Subjective
C/C: “I’m here for my routine gynecologic visit”
HPI: 45 year old G2P2 female presents to the office today for a routine gynecologic check including breast, external genital exam, and pelvic exam with no recent medical issues. Patient noted her menstrual cycle occurs every 30 days with bleeding lasting 7 days with associated symptoms. Denies dysmenorrhea, menorrhagia, dyspareunia, pelvic pain, vaginal discharge, itchiness or lesions on external genitalia. LMP 6/1/2017. Admits to abdominal bloating and fullness. States her daughter told her that her abdomen appears to be swollen and has increased in size. Denies any contraceptive use.
PMH:
• Past medical history o Hypertension
• Allergies o None
• Medications o Lisinopril
• Hospitalizations
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• Abdominal: mass in LLQ upon palpation, no lesion noted, abdomen soft and distended, tender to palpitation, no guarding or rebound tenderness. No splenomegaly.
• Pelvic: External Genitalia: no lesions or masses o Inspection of Cervix and Vagina: no discharge, cervix pink o Bimanual exam: uterus is anterior, midline, smooth, not enlarged. Exam confirms mass in left adnexa. Right adnexa is normal. o Rectovaginal exam: no masses or fissures. no hemorrhoids
• Breast exam: Both breasts were symmetrical and nipples were normally everted. Nipples were hyperpigmented. No fungal infection beneath the breast, no masses, no retraction of the nipples, no leakage and other abnormalities were noted
• Musculoskeletal: normal range of motion exhibited throughout all extremities
• Neurological: Alert, awake, and oriented x 3
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They are usually 3 to 8 cm in size and are asymptomatic and unilateral. Additional findings can include a large follicular cyst which causes a tender palpable ovarian mass and can lead to ovarian torsion when greater than 4 cm in size. Follicular cyst usually resolves spontaneously in 60 to 90 days. Another type of ovarian cyst are corpus luteum cyst which occur during the luteal phase of the menstrual cycle and are formed due to the corpus luteum failing to regress after 14 days and becomes enlarged or hemorrhagic. Patients usually present with dull lower quadrant
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
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.
History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and
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
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
Findings show a ratio of 1:3 between lateral and medial locations of torsion, and 53% of all cases occurred on the right side (Navve et al., 2013). Other notable findings concluded that cases involving the left ovary saw the whirlpool sign medial to the ovary, as opposed to cases involving the right ovary, where only half the cases saw the whirlpool sign medial to the ovary (Navve et al., 2013). One of the most important conclusions from the research conducted by Navve et al., (2013) correlated the medial location of the whirlpool sign with a smaller torsed mass, while the lateral location of the whirlpool sign is consistent with a larger torsed
Uterine fibroids affect 3 out of 4 women (Mayo Clinic, 2014). They are non-cancerous but they can cause pain and discomfort. This paper will discuss who can be effected by Uterine fibroids and its effects on the female reproductive system. This paper will show the three types of fibroids that develop in or near the uterus. It will discuss the symptoms and when a diagnosis is needed. This paper will also look into the various forms of treatment including medications and surgery.
General: no history of weight change, fever or chills, weakness, fatigue, or change in appetite;
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.
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”.
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