Xylia Sahara E.

Tocao
Post Graduate Intern
General data
A.G
46 years old / Female / Married
Matina, Davao City
G3 P1 (1021)
May 6, 2014
CHIEF COMPLAINT
VAGINAL BLEEDING
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
TVS
finding
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
TVS
finding
PAST MEDICAL HISTORY
MEDICAL:
(-) Thyroid problems (+) Chicken pox
(-) Diabetes mellitus (+) Hypertension
(-) Bronchial asthma
(-) Cardiac disease
PAST MEDICAL HISTORY
OBSTETRICAL / SURGICAL:

10 years PTA : Cesarean section





OB-GYNE HISTORY
Menarche: 10 years old
28-30 days , regular x 5 days x soaking 3
pads / day with dysmenorrhea
Coitarche : 35 years old with 1 sexual
partner
Pap smear (-)
Contraceptives (-)
LMP : April 30, 2014
PMP : March 2014

OB-GYNE HISTORY
G3 P1 (1021)

Gravidity Year Sex Type of
delivery
Place of
delivery
Complication

G1 2003 - - - Abortion
(-) D & C
G2 2003 - - - Abortion
(-) D & C

G3 2004 F Primary
LSTSC
Hospital Hypertension
FAMILY HISTORY
MATERNAL PATERNAL
(+) Hypertension (+) Bronchial asthma
(+) Cancer BREAST
(+) Heart disease

(-) Diabetes mellitus

REVIEW OF SYSTEMS

HEAD
EYES
EARS
NOSE
MOUTH
CARDIAC
PULMONARY
GASTROINTESTINAL
HEMATOPOIETIC
MUSCULAR
NEUROLOGIC
GENERAL
PHYSICAL EXAMINATION

GENERAL DESCRIPTION
Conscious and coherent
Not in respiratory distress
Alert and relaxed
well-nourished


Vital Signs:

Blood Pressure: 120/80 mmHg
Pulse rate: 89 bpm
Respiratory rate: 19 cpm
Temperature: 36 OC
Height:
Weight: 60.7 kg
BMI:
SKIN
Pallor
CRT >2 sec
No lesions noted
No clubbing of nails

LYMPH NODES
Non-palpable post-auricular, sub-occipital,
cervical and supraclavicular lymph nodes
HEAD
Normocephalic
No lesions noted
EYES
Anicteric sclerae
Pale palpebral conjunctivae
EARS
No lesions on pinnae
No discharge
Intact tympanic membrane
NOSE
Septum midline
No discharge
MOUTH AND THROAT
No lesions noted
No tonsillar discharge
NECK
Trachea midline
No thyroid enlargement
No bruits
No venous distention
BREAST
Symmetric
No breast mass
No nipple discharge
CHEST
No deformities
Chest expansion full and equal
Lungs resonant upon percussion
Breath sounds clear and vesicular
No crackles or wheezes noted
VASCULAR
Brisk brachial, radial, and carotid pulses
CARDIAC
Adynamic Precordium
Distinct Heart Sounds
Normal Rate And Regular Rhythm
ABDOMEN
Scar is present on the infraumbilical region
from CS delivery
Flabby abdomen
Normoactive BS (10/min) at the RUQ
Tympanitic
(+) tenderness at the hypogastric area
EXTREMITIES
No body deformities
No joint swelling
No tenderness in all joints
MOTOR:
Grade 5/5 muscle strength
SENSORY :
100 %
COURSE IN THE WARD
PLS INCLUDE OPERATIVE TECHNIQUE
WITH PICTURES PATI HISPTOPATH
WITH PICTURES ;)
COURSE IN THE WARD



DATE/ TIME MEDICAL ORDERS
April 27, 2014 To admitting OB-ROD:

For TAHBSO on May 7, 2014 at 8 AM
Secure consent and AC
Attach CP clearance c/o Dr. SH
Dr. L for anesthesia
Inform AP of admission
COURSE IN THE WARD

DATE/ TIME MEDICAL ORDERS
May 6 , 2014 >Please carry out APs order
>Inform OR and anesthesia team
>Secure 1 unit of fresh whole blood/
packed red blood cells and crossmatch
please
For possible OR use
Bowel prep:
Bisacodyl ( Dulcolax) 4 tablets PO at 4
pm
Fleet enema in early AM
Cefazolin (Lupex) 1 gram IVTT ANST ( )
1 hour prior to OR


COURSE IN THE WARD

DATE/ TIME MEDICAL ORDERS
May 6 , 2014 >Please inform once with AC
>Inform ROD once able to procure blood
>AP aware of this admission
>Refer acordingly


COURSE IN THE WARD

COURSE IN THE WARD

COURSE IN THE WARD

COURSE IN THE WARD

SALIENT FEATURES

ADMITTING IMPRESSION
G3 P 1 (1021) Abnormal Uterine Bleeding
, Multiple uterine myoma (submucous,
intramural, subserous)
Anemia secondary to chronic blood loss
s/p low segment transverse cesarean
section 1

DIFFERENTIAL DIAGNOSIS

FINAL DIAGNOSIS

DISCUSSION