Abnormal Uterine Bleeding HISTORY_LIST ***** HISTORY OF PRESENT ILLNESS age of menarche date of last menstrual period (LMP) pregnant symptoms of pregnancy onset of bleeding number of pads per day passing of tissue clots sexually active postcoital bleeding intermenstrual bleeding regular cycle length between periods irregular cycle length between periods (metorrhagia) normal cycle length = length of bleeding time regular length of bleeding time irregular bleeding time = scant flow moderate flow severe flow (menorrhagia) no pain during periods scant pain during periods moderate pain during periods severe pain during periods mid-cycle ovulation pain premenstrual increased discharge breast tenderness water retention dysmenorrhea fever chills hot flashes changes in hair texture changes in hair distribution changes in skin texture birth control birth control pills rhythm method condoms diaphragm (IUD) Depo-Provera Norplant ******** HISTORY INFECTIOUS DISEASES STD's post partum infections CHRONIC DISEASE SYSTEMIC DISORDERS coagulation disorder thyroid dz. pituitary dz. hypothyroid dz. diabetes Cushing's Dz. liver dz. obesity SURGERY PREVIOUS HOSPITALIZATIONS D & C dental procedures with bleeding post partum hemorrhage (Sheehan's syndrome) PREVIOUS TESTS pregnancy TRAUMA OR INJURIES head injury SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal FAMILY HISTORY bleeding disorders endocrine disorders MEDS_LAB_TESTS ***** MEDS diet pills aspirin psychotropics estrogen progesterone phenothiazines tricyclic antidepressants oral contraceptives propranolol digoxin cyproheptadine metoclopramide (Reglan) cimetidine ***** LAB urine or serum pregnancy test Electrolytes CBC platelets PT/PTT type & screen FSH LH estadiol prolactin TSH T3 T3RU T4 ***** TESTS ultrasound of uterus REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 VITALS Supine BP Supine Pulse Sitting BP Sitting Pulse Temp GENERAL secondary sexual characteristics obesity SKIN acne hirsutism alopecia HEENT papilledema optic atrophy NECK thyroid palpable thyroid nodules trachea midline trachea shifted REVIEW_OF_SYSTEMS_3 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge PHYSICAL_EVAL_1 CHEST breast development by Tanner staging Tanner Stage I (Preadolescent - no breast buds) Tanner Stage II Breast & papilla are small mounds Tanner Stage III (Breast & aerola enlarged; no contour separation Tanner Stage IV (Areola & papilla form secondary mound) Tanner Stage V (Mature breast) normal symmetry and contour of breast asymmetry and contour of breast discharge form nipple breast mass breast tenderness HEART Rate and rhythm are regular GU Pubic hair by Tanner staging Tanner Stage I (Preadolescent - no hair) Tanner Stage II (Sparse & lightly pigmented hair) Tanner Stage III (Darker, beginning to curl, increased amount of hair) Tanner Stage IV (Coarse, curly, abundant hair but less than adult) Tanner Stage V Full adult hair triangle, spread to medial surface of thighs RECTAL guaiac (occult blood) OB/GYN vaginal dryness vulvar nodules vaginal obstruction uterine enlargement uterine tenderness uterine myomas cervical tenderness on movement adnexal masses adnexal tenderness ovarian cysts ovarian tumors PHYSICAL_EVAL_2 OB/GYN Gravida Para miscarriages abortions living children metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty in fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization for psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia DIFF_DIAGNOSIS ANOVULATORY UTERINE BLEEDING hypothalamic-pituitary dysfunction polycystic ovarian syndrome hormonal disorder PREGNANCY RELATED threatened abortion postpartum bleeding ectopic pregnancy gestational trophoblastic dz. MALIGNANCY vulvar vaginal cervix uterus ovarian INFECTIOUS DISEASE vaginitis cervicitis endometritis pelvic inflammatory disease TRAUMA Intrauterine device (IUD) SYSTEMIC DISEASE coagulation disorder thyroid dz. pituitary dz. hypothyroid dz. diabetes Cushing's Dz. liver dz. obesity OTHER CAUSES medication induced hormone producing tumor hormone producing ovarian cysts endometrial hyperplasia leiomyomata endometrial polyps endocervical polyps