BGL 1 Clerks

FEU-NRMF - Dr.
Nicanor Reyes Medical Foundation

Department of Obstetrics and Gynecology
Learning Objectives:
 Identify the signs and symptoms as well as risk factors associated with the given case
 Discuss possible differential diagnosis
 Identify diagnostic work-ups/procedures for each given case and describe the classic
findings
 Discuss the management options for the given cases
DATE: July 1, 2022 INFORMANT: Patient

%RELIABILITY: 95%
GENERAL DATA:
P.A, 60 years old, Gravida 1 Para 1 (1001) , currently residing at Quezon City, consulted for the first time at
FEU-NRMF Medical Center – Out patient clinic department on July 1, 2022.
PATIENT’S PROFILE:
Birthday: October 20, 1961 Habits: smoker, non alcoholic drinker
Birth Place: Manila Availability of relatives: Nearby
Status: Single Religion: Roman Catholic
Occupation: Retired teacher
CHIEF COMPLAINT: left labial mass

HISTORY OF PRESENT ILLNESS
Three weeks prior to consult, the patient noticed a pea-sized, non- movable mass at the left labia
associated with minimal discomfort during movement. She has no associated hypogastric pain, dysuria,
nor any abnormal bleeding/discharge. No consult done, no medications taken.
Until 2 days prior to consult, she noticed gradual enlargement of the said mass now
measuring 8 x 7 cm with associated mild discomfort during movement. Still with no associated
hypogastric pain, dysuria, nor any abnormal bleeding/discharge. She self- medicated with Amoxicillin
1 tablet every 8 hours however due to the persistence symptoms, she sought consult at our
institution and was advised admission.
PAST MEDICAL HISTORY:

The patient had the usual childhood diseases such as measles and chickenpox. Patient is a known
hypertensive maintained on Losartan 50mg 1 tablet once a day and Amlodipine 5mg 1 tab once a day. She
is also diabetic maintained on Metformin 500 mg 1 tablet every 8 hours to which she is compliant, She
denies any other history of major illnesses, trauma and accidents. No history of diabetes mellitus, heart,
liver, kidney, lung or thyroid diseases. No known allergies to food or drugs.
FAMILY HISTORY:
The patient’s father is deceased at 70 years old due to myocardial infarction while her mother is deceased,
secondary to breast cancer. Patient has no siblings. She denies other heredofamilial diseases such as
heart, liver, kidney, lungs, nor allergies to food and drugs.
PERSONAL AND SOCIAL HISTORY:
The patient is an only child. She is a college graduate with a degree in bachelor of science in education
major in social studies and a retired teacher. She is a 30 pack year smoker and an non alcoholic beverage
drinker. She prefers eating meat vegetables and seafoods. She denies any history of illicit drug intake.
REPRODUCTIVE HISTORY
0. Gynecologic History
The patient had her menarche at 12 years old which lasted for 5 days and consumed 3-4 pads/day
with no associated dysmenorrhea. Subsequent menses were regular, with an interval of 28-30 days lasting
for 5 days, consuming 3-4 pads per day, moderately soaked, with no associated dysmenorrhea. Patient
had her menopause at 55 years old.She denies any history of exposure to sexually transmitted disease.
Pap smear was not done.
B. Obstetrical History
The patient is a G1P1 (1001). Her only pregnancy was delivered to a term baby boy via Normal
spontaneous delivery at a hospital with no complications.
C. Method of Contraception
none.
D. Sexual History
The patient had her coitarche at 30 years old with 1 sexual partner. She had no partner ever since.
She denies any history of sexually transmitted diseases.
REVIEW OF SYSTEMS
● Constitutional Symptoms: (-) weight loss; (-) weakness; (-) fatigue; (-) chills; (-) loss of appetite
● Skin: (-) itchiness; (-) excessive dryness/sweating; (-) change in color (-) cyanosis, (-) pallor, (-)
jaundice, (-) erythema
● Head: (-) headache; (-) dizziness/vertigo
● Eyes: (-) pain; (-) blurring of vision; (-) double vision; (-) lacrimation; (-) photophobia; (-) use of
eyeglasses
● Ears: (-) earache; (-) deafness; (-) tinnitus; (-) ear discharge
● Nose and Sinuses: (-) changes in smell; (-) nose bleeding; (-) nasal obstruction; (-) nasal
discharge; (-) pain around paranasal sinus
● Mouth and Throat: (-) toothache; (-) gum bleeding; (-) disturbance in taste; (-) sore throat; (-)
hoarseness
● Neck: (-) pain; (-) limitations of movement; (-) presence of mass
● Respiratory System: (-) dyspnea (DOB/SOB); (-) chest pain; (-) cough; (-) sputum production; (-)
hemoptysis; (-) wheezing; (-) Hx of asthma
● Cardiovascular System: (-) substernal pain; (-) palpitations; (-) dyspnea (DOB/SOB); (-)
orthopnea; (-) paroxysmal nocturnal dyspnea; (-) easy fatigability
● Gastrointestinal: (-) nausea; (-) vomiting; (-) dysphagia; (-) diarrhea; (-) constipation; (-)
hematemesis; (-) melena; (-) hematochezia; (-) regurgitation
● Genitourinary Tract: (-) dysuria; (-) urinary frequency; (-) urgency; (-) hesitancy; (-) polyuria; (-)
hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge
● Extremities: (-) edema; (-) swelling of joints; (-) stiffness; (-) numbness; (-) intermittent claudication;
(-) limitation of movement
● Nervous System: (-) headache; (-) vertigo; (-) syncope; (-) loss of consciousness; (-) weakness; (-)
paralysis; (-) numbness; (-) paresthesia; (-) speech disorder; (-) loss of memory; (-) confusion
● Hematopoietic System: (-) bleeding tendencies; (-) easy bruising; (-) Hx of transfusion reactions
● Endocrine System: (-) heat/cold intolerance; (-) excessive weight gain/loss; (-) polyuria; (-)
polydipsia
PHYSICAL EXAMINATION:
PHYSICAL EXAMINATION
General Survey: The patient is conscious, coherent, not in distress with the following vital signs:
BP: 110/70mmHg CR: 89 bpm RR: 20 cpm T: 36.9 C O2 Sat:98%
HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion.
Neck: Supple, no neck vein engorgement, no palpable lymph nodes Chest:
Symmetrical chest expansion, no retractions, no lagging Lungs: Vesicular breath
sounds, no crackles, no wheezes
Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs.
Breasts: Symmetrical in contour, no dimpling, no palpable mass or abnormal nipple discharge Abdomen: flabby,
soft, nontender, no palpable masses
Speculum: clean-looking cervix with minimal whitish non foul smelling discharge
Internal Exam: With 8 x 7 cm fluctuant, cystic, mass at the 7 o’clock position of the vaginal opening, nontender,
vagina admits 2 fingers, cervix is firm and closed, uterus unenlarged, no adnexal mass nor tenderness
Extremities: No gross deformities, No edema on both upper and lower extremities, full pulses. Skin: No Active
Dermatoses
What is your assessment and plan?

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FEU-NRMF - Dr.

Nicanor Reyes Medical Foundation

DATE: July 1, 2022 INFORMANT: Patient

CHIEF COMPLAINT: left labial mass

PAST MEDICAL HISTORY:

What is your assessment and plan?

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