This document contains a medical history and physical examination report for a 24-year-old female presenting with irregular menses for 1 year. Her history is notable for facial acne, facial hair growth, and a family history of diabetes and hypertension. On examination, she is found to be obese with a BMI of 35.15 and signs of hyperandrogenism. Laboratory results show impaired fasting blood sugar of 115 mg/dL. The differential diagnosis includes polycystic ovarian syndrome (PCOS), metabolic syndrome, and late-onset congenital adrenal hyperplasia. The impression is PCOS and metabolic syndrome based on her history and physical exam findings. The treatment plan involves lifestyle modifications, metformin, and oral contraceptives

2. IDENTIFYING DATA
AGE
ADDRESS
BIRTHDAY
24 years old
TUGUEGARAO CITY
JUNE 13, 1996
A. B.
MARITAL STATUS
SINGLE
OCCUPATION
NATIONALITY
RELIGION
ONLINE ENGLISH TUTOR
FILIPINO
PROTESTANT CHRISTIAN

3. CHIEF COMPLAINT
IRREGULAR
MENSES

4. HISTORY OF PRESENT ILLNESS
1 year
PTC
Menses occurred
every 2-3 months
No other associated
symptoms.
No consultation done.
No medications taken.
Persistence of the
symptoms prompt
consultation.
(+) facial acne
(+) facial hair on
upper lip and chin

5. PAST MEDICAL HISTORY
CHILDHOOD ILLNESSES
ADULT ILLNESSES
(+) Chicken pox – year unrecalled
(+) Mumps – year unrecalled
MEDICAL:
No history of HTN, DM,
asthma, CVD, renal disease
SURGICAL:
No history of any surgical
procedures done.
IMMUNIZATION
ALLERGY
PSYCHIATRIC:
No history of psychiatric
illnesses
Unrecalled
No known allergies with
food and medication

6. FAMILY HISTORY
(+) HTN – maternal side
(+) DM – paternal side
(-) Asthma, tuberculosis, cancer,
or bleeding disorders.

7. PERSONAL, SOCIAL AND
EVIRONMENTAL HISTORY
College graduate
Works as an online English tutor
Non-smoker
Non-alcoholic beverage drinker
Denies use of illicit drugs

8. SEXUAL HISTORY
Coitarche: None
No sexual partner
No history of STIs
No history of OCP use

9. MENSTRUAL HISTORY
Menarche: 12 years old
SMP: Irregular, every 2-3 months,
3 days duration, consuming 1-2
pantyliners per day
(+) dysmenorrhea (occasionally)
LMP: January 18, 2021

10. OBSTETRICAL HISTORY
G0

11. REVIEW OF SYSTEMS
HEENT
No head trauma, no dizziness, no
headache, no visual impairment, no
hearing impairment, no ear pain, no
nasal stuffiness, no epistaxis, no
bleeding gums, no mouth sores, no
neck stiffness, no hoarseness
INTEGUMENTARY
No rashes, no
sores, no itching, no
change in color
CARDIOVASCULAR
No chest pain, no
palpitations, no
orthopnea
CONSTITUTIONAL
No unintentional weight
loss, no easy fatigability,
no generalized body
weakness
RESPIRATORY
No difficulty of
breathing, shortness
of breath, no cough,
no hemoptysis
BREAST
No pain, no
discharges

12. REVIEW OF SYSTEMS
MUSCULOSKELETAL
No muscle
weakness, no back
pain, no joint pain, no
joint swelling
GENITOURINARY
No gross hematuria, no
incontinence, no urinary
frequency, no urgency,
no vaginal bleeding
NEUROLOGIC
No seizures, no
numbness
GASTROINTESTINAL
No constipation, no bloating,
no diarrhea, no increase
appetite, no hematemesis, no
hematochezia, no nausea, no
vomiting, no abdominal pain
ENDOCRINE
No polydipsia, no
polyphagia, no profuse
sweating, no heat/cold
intolerance
HEMATOLOGIC
No bleeding, no easy
bruising

13. PHYSICAL EXAMINATION
GENERAL SURVEY
Conscious, coherent and oriented to person, time and place.
VITAL SIGNS
Blood Pressure: 140/80 mmHg
Pulse Rate: 80 bpm
Respiratory Rate: 20 cpm
Temperature (axillary): 36.6˚C
Oxygen Saturation: 99% at room air
Weight: 90 kg
Height: 1.6m
BMI: 35.15 (Obese Class II)

14. PHYSICAL EXAMINATION
SKIN
Has fair complexion, (-) dark discoloration in body folds and creases, (+)
prominent facial hair on the upper lip and chin, (+) pustular acne concentrated
on the chin and neck. No cyanosis, no jaundice.
HEENT
Head: Normocephalic, atraumatic, face is symmetrical. Scalp without lesions
and hair of average texture and evenly distributed. No tenderness.
Eyes: Symmetrical. Conjunctiva is pink and sclera is white. Pupils equally
round, 6 mm constricting to 2 mm, reactive to light, accommodation and
moves freely and in synchrony. Normal visual fields. Extraocular muscles
intact.
Ears: Pinna symmetrical, normal in size and contour, no discharge, no skin
tags. No mastoid tenderness, no hearing impairments.

15. PHYSICAL EXAMINATION
HEENT
Nose: Mucosa is pink. No obstruction/congestion, no nasal flaring, septum
midline, no sinus tenderness.
Mouth and Throat: No mouth sores, no bleeding gums, tongue and uvula in
the midline.
NECK
No neck vein engorgement. No masses, trachea midline, with no palpable
lymph nodes. No swollen glands, no tenderness.
CHEST AND LUNGS
Symmetric with equal lung expansion. Lungs resonant with normal tactile
fremitus. Clear breath sounds.

16. PHYSICAL EXAMINATION
HEART
Adynamic precordium, no apical heaves, no thrills. Heart sounds with
regular rate and rhythm, apical impulse at 5th left ICS midclavicular line, no
murmurs. Good S1 and S2 with no S3.
BREAST
No suspicious nevus, no tenderness, no mass, no discharge.
ABDOMEN
Flabby abdomen, waistline: 35”, active bowel sounds on all quadrants,
tympanitic on percussion. Soft and nontender; no palpable mass.
GENITALIA
External genitalia without ulcerations and erythema.
IE: Cervix closed, uterus small, no adnexal mass nor tenderness.
(-) discharge

17. PHYSICAL EXAMINATION
MUSCULOSKELETAL
No gross deformities, no edema with full and equal pulses. CRT <2s.
NEUROLOGICAL
Intact sensory, 5/5 muscle strength and normotonic on all extremities, GCS
15.

18. SALIENT FEATURES
24 years old
Nulligravid
Irregular menses with scant amount
(+) dysmenorrhea
Family history of DM, HTN
Hypertensive (140/80 mmHg)
With central obesity (Obese class II, waistline: 35”)
(+) acne, (+) hirsutism
FBS: 115 mg/dL

19. DIFFERENTIAL DIAGNOSIS
 24 years old
 Irregular menstruation
 (+) acne, (+) hirsutism
 Obese
 Impaired FBS (115mg/dL)
 Fam hx of DM
RULE IN RULE OUT
 Cannot be ruled out
POLYCYSTIC OVARIAN SYNDROME
ROTTERDAM CRITERIA (2/3)
Menstrual irregularity
Hyperandrogenism (clinical or
biochemical)
Polycystic ovaries on ultrasound

20. DIFFERENTIAL DIAGNOSIS
 Irregular menstruation
 (+) acne (+) hirsutism
 With central obesity
 Hypertensive
 Impaired FBS (115mg/dL)
RULE IN RULE OUT
 (-) Moon face with reddish cheeks
 (-) Buffalo hump
 (-) Fatigue
 (-) Purple striae
CUSHING SYNDROME

21. DIFFERENTIAL DIAGNOSIS
 Irregular menstruation
 (+) acne (+) hirsutism
RULE IN RULE OUT
 (-) Family history
 Hypertensive
 Impaired FBS (115 mg/dL)
LATE-ONSET CONGENITAL ADRENAL HYPERPLASIA

22. DIFFERENTIAL DIAGNOSIS
 Irregular menstruation
 (+) acne (+) hirsutism
 Obese
RULE IN RULE OUT
 (-) Generalized body weakness
 (-) Moon facies
 (-) Dry, coarse skin
 (-) Cold intolerance
HYPOTHYROIDISM

23. DIFFERENTIAL DIAGNOSIS
 Irregular menses
 (+) acne (+) hirsutism
RULE IN RULE OUT
 (-) Galactorrhea
 (-) Breast pain
 No intake of medications
HYPERPROLACTENEMIA

24. IMPRESSION
G0, Polycystic Ovarian Syndrome,
Metabolic Syndrome, Obese Class II
ROTTERDAM CRITERIA (2/3)
Menstrual irregularity
Hyperandrogenism (clinical or
biochemical)
Polycystic ovaries on ultrasound
METABOLIC SYNDROME (3/5)
Waist circumference >88 inches
HDL <50 mg/dL
Triglyceride >150 mg/dL
BP >130/85 mmHg
FBS >110 mg/dL

25. PLAN
Manage as outpatient
DIAGNOSTICS
 Urinalysis with PT
 Transrectal ultrasound
 75g-OGTT
 Lipid profile
MEDICATIONS
 COC
 Metformin 850mg PO BID
NON PHARMACOLOGIC
 Diet modification (low fat, low salt, low sugar)
 Weight reduction (5-10% decrease)
 Regular exercise: minimum of 250 min/week of
moderate intensity activities
 Maintain adequate sleep (at least 8 hours/day)
Follow-up after 6 months.

26. THANK YOU!