. Physical Examination • Internal Examination: • Normal external genitalia; smooth, parous vagina; cervix smooth, closed, firm; corpus small; (-) adnexalmasses/tenderness • Rectovaginal Examination: • Good sphincter tone, intact rectovaginal septum, smooth and pliable parametria, (-) fullness in the cul de sac, (-) intraluminal masses, (-) blood per examining finger

  16. Assessment • Abnormal uterine bleeding probably secondary to adenomyosis, r/o endometrial pathology

  17. Plan • Diagnostics • CBC, Pap smear, Transvaginal ultrasound • Therapeutics • FeSO4 325 mg/tab OD • Others • Increase OFI, full body bath + perineal hygiene daily • Menstrual calendar • For endometrial biopsy with endocervical curettage once with ultrasound results

  18. Results • CBC: WBC 9.7, Hgb 117, Hct 0.379, Plt 359, Neut 0.76, Lym 0.23 • Transvaginal Ultrasound • The uterus is anteverted with smooth contour and homogeneous echopattern, measuring 8.1x5x4.5cm, the cervix measures 3.4x3.2x2.8cm, the left ovary measures 1.9x2x1.6cm. There is no free fluid in the cul de sac • IMPRESSION: thickened endometrium, r/o endometrial pathology, normal ovaries

  19. Results • Endometrial Biopsy and Endocervical Curettage was done • Final Histopathologic Diagnosis: • Endometrial polyp • Secretory phase endometrium • Chronic endocervicitis

  20. Guide Questions • What is abnormal uterine bleeding (AUB)? How is this different from dysfunctional uterine bleeding? • Differentiate menorrhagia, metrorrhagia, polymenorrhea, and menometrorrhagia. • How is this diagnosed? • What are the possible causes of AUB? • What other diagnostics may be ordered for the patient?

  21. Guide Questions • What are the possible methods of medical management for AUB? • What are the possible methods of surgical management of AUB? • What is an endometrial polyp? • What is endocervicitis? • How should this patient be managed?

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