OB-GYN Case Studies

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Uterine prolapse.

HISTORY OF PRESENT ILLNESS

This is a 64-year-old woman who is para 4, who was referred because of a large cystocele and uterine prolapse.  The patient states that when she is on her feet, a bulge comes out of the vagina between her legs.  She was found to have a large cystocele and a second-degree uterine prolapse, the cervix protruding through the os even with the patient lying down, when she strains.  She does not have any significant problem with urinary tract control.  She enters at this time for vaginal hysterectomy and A&P repair.

PAST HISTORY

Her general health has been reasonably good.  She is taking Lanoxin 0.25 mg 1/2 tablet per day.

PHYSICAL EXAMINATION

GENERAL:  Physical examination reveals a well-developed,
well-nourished, slender white female at 131 pounds.  Blood pressure is 130/70.

HEENT:  Ears negative.  Eyes:  Pupils small, react well to light.  Sclerae clear.  Mouth:  I believe the patient has dentures.  The throat is clear.  Tonsils are absent.

NECK:  Supple.  No masses felt.

BREASTS:  Quite good turgor for her age.  No masses are felt.

LUNGS:  Lungs are clear to P&A.

HEART:  Regular rhythm, no murmur.

ABDOMEN:  The abdomen is soft and nontender.

GYNECOLOGIC EXAMINATION:  On gynecologic examination, there is relaxation.  When the patient strains, the bladder bulges down and out and the cervix comes out through the introitus.

RECTAL:  Rectal is negative.  No intrinsic masses.  Moderate rectocele.

EXTREMITIES:  No significant deformities are noted.  No edema.  Reflexes are physiologic.

IMPRESSION

1. Second-degree uterine prolapse.

2. Cystocele with some rectocele.

PLAN

Plan is for vaginal hysterectomy, anterior repair, and possibly posterior repair at the same time.

FOOTNOTE

Line 16 (Page 1).  The word but dictated after lying was deleted because the doctor means that the cervix protrudes when she strains lying down.

Line 23 (Page 1).  Lanoxin is prescribed in milligrams; thus, the proper metric unit of measurement was added to the medication dosage.

Lines 26, 29, 37 (Page 1).  The subheadings were added for clarity.