Task (1) List of Symptoms, Risk Factors or Exposure (Pertinent Points) Processed List
Task (1) List of Symptoms, Risk Factors or Exposure (Pertinent Points) Processed List
Task (1) List of Symptoms, Risk Factors or Exposure (Pertinent Points) Processed List
Processed List
Menorrhagia
Menorrhagia
Anemia
History of Miscarriage
7. No hx of STIs
8. Mother has hypertension and uterine fibroids for
which she had an hysterectomy
9. She is a non-smoker, consumes 1 glass of wine/night,
10. Has had 5 sexual partners in her life, uses condoms
with her spouse and is monogamous
Pelvic examination
o Speculum examination
o Bimanual palpation
o Rectovaginal examination
HEENT
o Conjunctiva
o Mucous membranes
Pertinent Physical
Examination
Inspect the external genitalia
Perform Speculum examination
Perform Bimanual palpation
Perform Rectovaginal examination
Inspect the conjunctiva for pallor
Inspect mucous membrane for
dehydration
Uterine Fibroids
Adenomyosis
Endometrial Cancer
CC: My periods have become really heavy for the past four months
HPI: Patient presents for evaluation of heavy periods for the past four months. One week ago the patient had a very
heavy period in which she required the use of multiple pads and tampons. Prior to this episode she notes regular
periods every 28 days lasting about 5 days in length. She denies any pain and intermenstrual bleeding associated
with these episodes. There are no relieving or exacerbating factors. ROS is remarkable for fatigue and lightheadedness
OB/GYN: LMP was one week ago. Menarche at age 12, regular and used 3 tampons/day before the symptoms started.
There is a history is miscarriage at 8 weeks which occurred three years ago. Last pap smear and breast exam was six
months prior.
SEXUAL: She is currently in a monogamous relationship with her husband, uses condoms, no hx of STIs. She has had
five sexual partners in the past.
Allergies: none
Medications: multivitamins
PMHx: She has had a dilation and curettage for miscarriage 3 years ago.
Social: Non-smoker, drinks one glass of wine occasionally, and has no history of drug use. Accountant.
Objective History
Vital Signs: T 98.6 BP 100/70, PR 70, RR 14
General Assessment: middle-aged anxious woman in no acute distress
Primary system: Female Genitourinary
Vaginal mucosa without lesions or exudates, cervix without lesions or masses, cervical os closed with scant blood
present in the vaginal vault. Bimanual examination without enlargement, masses, or nodularity. Rectal
examination with appropriate tone and without palpable masses.
Additional Systems to examine
- HEENT: pallor
Menorrhagia
Fatigue
Light headedness
Family history of uterine fibroid
Anemia
Menorrhagia
Fatigue
Anemia
Lightheadedness
Diagnosis #3: Endometrial Cancer
HISTORY FINDING(S)
Menorrhagia
Fatigue
Light headedness
Anemia