patient mp - ob draft

Informant: Patient and her boyfriend Patient MP, 28y/o, single, RC, from Manaoag, Pangasinan, admitted for the first time – R1MC – Feb. 3 @1pm CC: Profuse vaginal bleeding (March 2014) patient experienced twice heavy menstruation in just one month, with clots (dark-colored), 7 -8 days duration, 10 pads per day, fully soaked from first day to 5 th day. Associated with pallor, dizziness and pruritus. No meds taken. No consultation. 10 months PTA, (April 2015) heavy vaginal bleeding, 5 pads fully soaked, fresh red blood, no associated pain. Sought consult – District hospital in Manaoag. Referred – R1 – 1 st admission UTZ: mass in the ovaries, mongo size 4 days confinement Prescribed with OCP (color blue) unrecalled name, OD, discontinued taking it last May 2015 Thereafter, patient had vaginal bleeding everyday, consuming of 5 pads per day, moderately soaked. She can no longer distinguish her normal cycle of menstruation 4 hours PTA, heavy vaginal bleeding with clots, dark-colored blood, associated with dizziness and weakness, no pain, no discharges Menarche: 12 y/o, 4 days duration, 1 pad per day, moderately soaked. No assoc dysmenorrhea and headache. Regular cycle of menstruation (28-30 days cycle) LMP: December 5, 2015 (she’s not sure) OB score: G0 1 year ago, 1 st pregnancy test, negative Accdg to the patient, they wanted to have a child, but she had difficulty to get pregnant Sexual hx: Coitarche: 25y/o – first boyfriend,assoc with dyspareunia and slight bleeding Had 2 sexual partners Present boyfriend, satisfied, no assoc pain during intercourse, 2x a week – sex

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Informant: Patient and her boyfriend

Patient MP, 28y/o, single, RC, from Manaoag, Pangasinan, admitted for the first time – R1MC – Feb. 3 @1pm

CC: Profuse vaginal bleeding

(March 2014) patient experienced twice heavy menstruation in just one month, with clots (dark-colored), 7 -8 days duration, 10 pads per day, fully soaked from first day to 5 th day. Associated with pallor, dizziness and pruritus. No meds taken. No consultation.

10 months PTA, (April 2015) heavy vaginal bleeding, 5 pads fully soaked, fresh red blood, no associated pain. Sought consult – District hospital in Manaoag. Referred – R1 – 1st admissionUTZ: mass in the ovaries, mongo size4 days confinementPrescribed with OCP (color blue) unrecalled name, OD, discontinued taking it last May 2015

Thereafter, patient had vaginal bleeding everyday, consuming of 5 pads per day, moderately soaked. She can no longer distinguish her normal cycle of menstruation

4 hours PTA, heavy vaginal bleeding with clots, dark-colored blood, associated with dizziness and weakness, no pain, no discharges

Menarche: 12 y/o, 4 days duration, 1 pad per day, moderately soaked. No assoc dysmenorrhea and headache. Regular cycle of menstruation (28-30 days cycle)

LMP: December 5, 2015 (she’s not sure)OB score: G01 year ago, 1st pregnancy test, negativeAccdg to the patient, they wanted to have a child, but she had difficulty to get pregnant

Sexual hx: Coitarche: 25y/o – first boyfriend,assoc with dyspareunia and slight bleedingHad 2 sexual partnersPresent boyfriend, satisfied, no assoc pain during intercourse, 2x a week – sex

Allergies: Chicken, unrecalled meds, derma prescribed her a lotion, unrecalled name

(-) chicken pox(-) measles(-) mumps

Unrecalled immunizations

No surgical hx

HS grad