Gynecologic Case Study

ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous structures of the abdomen appeared unremarkable. No free air was seen.

Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18

Abdomen: The lipases appeared unremarkable. The liver, spleen, gallbladder adrenals, kidneys, pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seemed consistent with acute appendicitis. All the structures of the abdomen appeared unremarkable. No free air was seen.

General: no history of weight change, fever or chills, weakness, fatigue, or change in appetite;

Diagnostic Studies: Flat plate and upright films of the abdomen revealed a localized abnormal gas pattern in the right lower quadrant with no evidence of free air.

The patient was on 17 weeks and 5 days of pregnancy on the admission day. The patient had experienced two previous miscarriages which happened two years ago. Two previous pregnancies also because of cervical incompetence secondary to bicornuate uterus. Instead of being pear-shaped, bicornuate uterus looks more like a heart, with a deep indentation at the top. Most of the women with bicornuate uterus might present with cervical incompetence or early pregnancy loss. Clinical manifestations of the patient shown are quite significant which are changed in vaginal discharge for one week and also light vaginal bleeding in the later stage. Vaginal discharges are thick in consistency, whitish in color and no foul

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

22. An office consultation is performed for a postmenopausal woman who is complaining of spotting in the past 6 months with right lower quadrant tenderness. A comprehensive history and physical are

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

Regardless of whether the patient is admitted for IV antibiotic therapy or whether she is treated at home with oral antibiotic therapy, she should be reassessed within 72 hours of beginning treatment, and if she shows no improvement, she needs to be further evaluated (Sabb). Pelvic inflammatory disease is difficult to diagnose. Many women present with vague symptoms or none at all; therefore, any sexually active woman at risk for STDs should undergo periodic screening for STDs and PID (Ashear, 2017). Early detection and treatment are key for clients with PID as delayed treatment allows for further scarring and could lead to irreversible difficulties including infertility. Other long-term complications include ectopic pregnancy and

Research conducted by Navve et al., (2013) examined 30 confirmed cases of adnexal torsion, all of which had positive whirlpool signs seen with sonography. Certain sonographic characteristics were noted in all 30 cases. Appearance of ovarian

Last Examinations: Last examination 2 weeks ago, general check up, told “normal”. Yearly clinical breast examination (CBE), mammography, told “normal”. Yearly Pap smear, last performed January last year, 2010. Last visit to oncologist, 2008, told “normal”.

Uterine Fibroids are non-cancerous growths that develops in the myometrium layer of the uterus. A single cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue (EA, 2013). There are different types of growth patterns to uterine fibroids. Sometimes they are small and in some cases they are extremely large. Woman between the ages of 30-and 40 years old are more at risk of developing uterine fibroids. They develop mostly in the child bearing years of a woman’s life. African American women have a greater risk of developing uterine fibroids at a younger age than any other race. Uterine fibroids are also called leiomyomas or myomas. Uterine Fibroids can develop on the inside or outside of the uterus.