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Gynecologic Case Study

Satisfactory Essays

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 …show more content…

• 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 …show more content…

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

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