Gynecology Case report sample for ZSMU ,Ukraine

1 Ministry of Public Health of

Ukraine

Zaporozhye State Medical University

CASE REPORT

for the 5-year students of Medical faculty

Zaporozhye – 2011

2 PLAN of case history 1. General biographical particulars, passport data 2. Complaints 3. Systems review 4. History 5. Past history (PH) 6. Patient’s objective examination 7. Gynecologic research 8. Tentative diagnosis 9. Examination plan 10. Additional investigations data 11. Differential diagnosis 12. Final clinical diagnosis 12. Treatment 14. Observation diary 15. Epicrisis

3 I.

GENERAL

BIO- GRAPHICAL

PARTICULARS

(PASSPORT DATA) 1. Name, patronymic name, surname. 2. Age. The age of the patient is of great importance. The same signs have various value in the various age terms (a bleeding in the reproductive period and in postclimacteric; appearance of the discharge of the girl, at the young woman and the woman of senile age, etc.). 3. Nationality. 4. Education: primary, secondary, higher (necessary underline). 5. Profession Trade and working conditions. The trade quite often prompts the causes of gynecologic diseases: the work connected to long standing on legs or with raising of gravities, can cause stagnation of a blood in the inferior extremities and in a basin that can result in intensifying a menses, a hypersecretion from mucosas, to a phlebectasia, a varicous veins, a ptosis of generative organs, etc. Work with phosphorus, lead, an arsenic, ethylene, aniline paints, an acetone can be reflected in menstrual and reproductive functions (frequently there is an infertility and miscarriage). Intense brainwork can cause dysfunction of a menstrual cycle, dropping libido, etc. Conditions of life. Living conditions (refrigerating of foots, dampness, draughts) can be the cause of inflammatory diseases, an incomplete feeding of girls - teenagers - a late sexual development, a underdevelopment of generative organs (an infantilism, UUB). 6. The marital status - girl, married woman, widow. 7. Date (day, month, year, hours with minutes) of admission to the hospital.

4 2. COMPLAINTS Complaints of the patient. It is necessary precisely to find out character and nature of complaints of the patient, duration and variability of signs. Pain. Character of a pain - whining (at an incorrect position of a uterus, at chronic inflammatory processes in appendages of a uterus and a pelvic fat, etc.); contractive (contraction of a uterus at abortion, at tubal abortion, at a submucous leiomyoma, etc.); choped and cutting pain it is observed at a boring of a peritoneum by the blood given vent in a abdomen cavity at a extrauterine pregnancy, an exudate at inflammatory processes; the gnawing pain, is more often strong and long, is characteristic for the started forms of a pelvic members cancer. Localization of a pain can be various: at inflammatory processes in a uterus and urinary bladder the pain is localized in the inferior department of an abdomen on centerline; at disease of appendages of a uterus - in lateral departments of inferior part of abdomen, at retroflexion of a uterus, a parametritis, a perimitritis - in a sacrum and a loin. At some diseases (at an extrauterine pregnancy and etc) the pain can irradiate in range of a scapula and a brachium (phrenicus-sign). Infringement of a menses: infringement of a menstrual bleeding at the kept cycle; change of duration, intensity, morbidity at a menses; padding bleeding abjections; acyclic bleedings; a delay or absence of a menses; appearance of a bleeding after coitus, etc. Discharge (fluor) - from a vagina: conditions of appearance of abjections, quantity, character, colour, smell. The increased quantity it is

5 marked at an incorrect position of a uterus, at inflammatory processes of generative organs, at tumours, etc. Other disorders of sexual function of the woman: infertility, habitual abortions, an itch, a tumour in ranges of generative organs, a falling of the uterus, walls of a vagina, etc. Anomalies of sexual sense: complaints to weakening of a sexual appetence, absence of an orgasm, etc. Disorders of function of interfacing organs: painful urination, urinary incontience, a constipation, diarrhea, a pain at a defecation, etc. The general disorders: bad state of health, palpitation, inflows to a head, a syncopal state, emaciation, an obesity, a sleeplessness, etc. The beginning of disease. The prospective causes: a trauma, an exertion, coitus, abortion, labors, a supercooling, etc.; the first signs of disease. Development of the present disease. The detailed description of a pattern of disease development, where it was, what is the time treated concerning the present disease, what were applied methods of treatment, relapses of disease, etc. 3. SYSTEMS REVIEW

a) General state of the patient: asthenia, rise in temperature, chills, edemas (localization, persistency, causes of appearance. b) Respiratory Organs Breathing through the nose (free, difficult). Nasal cold. c) Cardiovascular system d) Digestive organs e) Liver

6 f) Urogenital system Low back pains (persistent or paroxysmal). Frequency and duration, radiation into femur and genitals. Low back pains accompanied with rise in temperature, chills, nausea, and vomit Diurnal urine excretion, polyuria, oliguria, anuria, nicturia, pollakiuria, hematuria, pyuria. 4. CASE HISTORY (Anamnesis morbi) When did the woman feel herself ill or when did she know about his isease and in what circumstances? What were the complaints? Did the disease begin in acute form or the symptoms developed gradually? Which painful phenomena began earlier and which joined later? What was the cause of the disease from the patient’s point of view? Did she consult a doctor or not? When did she consult a doctor? What was the diagnosis? Was she treated at a hospital or in outpatient conditions? What drugs have been used for treatment (enumerate if possible)? Administration of medicines: peroral or parenteral. What was the treatment response? Whether it was amelioration or changes for worse? What unpleasant feelings decreased? What complaints disappeared? What can woman say about his working capacity? What unpleasant feelings kept on after the woman had been discharged from the hospital? What were the results of treatment in the remission period? Did the patient feel herself better or her state gradually changed for worse? What new complaints appeared? became more intensive? What was the cause of this exacerbation from the woman’s point of view? Where was she treated? What was the di-

7 agnosis? What medicines were used for treatment? What was the treatment response? What complaints disappeared or decreased? What was the treatment in remission period? 5. MEDICAL HISTORY OF LIFE (Anamnesis vitae) Anamnesis of life Heredity, or family anamnesis. Data on parents, health and diseases of parents (the cause of their mortalities), brothers and sisters, the husband. At relatives mental, oncologic, endocrine diseases, a tuberculosis, a lues, etc. (inheritable predisposition to diseases, family infestation by contagions). The childhood. Data on the common development at children's age: when the first dens appeared, when began to go, whether well studied. Conditions of life and a feeding in the childhood. The transferred diseases in the childhood. Children's infection contaminations (a scarlatina, a diphtheria, measles, a tuberculosis, rheumatic disease, an adenoid disease) can cause a stenosis or an atresia of a vagina, Аsherman’s syndrome (endometrial synechias), infringement of menstrual function, infertility; the rachitis transferred in the childhood conducts to deformation of pelvis. The diseases transferred at mature age. Long debilitating diseases (circulation system, kidnies, persistent infections, etc.) can cause changes of function of ovaries, infringements of a menstrual cycle; the tuberculosis quite often results in an amenorrhea and infertility, etc. Data on the operations transferred earlier and traumas. Harmful habits. Аlcoholism, smoking, a narcomania, etc.

8 Allergological

anamnesis. What medicine is not tolerated by

the patient as the intolerance shows, reaction, how reaction has been removed, what is the time last. Gynecologic anamnesis Anamnesis of secretory function. The normal secretion of the sexual device of the woman does not invoke pathological sensations. The hypersecretion and change of character abjections always are an attribute of gynecologic or extragenital diseases. Quite often abjections are a unique attribute of disease (incipient states of a cancer of a corpus and cervix of a uterus, gonorrheal endocervicitis, etc.). Whether the quantity of abjections has increased, the smell, outward of abjections (diaphanous mucilage, caseous, lactate, with “a fish smell”, watery, foamy, the admixing of pus or a blood, watery character of abjections such as meat waters. Character of abjection (a constance, discontinuity) of discharge, that quite often can specify their source. Constant discharge are observed at inflammatory diseases of a uterus, cervix, a vagina, a vulva. The increased abjection of discharge (mucous) in follicular phase with their maximum quantity by the moment of an ovulation testifies to disease of cervix of a uterus. Petering of discharge before and during a menses is observed at pathological processes in uterine tubes (pyo-and a hydrosalpinx). Anamnesis of menstrual function. Age of the first menses, time of an establishment of a correct menstrual cycle; a hemorrhage, morbidity, duration of the first menses. Phylum of a menses: duration of a menses; quantity of a loss blood; it is a lot of, a little, moderately, with clots. A pain at a menses: during time, up to or after menses, character of pain (whining, contractive, etc.). The changes of a menstrual cycle connected to the beginning

9 of sexual life, after labors and abor- tions or without the seen causes. Character of changes of a menstrual cycle. Anamnesis of sexual function. Age of the beginning of sexual function, features. Bleeding contact discharge after the sexual act are an attribute of a cancer of cervix uterus, less often - erosion and an endometriosis of cervix uterus, etc. Infringements of the sexual act are observed at narrowing, overgrowth and aplasia of a vagina, and also at a hypoplasia of generative organs. Anamnesis of reproductive function. All pregnancies transferred by the woman and their outcomes. Quantity of labors, course, complications and operations at labors. Course of puerperal periods. Quantity of abortions, character of abortions (medical, spontaneous, medicamental, criminal). Terms of an abortion, course, complications of abortions. Infertility - initial or the secondary. The prospective causes and treatment. Application of contraceptives. 6. OBJECTIVE EXAMINATION OF A PATIENT (Status praesens) General state of the patient: good, satisfactory, grave, extremely grave. Patient’s posture: active, passive, forced. Consciousness: clear, dull, lost. Expression of the face: impartial, restless, frightened, dull, exhausted, face of Hyppocrat, distressed, sardonic smile. Height, weight, body constitution: strong or weak. Constitutional type: normosthenic, asthenic, hypersthenic. Nutritional state: moderate, reduced and excessive. Cachexia. Obesity of the I – IV degree.

10 Skin and visible mucosal

membranes: dry, moist (sweating);

colour – normal, pale, bile-tinged (icteric, subicteric), cyanotic (acrocyanosis, diffusive cyanosis). Pigmentation disturbance (depigmentation, hyperpigmentation). Rashes, hemorrhages, scars. Bedsores. Skin elasticity (turgor), hair, nails. Subcutaneous fat: the degree of its development. Edemas: spreading, localization, level of intensity, subcutaneous edema (anasarka). Lymphatic system: submandibular, cervical, occipital, supra- and subclavian, axillary, inguinal, femoral lymph nodes. Size, consistency, cohesion with subjacent tissues, painfulness, skin colour over lymphatic nodes. RESPIRATORY SYSTEM Auscultation of lungs: types of respiration (vesicular - normal, puerile, diminished, strengthened, rough respiration, saccadic; bronchial amphoric, metallic; mixed or undefined). CARDIOVASCULAR SYSTEM. Auscultation: cardiac rhythm (regular, irregular). Pulse: rate, filling, tension, rhythm, value, form. Determination of arterial pressure in the brachial artery from the left and from the right. DIGESTIVE SYSTEM. Examination of oral cavity: bad smell from the mouth, colour of lips and visible mucous membranes. State of teeth: carious teeth, absence of teeth, artificial teeth. Tongue: humid, dry, furred, pale, brightly red, cyanotic.

11 Examination of abdomen:

form, symmetry, participation in

breathing, abdominal swelling in hypogastric area and retraction in epigastrial area at the same time. Varicose cutaneous veins. Visible stomach and intestinal peristalsis. State of umbilicus: inverted, thrown out, smoothed. Postoperative scars on the abdominal wall. Hernias (omphalocele, incisional, inguinal, femoral). Palpation of abdomen: Surface preliminary palpation: determination of abdominal wall resistance, painfulness (defuse, local), Shchetkin – Blumberg’s peritoneal syndrome. Determination of abdominal dropsy by the fluctuation method. Deep, sliding, methodical, systematic, topographic palpation according to the V. P. Obraztov-N. D. Strazhesko begins with sigmoid palpation (determination of its thickness, mobility, consistency, painfulness), then caecum is palpated with determination of its state, then the bottom of stomach and transverse colon are palpated. Percussion of abdomen: Meteorism, presence of an ascites, definition of contours of a tumour and infiltrate. Auscultation of abdomen: Peristalsis of an intestine, at differentiation of pregnancy from a tumour. Liver: determination of sizes by percussion according to Kurlov, determination of the liver edge character (sharp, rounded), painfulness of liver, character of the surface, consistency (dense, soft). Special examination of gallbladder, its tenderness, enlargement. Courvoisier's symptom, phrenicus–symptom. Spleen: location, consistency, painfulness.

12 Kidneys and urinary blad-

der: bimanual palpation of kidneys

(nephroptosis, painfulness, tuberosity). Pasternatsky's symptom. Painfulness along ureter. Examination of suprapubic area (painfulness, swelling). 7. Gynecologic research Survey of outside generative organs. A degree of development. Phylum of development of pilosis (female, male). A phlebectasia, opening of sexual cleft, an intertrigo, a ulcer, a tumour, deformation. A ptosis, uterine and vaginal walls prolapse. A state of back commissure (seams after a breakage of a perineum). A state of an outside foramen of a urethra, paraurethral glands. A state of a hymen. Skin colour of a vestibule. Speculum examination: survey of uterine cervix and vagina. Size and the form of cervix uterus, the form of external os, colour mucous, discharge from the cervical canal (seams, ruptures, ovulas Nabothi, erosion, an ectropion, polyps, condylomas). Internal examination. A vagina, width of an orifice, distensibility, character mucous (a roughness, folding, smoothing). A state of fornicis (short, a diverticulum, pulsation, motility mucous, painless). Uterine cervix (size, a consistence, its attitude to a leading axis of a pelvis, permeability of the cervical canal). Bimanual vaginal examination. Uterine corpus: a position (anteflexio, retroflexio, interpositio, retropositio), size, the form and a consistence, a surface, sensitivity, motility, an interrelation of length of uterine cervix to uterine corpus. A state of appendages of a uterus (size, painless, presence of tumours). A state of fornicis, a parametric fat. 8. TENTATIVE (PROVISIONAL) DIAGNOSIS

13 (Scheme of substantiation of

a diagnosis)

The patient complains of … (name the complaints, which confirm the diagnosis). Anamnesis of the present disease. The patient considers herself to be ill since….. when…(briefly state the main stages of the disease, which confirm the diagnosis: beginning, symptoms, the course of the disease, the cause of the disease etc.). Anamnesis of life (anamnesis vitae). Describe only those diseases and unfavourable factors, which might contribute to the development of the present disease. Objective data: the results of examination, palpation, percussion, auscultation, which confirm the diagnosis. On the basis of the above-stated it may be considered that the woman has … (formulate the diagnosis in full). 9. Plan of examination 10. ADDITIONAL INVESTIGATIONS DATA Blood, urine, and feces bulk analyses. Biochemical blood investigation data. Bacterioscopy discharge examination, Pap-smear, USG. Instrumental methods of the investigation. 11. The differential diagnosis It is necessary to describe diseases which can give a similar clinical pattern. On the basis of reasonings, the fact data and clinical course of illness, padding methods of inspection to carry out differential diagnostics and give the final diagnosis (a basic disease, the complications, concomitant diseases). 12. FINAL CLINICAL DIAGNOSIS.

14 On the basis of woman’s

complaints. On the basis of anamne-

sis. On the basis of physical examination data. On the basis of additional investigations data. To describe in detail given disease, an etiology, a pathogeny, treatment. 13. TREATMENT. The prescribed treatment: the regime, the diet, drugs and other applied methods of treatment. To prove treatment of the patient. If the patient had operation, point indications and to describe the report of operation, a macropreparation and the data of histological research. The prognosis (for health, for life, for work). 14.

OBSERVATION DIARY.

The diary reflects the woman’s state in dynamics taking into consideration the effectiveness of the applied treatment. Complaints, the common state of the patient, Тo, Рs, dream, appetite, tongue, an abdomen, function of an intestine, a diuresis, character of vaginal abjections and other changes descending for day. Assignments: a diet, a regimen (bed, common). Administration of pharmaceuticals to write down accordingly recipes (without the indicating of a patient’s surname). In a diary it is carried out short substantiation appointed agents, change of treatment. 15. EPICRISIS. Epicrisis includes short summary of anamnesis, objective examination data, clinical diagnosis of the disease with its substantiation and the most important additional methods of the investigation, which confirm the

15 diagnosis. The applied treatment

and its effectiveness (the improve-

ment, impairment, without any changes) should be indicated. Epicrisis is concluded with recommendations to the woman (regime, diet, treatment, including a sanitary – resort one and etc.). The list of the worked literature Date

Signature of the curator