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

