SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Bernadas

DATE: MARCH 04,2015
SUBMITTED BY: DE LOS SANTOS, ROSHEIL MAE C.

SUBJECT: GYNE

CASE
IDENTIFYING DATA: A case of 70 year old widow
CHIEF COMPLAINT: Postmenopausal spotting
HISTORY OF PRESENT ILLNESS:
8months PTA, patient claimed to have vaginal spotting staining her underwear. No consultation was
done.
4months PTA, the condition advanced to vaginal bleeding consuming 2 sanitary napkins/day. Patient
just tolerated the condition.
1month PTA, due to persistent demand of relatives, patient has decided to seek consultation with a
local physician. Iron preparation was given and advised observation.
2weeks PTA, persistence of vaginal bleeding prompted her to seek consultation with an OB-GYN. On
BPE, a slightly enlarged uterus with minimal bloody discharges on the examining finger. TVS was
ordered which revealed a thickened endometrium m. 31mm. The patient underwent Fractional D and
C. Histopathology result revealed a crowded back-to-back endometrial glands.
OB-GYN HISTORY:
The patient claimed she had her menarche at 15 y.o. with regular menstrual cycle during her entire
reproductive years. She consumed 4 sanitary pads/day moderately soaked with blood. No
dysmenorrheal was noted. Menopause at 55 y.o. Pap smear (2004) with unremarkable results.
G3P3 (2102) all NSVD
PAST MEDICAL HISTORY:
Patient is a known hypertensive for 20 years now. Maintained Enapril with good compliance. Known
diabetic for 10 years now. Maintained Glicazide with good compliance.
PAST SURGICAL HISTORY:
July 2013 S/P Radical Mastectomy for Left breast cancer. Presently, on Tamoxifen Therapy.
FAMILY HISTORY: No data given.
PERSONAL AND SOCIAL HISTORY: No data given.
REVIEW OF SYSTEM
PHYSICAL EXAMINATION
General: Examined awake, conscious, coherent, not in respiratory
NO DATA GIVEN
distress
General:
Vital signs:
Skin:
BW: 98kg
HEENT:
Cadiac Rate: 64 bpm
Breast:
Respiratory Rate: 14 cpm
Respiratory:
Blood Pressure: 150/90 mmHg
Cardiovascular:
HEENT: Slightly pale palpebral conjunctiva
Gastrointestinal:
Breast: Surgically absent left breast. No palpable masses on right
Urinary:
breast.
Genitals:
Abdomen: Flabby, normoactive bowel sounds, soft, (-) tenderness
Peripheral Vascular:
on all quadrants

Musculoskeletal:
Psychiatric:
Neurologic:
Hematologic:
Endocrine:
Functional Status:

SE: Pale pink and atrophic cervix, (+) trickling bloody discharge
BPE:
I: Parous
C: Closed, atrophic, smooth
U: 8 weeks size uterus
A: Negative
D: Minimal bloody discharge on examining finger, no foul-smelling
discharges