The history of the uterus disease. The main symptoms of gynecological diseases

Gynecological status. Inspection of external genital organs The external genital organs is developed correctly. Summary by female type. Large sex lips are completely covered with small. Absadina, edema, hyperemia are absent. Anus area and large genital lips without visible pathological changes. The mucous entrance to the vagina is cyanotic, wet, clean. Inspection in the mirrors (11/11/08) the vagina is free.

The mucous vagina is cyanotic, folded, without ulcerations. No partitions, strictures and scar changes in the vagina. Cervical cervical neck, cervical mucosa cyanotic, without impaired epithelial cover. Outdoor zev rounded form. Moderate selection of BELI, white color without smell. Vaginal study (11/11/08) The cervix is \u200b\u200bdeflected by the fork, length is up to 2.5 cm, softened with rolic-shaped seal in the area of \u200b\u200bthe internal zea. The cervical channel is passing for one finger to the inner mouth. Through the vaginal varieties, the fetus head is determined, movable above the entrance to a small pelvis. Cape is not achieving.

Exostoses, tumors, bone deformations in a small pelvis have not been identified. Selection - scarce mucous odorless. CONJUGATA DIAGONALIS\u003e 12 cm. Vagina varieties are deep, painless. The uterus is increased in sizes, respectively, up to 28 weeks; Easily excumbed with palpation. Evaluation of the matte of the cervix in Bishop: the cervical consistency: softened with a rolic-shaped seal in the area of \u200b\u200bthe internal zea - \u200b\u200b1 point. Cervical length: 2.5 cm - 0 points.

Channel Patenienability: Cerval Cerval Came We pass for one finger to the inner throat-1 point. The position of the neck: rejected by the stop - 0 points. Conclusion: 2Ball - immature cervix. Pre-diagnosis Pregnancy 28 weeks. Head prepay. Threatening premature labor. The diagnosis of pregnancy is made on the basis of: availability of reliable signs of pregnancy: 1) the definition of the fetal parts, during palpation; 2) listening to the fetal heartbeat under auscultation 3) identification of a living fetus, corresponding to the term of gestation when ultrasound. 28 weeks of pregnancy are exhibited by: the first day of the last menstruation: April 29, 2008. From the date of the last menstruation passed 28 weeks.

The term of pregnancy on 11.11.08 is 28 weeks. The first appeal to the female consultation: the date of the first appeal to the female consultation on July 8, 2008. Diagnosis 10 weeks of pregnancy.

The term of pregnancy at the time of the corporation: 10 weeks + 18 weeks (the number of weeks of passed after this circulation) \u003d 28 weeks. The standing height of the bottom of the uterus - the bottom of the uterus is located on 2 fingers above the navel (25 cm above the level of the left), which corresponds to 28 weeks. Pregnancy. The first movement of the fetus: September 16, 2008, which corresponds to 20 weeks of pregnancy, since the primary fetus, usually, the first movement of the fetus occurs under the period of gestation 20 weeks. The term of pregnancy at the time of the corporation: 20 + 8 (the number of weeks of the fetus passed after the first movement) \u003d 28 weeks. According to the ultrasound (from 22.07.08): Pregnancy is 12 weeks. The term of pregnancy for 11.11.08g.: 12 weeks (number of weeks according to ultrasound) + 16 (the number of weeks of passed after this ultrasound) \u003d 28 weeks.

The head presence is established on the basis of: Outdoor obstetric study (Leopold - Levitsky receptions): 3 - 4 Receptions - the head will take place, moving over the entrance to a small pelvis. Vaginal Studies: The fetus head is determined through the vaults, movable over the entrance to a small pelvis. The diagnosis of threatening premature childbirth is made on the basis of: complaints when entering periodic pulling, non-irradiation pains in the lower abdomen duration up to 10 minutes; Based on the data of the bimanual research - the uterus during palpation is easily excited. The presence of risk factors in pregnant women: CMV carriage (Torch infection). Anamnese data: On November 10, it is suddenly a periodic pulling, buttering pains without irradiation appeared in the lower abdomen, duration up to 10 minutes.

End of work -

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Pregnancy 28 weeks. Head prepay. Threatening premature birth

Threatening premature labor. Complaints at the time of the beginning of the church there are no complaints. Complaints when admission: on periodicals pulling, noah pain without .. The history of the development of pregnancy The first day of the last menstruation - April 29th .. The female consultation was attended regularly. Indeed pregnancy I, childbirth I. September 16, 2008 felt first ..

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Passport part
FULL NAME
AGE
PROFESSION
Time arrival in the clinic
CLINICAL DIAGNOSIS:
Main
accompodiable
complications
operation

Complaints at the time of the corporation

Anamnesis of the disease

ANAMNESIS OF LIFE
Physical and mental development, labor nature, production harm, heredity, allergic history, transferred general and gynecological diseases, material and domestic conditions, bad habits.

Special anamnesis
Menstrual function: the time of appearance of the first menstruation, after what time was established (if it was not installed immediately, then what type and nature had), the type of menstruation: since days last, after what time the character of menstruation occurs, the number of lost blood (abundant, moderate, scarce ), painless or painful (in front of menstruation, in the first days, at the end of menstruation), the nature of the pain (grapple-shaped, nunning, permanent, etc.), whether menstruation has changed after the start of sexual life, after childbirth suffered by the diseases, which changed changes. The date of the last normal menstruation.
Sexual function: The beginning of sex life coincided with marriage, lives regularly or has random sexual bonds, pain during interchange, bleeding during intercourse, whether the sexual attraction and sense of satisfaction. Pregnancy protection. Husband's health.
Children's function: after what time the pregnancy occurred after the start of sexual life. How many pregnancies were (listed in chronological order) as each of them proceeded, which ended.
Regarding childbirth - normal or pathological, whether obstetric operations were, the course of the postpartum period, the weight of the child at birth is alive and as evolving. With regard to abortions - spontaneous or artificial, with what time it was the screening of the walls of the uterine cavity, complications in the production of abortion, the course of the afternoon period.
Secretor function: when there were allocations from the vagina, quantity (abundant, moderate, meager) permanent or periodic (whether frequency with menstruation is connected), color (white, yellow, bloody, etc.), smell (odorless, with a sharp smell) Are surrounding the surrounding fabrics, consistency (liquid, thick, curls).
The function of adjacent organs:
urination
defecation

Objective examination.
Inspection: view of the patient, pose, consciousness, growth, weight; The color of the skin, varicose veins, swelling, the state of the thyroid gland, so on.
Study of the mammary glands: form, consistency, soreness of glands, pronounced or rotten nipple, the nature of the secret (colostrum, milk, succinous liquid).
RESPIRATORY SYSTEM
Circulatory organs
Digestive and stomach organs:
form, percussion, palpation, etc.
Urinary organs
Nervous system and senses

Special status
Inspection: Type of exhaust, the condition of large and small sexual lips, the clitoris, paralyutrochny moves, borotinium glands, crotch, anus.
Inspection with the help of mirrors: the state of the vagina (folding, the color of the mucous), and the vaginal part of the cervix, the outer zea, the nature of the selection from the channel separated by the vagina.
Manual study: entrance to the vagina, pelvic bottom muscles, vaginal walls, vaults, depth, mobility of the mucous membrane, cervical consistency, its shape, outer zev (closed, passes the finger tip, finger).
Bimanual study: uterus, its position, sizes, shape, consistency, mobility, soreness, changes from the appendages, their size and shape, soreness, state of parameter fiber. The nature of the selection after the study.
According to the testimony: rectal, rectovaginal-abdominal research.

Preliminary diagnosis

Additional examinations and laboratory datawith their assessment.

Differential diagnosis
In general, according to a given disease, and by the disease in the supervised patient.

CLINICAL DIAGNOSIS
main
accompodiable
complications

Plan of treatment and examination of this patient
If an operation is planned, then the testimony for the operation, the rationale for the volume of operation, the name of the operation and preparation for it. Type of anesthesia.
Operation description.
Description of the remote macro production.
Conclusion of a histologist.
Postoperative diagnosis.

DIARY
view of the patient, position, condition, breathing, consciousness, pulse, blood pressure, language, belly, etc., physiological shipments.

FORECAST
With regard to life, the working capacity of specific functions.

Epicris

List of used literature

Curator signature

I. Passport part

1.F.I.O. ______________

2. TRAST: 22/09/72 (40 years)

3. Work, Profession: Postman

4. Seating: ___________________

5.Data and time of receipt of the hospital: 03/04/13

6. Makes aimed: _____________________

7. Hospitalized in the hospital in a planned manner

8. Diagnosis when entering the hospital: Myoma of the uterus of large sizes

9. Diagnosis Final clinical: multiple mioma uterus of large sizes. Fast growth

10. Surgery - Laparotomy: uterine amputation, intelligence method: endotracheal anesthesia.

II. Complaints at the time of the corporation

At the time of arrival: on pulling pain at the bottom of the abdomen, the feeling of rounded formation at the bottom of the abdomen.

At the time of the corporation: does not present.

III. The history of the development of the present disease

The patient considers herself to be a patient for 6 years, when for the first time was diagnosed with Mioma uterus on a profile. It was put on dispensary accounting, was constantly observed at the gynecologist. In the interval from November 2012 to January 2013, there was an increase in Moma of the uterus (about 6 weeks of pregnancy), the uterus corresponds to 16-17 weeks of pregnancy. There were drawing pain at the bottom of the abdomen, abundant and painful menstruation. The patient was aimed at planned hospitalization in the gynecological department of the Roadoma No. 2 for operational treatment.

IV. Anamnesis of life

Hereditary history is not burdened.

From the suffering diseases marked colds. Venestic diseases, viral hepatitis, tuberculosis denies.

In 2008, cholecystectomy. Gemotransfusion was not conducted.

Allergological history is not burdened. Bad habits denies.

Obstetric and gynecological history.

Gynecological status

The first menarh appeared 14 years, established during the year. The duration of the menstrual cycle is 22 days, the duration of menstruation is 5 days, moderate painless. The last six months of menstruation painful abundant, with clots. The date of the last menstruation is 02/25/13.

The nature of the selection of sex tract: moderate selection, periodic, light, odorless, mucous, do not irritate the surrounding fabrics.

Sex life: sex life started in 19 years. Random sexual communications denies. There are no contact bleeding pains with sexual interchange. It is married, lives regular sex life from 20 years. Contraceptives did not accept condoms used. Husband is healthy.

In 1994, the first pregnancy occurred, ended with childbirth. Births are natural, without complications. Born healthy child. Postpartum period without complications.

In 1998, the second pregnancy ended in childbirth. Gifts are natural, it was made of episotomy. The child was born healthy. Postpartum period without complications.

Subsequently, there were 2 pregnancies that ended with vacuum (2000,2001).

Transferred gynecological diseases: consists of dispensary accounting about the uterine misa.

V. Lessuring examination

Consciousness is clear. The position of the patient is active. The physique is normal-bench. Growth-164cm., Weight-55 kg.

Clean cover clean, light pink colour, the turgor is normal; Buli, Absadin, there are no bloodthrovods. Visible mucous membranes are moistened, pink, without ulcers and erosion

Study of the mammary glands: Rounded shape mammary glands, with painless, soft consistency, without focal and diffuse seals. Skin covering over the glands is not changed, pathological formations, rashes are missing. Nipples are not drawn, no pathological discharge.

The thyroid gland is not increased, painless during palpation, without nodal formations, elastic consistency. Sublimatic, cervical, occipital, connectible, permissible, axillary lymph nodes during palpation are not defined. Outflows, varicose veins are missing.

With auscultation of the lungs on symmetric areas, vesicular breathing is determined.

With auscultation of the heart, the tones are rhythmic, clear, no noise. Pulse on radiation arteries is the same, rhythmic, frequency - 76 per minute. Hell 120/80.

The stomach during inspection is increased in volumes due to the uterus tumor, the palpation is soft, painless.

The symptom of the tender is negative on both sides. Urination is free, painless, not rapidly.

Gynecological status

Inspection of external genital organs: Summary of the female type. Exterior genitals are developed correctly. Skin conventional coloring, clean. The mucous entrance to the vagina pink, clean. Urethra, parauthetral strokes, the output of the large glands of the vagina's high glands without features. Ottoms back wall There is no vagina.

In Speculum: The mucule vagina is bright pink. The cervix of the conical shape, clean. Outdoor zev slotted, closed. Selection of light, mucous membranes.

Per Vaginum.: The vagina is narrow, the vaults are deep, painless. The cervix of the conical shape, is shortened to 1 cm, centered, dense, the channel is closed, does not pass the fingertip. The uterus in the Anteversio Flexio position, the value of 16-17 weeks, dense, buggy, moderately mobile, painless. The appendages on both sides are not palpable. The displacement for the cervix is \u200b\u200bpainless. Sacriforms and uterine ligaments and parameter are not changed.

Per Rectum: The rectal mucosa is smooth, movable. There is no blood on the glove.

1

The purpose of the submitted report was the assessment of the gynecological status of girls and teenage girls, patients with primary dismenoria (PD). In this regard, a gynecological examination of 165 patients of the main group (OG) and 55 healthy control groups (kg) aged 12-18 years have been carried out.

The obstetric and gynecological history in OG was represented by a number of features. The age of menarche in patients has amounted to an average of 13.1 years. In 15 (9.1%) patients regulated were not established (had different duration). The average cycle duration was 26.3 days, menstrual secretions - 4.4 days. The experience of intimate links had 58 (35.1%) patients, of which one pregnancy fell in 19 (11.5%) observed, 2 or more pregnancy occurred in 9 (5.4%). Pregnancy ended with medical or spontaneous abortions in 17 (10.3%) or clan in 2 (1.2%). Different methods of contraception used 12 (7.3%) girls. Indications for chronic gynecological pathology in ogov not marked. Acute STIs (fresh gonorrhea, candidalosic vulvovaginitis, trichomoniasis, bacterial vaginosis) had an anamnesis 8 (4.8%) of the surveyed.

An obstetric and gynecological history in kg had a number of features. The age of menarche girls and teenage girls kg amounted to an average of 12.6 years. In 8 (14.5%) of the surveyed registers were not established (had different duration). In 55 (100%) girls and teenage girls, menstrual discharge were not accompanied by pain. The average cycle duration was 25.9 days, menstrual secretions - 3.9 days. The experience of intimate connections had 15 (27.2%) of girls, of which the pregnancy fell in 10 (18.2%) observed. Pregnancy ended with medical or spontaneous abortions in 7 (70.0%) and 3 (30.0%) of girls, respectively. No pregnancy ended with childbirth. In various methods of contraception used 9 (16.4%) girls. Acute STIs (fresh gonorrhea, candidalosic vulvovaginitis, trichomoniasis, bacterial vaginosis, etc.) had a history of 4 (7.2%) examined. Indications for chronic gynecological diseases were not marked.

Special gynecological examination was carried out at the time of appeal after emptying the bladder and intestines. It was carried out in og and kg according to the generally accepted method, taking into account the age features of the studied groups of girls and teenage girls. When examining the patients, the external genitals were established that the external genital organs were developed and formed correctly, the exhaustion on the female type, on the skin and mucous membrane of the vulva of pathological rashes was not detected. The color of the mucous membrane is pale pink. The outer hole of the urethra, parauretral moves, the output of the large glands of the vagina standing gland without visible changes. The virgin Piere was intact in 97 (58.8%) of the surveyed.

The inspection of the mucous membrane of the uterus and the mucous membrane was produced by the "children's" mirrors. In 2 (1.2%) patients, the cervical cervix was cylindrical, in 163 patients cervical cervix had a conical shape. The outer zev of the cervix was open, selection from the cervical canal - bloody. Among girls and teenage girls, pronounced bloody discharge were determined in 38 (23.0%) patients, moderate bleeding were 104 (63.0%) and scarce were marked in 23 surveys.

Depending on the presence or absence of Hymen, the study of the internal genital organs was carried out by bimanual straightforward-abdominal and vaginal-abdominal methods. All girls and teenage girls exeted the similar characteristics of the internal genital organs. The body of the uterus was in the position of Anteversio-Anteflexio. Dimensions, shape, consistency and mobility of the uterus correspond to the norm and biological age. The area of \u200b\u200bappendages and the parameter fiber did not palpate. The behavioral response to the examination in the studied groups was different. In the study of girls, the intensity of pain did not change in 48 (29.1%), and 117 (70.9%) patients noted the gain of pain syndrome.

When examining patients kg, it was found that the external genital organs were developed and formed correctly, the exhaustion of female type, on the skin and mucous membrane of the vulva pathological rashes was not detected. The color of the mucous membrane is the eve of the vagina pale pink. The outer hole of the urethra, parauretral moves, the output of the large glands of the vagina standing gland without visible changes. The virgin Pepper was intact at 38 (69.1%) of the surveyed.

The inspection of the mucous membrane of the uterus and the mucous membrane was produced by the "children's" mirrors. In 3 (5.4%) girls kg, the cervical cervix was cylindrical, in 52 surveyed kg of the cervix was a conical shape. The outer zev of the cervix was closed, there was no selection from the cervical canal.

Bimanual abdominal and vaginal research was conducted by the surveyed kg, living sex life, and bimanual recoabdomominal girls and teenage girls Virgo. In the survey process, it was revealed that the body of the uterus was in the position of Anteversio-Anteflexio. Dimensions, shape, consistency and mobility of the uterus correspond to the norm and biological age. The area of \u200b\u200bappendages and the parameter fiber did not palpate. Examination 55 (100%) girls and teenage girls kg was painless.

In the subsequent phases in the comprehensive examination of girls and teenage girls included laboratory (clinical blood test, general urine analysis, biochemical blood test, determination of trop hormones of pituitary glands and sex steroids, microbiological examination of smears, etc.) and testing instrumental ( ECG, ultrasound, FGDS, etc.) research methods.

Bibliographic reference

Mosolov K.V., Osin A.Ya., Ishpakhtin Yu.I. Gynecological status of girls and teenage girls, patients with primary dismenoria // Succes modern natural science. - 2004. - № 10. - P. 44-45;
URL: http://natural-sciences.ru/ru/article/view?id\u003d13573 (date of handling: 07/19/2019). We bring to your attention the magazines publishing in the publishing house "Academy of Natural Science"