BROKENSHIRE INTEGRATED HEALTH MINISTRIES INCORPORATED

DEPARTMENT OF OBSTETRICS
HISTORY TAKING AND PHYSICAL EXAMINATION

GENERAL INFORMATION
Name: L.A.
Age: 49 y/o
Address: Matina, Davao City
Date/Time of Admission: 12/14/15; 3:00 pm
Date/Time of Assessment: 12/14/15; 5:00 pm

Gender: Female
Civil Status: Widowed
Occupation: Govt. employee
Blood Type: A+
Reliability: 95%

CHIEF COMPLAINT:
Vaginal Bleeding
HISTORY OF PRESENT ILLNESS:
3 months prior to admission, patient who previously had regular menstrual cycles had
amenorrhea. This was not associated with pain, weight loss, or any other constitutional
symptoms.
2 months prior to admission, patient still had no menstruation but had one day when
she had vaginal spotting. It was bright red and minimal in amount, soaking only 1 panty liner.
3 weeks prior to admission, patient had menorrhagia. Her menstruation was similar in
character to her usual menses, there were minimal clumps noted and she was able to soak
around 3-4 pads per day. However, her menstruation persisted for two weeks. On the second
week of her menstruation, patient experienced dizziness and easy fatigability.
1 week prior to admission, persistence of symptoms prompted her to consult with her
gynecologist. Ultrasound findings revealed thickened endometrium (1.8 cm thickness). She
was prescribed with Tranexamic acid 500 mg TID and Mefenamic acid 500 mg TID x 5 days,
with good compliance. She was also advised to undergo D&C, thus her current admission at
this institution.
OBSTETRICAL HISTORY:
G7P6 (5-1-1-5)
Gravidity

Date

Age of
Gestation

Sex

1987

Premature, 7

Mode
of
Deliver
y
NSVD

Outcome

No maternal illnesses during

1988

1990

months
Premature, 6
months
Full Term

1993

5
6
7

NSVD

NSVD

Full Term

NSVD

1994
1998

Aborted
Full Term

-NSVD

2001

Full Term

NSVD
with
BTL

the pregnancy
Neonate died within a few
days of delivery
No maternal illnesses during
the pregnancy
No maternal illnesses during
the pregnancy
D&C performed at BIHMI
No maternal illnesses during
the pregnancy
No maternal illnesses during
the pregnancy

PAST MENSTRUAL HISTORY

Menarche: 12 years old
Coitarche: 19 years old, 2 sexual partners
Menstrual Cycle:
Prior to first pregnancy, she had irregular menses. Menses became regular thereafter.
28-35 days cycle, regular
Duration: 7 days
Amount: 3-4 napkins per day
Contraceptives:
OCP x 7 years (in between pregnancies); specific kind cannot be recalled
Bilateral Tubal Ligation (2001, with last delivery)
Pap Smear:
Once, date unrecalled but with normal findings.
Mammogram:
Once, date unrecalled but with normal findings.

PAST MEDICAL HISTORY

Past Illnesses
(+) Chickenpox

(-) Measles, Mumps

(-) Allergies, Asthma

(+) Anemia; 2012 with Hemoglobin ranging from 85-96 mg/dL; Iron
supplementation given, no follow up.

(-) Diabetes Mellitus, Hypertension, Hypercholesterolemia

Past Admissions
Year
2011

Description/ Diagnosis/Management
UTI, antibiotics given; specific drug and dose unrecalled;
compliant to treatment; no complications

p
Surgeries/Blood Transfusions:
2001- Bilateral Tubal Ligation
Vaccination History:
Childhood immunizations complete
Adult immunizations include TT during her pregnancies, number of doses received
unrecalled.
PERSONAL AND SOCIAL HISTORY
Occupation: Patient works at the HR department of the Civil Service Commission.
Residence: She lives in Matina Aplaya, Davao City with her whole family.
Diet: Patient eats 3 meals a day. She has no preference for specific types of food.
Smoking and Alcohol use: None
Exercise: Patient does not regularly exercise.
Habits: Patient sleeps an average of 8 hrs and reports that she feels well-rested when
she wakes up in the morning.
Relationship with family: Patient is in good terms with her family, and they were with
her in the hospital to give their support. Patient is already widowed. She lost her
husband in 2001 but she has coped well.
EDUCATIONAL PROFILE: College graduate
FAMILY SIZE: 6
SOCIOECONOMIC PROFILE: Patient is employed and is able to support the needs of herself
and her family.
v
FAMILY MEDICAL HISTORY
Maternal side
(+) HPN, Asthma: Mother
(+) Ovarian CA: Aunt
(+) Colon CA: Aunt
Paternal side
(+) Gout, Goiter: Father
REVIEW OF SYSTEM (R.O.S.)

General: Patient has no weakness, weight loss, fever, loss of appetite.

Endocrine: She has no temperature intolerance or excessive weight gain or loss.
Eye: No redness, photophobia, diplopia or nystagmus.
Ear: Patient has no hearing loss, infections, tinnitus, and ear pain.
Nose: No changes in smell, epistaxis or inflamed sinuses.
Mouth: No pallor or lesions noted.
Neck: No masses, pain or limitation in movement.
Gastrointestinal: No dysphagia, nausea, vomiting, and indigestion. No jaundice, liver
problems, or gallbladder problems. Bowel movement daily.
Pulmonary: No dyspnea, chest pain or hemoptysis.
Cardiovascular: There is easy fatigability. No palpitations or orthopnea
Genito-urinary: No urinary frequency, incontinence, dysuria, or recent flank pain.
Skin: No dryness, rashes or lesions noted
Neurologic: No seizures, motor or sensory loss. Memory is good.
Hematopoietic: There is slight pallor. No easy bruising, bleeding tendencies
Musculoskeletal: No joint pain, stiffness, numbness or limitation of movement.
Psychiatric: No history of depression or treatment for psychiatric disorders.

PHYSICAL EXAMINATION
General Survey.
Patient L.A. has an ectomorphic body built. She was sitting on her bed, conscious, coherent,
participative, well-groomed, and was in a good mood. No signs of respiratory distress.
Vital Signs.
Temperature: 36.3 degrees celsius (axillary)
BP : 110/80 mmHg
RR: 20 cpm
Weight: 53 kg
PR: 84 bpm
BMI: 24.14 kg/m2 (Normal)
Height: 5'2
Skin, Hair, and Nails.
Skin is light brown in color and body hair is evenly distributed throughout the body. Skin is
warm to touch with good skin turgor. Hair is black in color. It is smooth, oily, with no signs of
infestation. Nails on the fingers and toes are slightly pale in color with no clubbing noted.
Capillary refill time of 2 seconds.
Head, Eyes, Ears, Nose, Throat (HEENT).
Head. Normocephalic with no deformities noted. No nodules noted upon palpation.
Eyes. Eyebrows are black, symmetrical and evenly distributed. Palpebral fissures are
symmetrical. No eyelid edema, ptosis or lid-lag noted. Eyelashes are thick, evenly distributed

and growing outwards. Eyeballs are normal in size with no signs of exophthalmos.
Conjunctiva is pink with no lesions, Sclera is white and anicteric. There is no corneal opacity.
Irises are brown. Visual fields are full by confrontation. Pupils are isocoric with a diameter of 3
mm and equally reactive to light and accommodation. Extraocular movements are intact.
Ears. No masses or lesions on external ear. Auricles are elastic and the top of the pinnae are
in line with the outer canthus of the eye. Ear canals are patent with no discharges. Tympanic
membrane is visible, pearly gray and intact with no signs of inflammation. There is good
hearing acuity.
Nose and Sinuses. Nasal septum is in midline. No nasal discharge noted. Frontal, maxillary,
mandibular and ethmoid sinuses are non-tender.
Mouth. Oral mucosa is pink, tongue and uvula are in midline. No ulcerations, hoarseness of
voice, bleeding gums, sores, fissures, dental carries, tonsillitis. No tongue enlargement or
deviation.
Neck. No visible masses and gland enlargement. No neck deformities or stiffness noted.
Trachea is in the midline. No palpable mass, nodules noted. Thyroid gland not palpable.
Lymph Nodes. No visible and palpable lymph nodes in the cervical, supraclavicular, posterior
auricular, and axillary area.
Thorax and Lungs.
No chest deformities or intercostal muscle retractions noted. Patient has symmetrical chest
expansion. There was no tenderness noted upon palpation. Normal tactile fremitus felt on
both lung fields. Resonant sound percussed on both lung fields. Vesicular breath sounds and
normal vocal fremitus heard throughout the lung fields. No adventitious sounds noted.
Cardiovascular.
No lifts and heaves noted. Bruit not palpated. Point of maximal impulse is felt at 5th
intercostal space midclavicular line. Regular cardiac rhythm heard at the apical, pulmonic,
tricuspid, and mitral area. Apex beat is best heard at the point of maximal impulse. Murmurs
not noted.
Breasts. Breasts are symmetrical with no nipple discharges noted. No deformities, dimpling
or retractions, mass or nodules noted.
Abdomen. Abdomen is slightly protuberant. Stretch marks noted on lower abdomen. Scar
from previous Bilateral Tubal Ligation noted at the infraumbilical area. Normoactive bowel
sounds on all quadrants. Liver span in right midclavicular line within normal range. Spleen
and kidneys are non-palpable with no signs of enlargement. No ascites, tenderness or
masses on palpation. No radiating pain.

Pelvic Exam
External Genitals: grossly normal genitalia
Speculum exam: cervix is pinkish, smooth, with no lesions or masses noted.
Bimanual exam: No cervical motion tenderness, Uterus is non-enlarged with smooth
contours, No adnexal masses palpated.
Extremities: No deformities, edema or ulceration noted.
Peripheral Vascular. No varicosities or edema noted. Pulses are full and brisk.
Musculoskeletal. No joint deformities, swelling and tenderness on the joints. Good range of
motion noted with hands, wrists, elbows, shoulders, knees, and ankles.
Neurologic. Patient is alert, responsive and coherent. She has good memory with orientation
to person, place, and time.
Motor. Good muscle tone. Muscle strength of 5/5. She is able to do finger to nose test and
rapid-alternating movements without difficulty.
Reflexes. normoactive reflexes.
Cranial Nerves.
CN I. Olfactory Able to smell the scent of coffee.
CN II. Optic Able to read prints with a font size of 12 without glasses on. Intact visual fields.
Pupils constrict upon direct exposure to light. Intact consensual reflex.
CN III. Oculomotor Pupils are equally round, reactive to light and accommodation. Able to
open eyes without difficulty. Intact extraocular muscles.
CN IV. Trochlear Able to rotate eyes internally and gaze downward.
CN V. Trigeminal Able to open and close mouth. Has strong muscles for mastication. Able
to distinguish soft from sharp touch.
CN VI. Abducens Able to deviate eyes laterally.
CN VII. Facial Able to smile, frown, raise eyebrows, close eyes, and close mouth.
CN VIII. Vestibulocochlear Able to hear tick of the fingers.
CN IX. Glossopharyngeal Able to swallow without difficulty. With good articulation.
CN X. Vagus - Able to speak well. Uvula is in midline.
CN XI. Spinal Accessory - Able to shrug both shoulders and turn head from right to left
against resistance.
CN XII. Hypoglossal Able to move tongue from right to left, up and down.
ADMITTING IMPRESSION
G7P6 (5-1-1-5); Endometrial Hyperplasia; Anemia
DIFFERENTIAL DIAGNOSIS
Diagnosis
Rule In
Endometrial Hyperplasia
Vaginal bleeding

Rule Out
Cannot be ruled out without

Endometrial Cancer

Endometrial Polyp

Endocervical Polyp
Leiomyoma
Adenomyosis

History of OCP use

biopsy
Family history of ovarian and
colon cancer
Ultrasound finding of
thickened endometrium
Vaginal bleeding
Cannot be ruled out without
History of OCP use
biopsy
Family history of ovarian and
colon cancer
Ultrasound finding of
thickened endometrium
Vaginal bleeding
No protruding mass on the
cervix noted during
speculum exam
No polypoid growth detected
during previous ultrasound
Vaginal bleeding
No polypoid growth noted on
speculum exam
Vaginal bleeding
No irregular masses
palpated on bimanual exam
Vaginal bleeding
No uterine enlargement

CASE DISCUSSION
Endometrial hyperplasia is the proliferation of endometrial glands leading to a greater
than normal gland-to-stroma ratio. It can be classified based on the degree of architectural
disruption and cytologic atypia. This is significant because of the risk of progression to
endometrial adenocarcinoma.
Endometrial hyperplasia most often is caused by unopposed exposure to estrogen. If
ovulation does not occur, progesterone is not made to counteract estrogen, and the
endometrial lining is not shed. The endometrium becomes hyperplastic and in some women
may progress to dysplasia and cancer.
Endometrial hyperplasia usually occurs after menopause. However, it also can occur
during perimenopause, when ovulation may not occur regularly.
The most common sign of hyperplasia is abnormal uterine bleeding. It can manifest as
menses that are heavier or lasts longer than usual, which is what happened to our patient.
Alternatively, you can have menstrual cycles that are shorter than 21 days or any bleeding
after menopause.
RISK FACTORS
Older than 35 years (our patient is 49 years old)
Caucasian
Nulligravid

Late menopause
Early menarche
Personal history of DM, PCOS, Thyroid or Gall bladder disease
Obesity
Cigarette smoking
Family history of ovarian, colon, or uterine cancer (Present in our patients family
history)

DIAGNOSIS
This can be done via transvaginal sonography, which can detect thickening of the
endometrium. However, to make sure it is not cancer, performing a biopsy is the only way.
This can be carried out via endometrial biosy, dilatation and curettage or hysteroscopy.
TREATMENT OPTION

Davao Medical School Foundation, Inc.

Medical School Drive, Bajada, Davao City

OB-GYNE HISTORY TAKING AND PHYSICAL ASSESSMENT

In Partial Fulfillment
Of the Course Requirements
In Obstetrics and Gynecology

Submitted to:
Dr. Tessa Mae J. Bonguyan, M.D.

Submitted by:
Ang, Vivien Q.
Medicine 3
December 19, 2015