Ministry of Public Health of Ukraine

Zaporozhye State Medical University

CASE REPORT

for the 5-year students of Medical faculty

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Zaporozhye – 2011

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

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I. GENERAL BIOGRAPHICAL 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 repro-

ductive 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 repro-

ductive 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, damp-

ness, draughts) can be the cause of inflammatory diseases, an incomplete

feeding of girls - teenagers - a late sexual development, a underdevelop-

ment 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.

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2. COMPLAINTS

Complaints of the patient. It is necessary precisely to find out char-

acter 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 ob-

served 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 lat-

eral 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; pad-

ding bleeding abjections; acyclic bleedings; a delay or absence of a menses;

appearance of a bleeding after coitus, etc.

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Discharge (fluor) - from a vagina: conditions of appearance of ab-

jections, quantity, character, colour, smell. The increased quantity it is

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, habit-

ual 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 ap-

petence, absence of an orgasm, etc.

Disorders of function of interfacing organs: painful urination, uri-

nary 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 ex-

ertion, coitus, abortion, labors, a supercooling, etc.; the first signs of dis-

ease.

Development of the present disease. The detailed description of a

pattern of disease development, where it was, what is the time treated con-

cerning the present disease, what were applied methods of treatment, re-

lapses 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.

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c) Cardiovascular system

d) Digestive organs

e) Liver

f) Urogenital system

Low back pains (persistent or paroxysmal). Frequency and dura-

tion, 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 doc-

tor 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 un-

pleasant feelings decreased? What complaints disappeared? What can

woman say about his working capacity?

What unpleasant feelings kept on after the woman had been dis-

charged from the hospital? What were the results of treatment in the remis-

sion period? Did the patient feel herself better or her state gradually

changed for worse?

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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-

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 conta-

gions).

The childhood. Data on the common development at children's age:

when the first dens appeared, when began to go, whether well studied. Con-

ditions 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 trans-

ferred 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.

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Data on the operations transferred earlier and traumas.

Harmful habits. Аlcoholism, smoking, a narcomania, etc.

Allergological anamnesis. What medicine is not tolerated by the pa-

tient 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 sex-

ual 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 mu-

cilage, caseous, lactate, with “a fish smell”, watery, foamy, the admixing of

pus or a blood, watery character of abjections such as meat waters. Charac-

ter 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, du-

ration of the first menses. Phylum of a menses: duration of a menses; quan-

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tity 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, con-

tractive, etc.). The changes of a menstrual cycle connected to the beginning

of sexual life, after labors and abortions or without the seen causes. Charac-

ter of changes of a menstrual cycle.

Anamnesis of sexual function. Age of the beginning of sexual func-

tion, features. Bleeding contact discharge after the sexual act are an at-

tribute of a cancer of cervix uterus, less often - erosion and an endometrio-

sis of cervix uterus, etc. Infringements of the sexual act are observed at nar-

rowing, overgrowth and aplasia of a vagina, and also at a hypoplasia of gen-

erative 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 con-

traceptives.

6. OBJECTIVE EXAMINATION OF A PATIENT (Status prae-

sens)

General state of the patient: good, satisfactory, grave, extremely

grave.

Patient’s posture: active, passive, forced.

Consciousness: clear, dull, lost.

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Expression of the face: impartial, restless, frightened, dull, ex-

hausted, face of Hyppocrat, distressed, sardonic smile.

Height, weight, body constitution: strong or weak. Constitutional

type: normosthenic, asthenic, hypersthenic. Nutritional state: moderate, re-

duced and excessive. Cachexia. Obesity of the I – IV degree.

Skin and visible mucosal membranes: dry, moist (sweating);

colour – normal, pale, bile-tinged (icteric, subicteric), cyanotic (acro-

cyanosis, 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, co-

hesion 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.

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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.

Examination of abdomen: form, symmetry, participation in

breathing, abdominal swelling in hypogastric area and retraction in epigas-

trial 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, inci-

sional, inguinal, femoral).

Palpation of abdomen:

Surface preliminary palpation: determination of abdominal wall re-

sistance, painfulness (defuse, local), Shchetkin – Blumberg’s peritoneal

syndrome. Determination of abdominal dropsy by the fluctuation method.

Deep, sliding, methodical, systematic, topographic palpation ac-

cording to the V. P. Obraztov-N. D. Strazhesko begins with sigmoid palpa-

tion (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.

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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 examina-

tion of gallbladder, its tenderness, enlargement. Courvoisier's symptom,

phrenicus–symptom.

Spleen: location, consistency, painfulness.

Kidneys and urinary bladder: bimanual palpation of kidneys

(nephroptosis, painfulness, tuberosity). Pasternatsky's symptom. Painful-

ness 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, uter-

ine 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, parau-

rethral 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, dis-

charge 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

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(size, a consistence, its attitude to a leading axis of a pelvis, permeability of

the cervical canal).

Bimanual vaginal examination. Uterine corpus: a position (ante-

flexio, retroflexio, interpositio, retropositio), size, the form and a consis-

tence, 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

(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

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Blood, urine, and feces bulk analyses. Biochemical blood investiga-

tion 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 ill-

ness, 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.

On the basis of woman’s complaints. On the basis of anamnesis. On

the basis of physical examination data. On the basis of additional investiga-

tions data.

To describe in detail given disease, an etiology, a pathogeny, treat-

ment.

13. TREATMENT.

The prescribed treatment: the regime, the diet, drugs and other ap-

plied 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 con-

sideration the effectiveness of the applied treatment.

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Complaints, the common state of the patient, Тo, Рs, dream, ap-

petite, 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 ap-

pointed agents, change of treatment.

15. EPICRISIS.

Epicrisis includes short summary of anamnesis, objective examina-

tion data, clinical diagnosis of the disease with its substantiation and the

most important additional methods of the investigation, which confirm the

diagnosis. The applied treatment and its effectiveness (the improvement,

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

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