University of Santo Tomas Hospital

University of Santo Tomas Hospital

Department of Obstetrics and Gynecology

Section of Gynecology

April 9, 2010 FRIDAY

Total No. of patients: 10 / ADMISSIONS: 0 / NEW REFERRALS: 0 / DISCHARGED: 1 / DAMA: 0 / EXPIRED: 0 / TRANSFER: 0
/ WARD: 6 / REFERRALS: 4 / COMGT: 0
New Admissions :
ROOM / NAME / DIAGNOSIS / REFERRAL / DIET & MEDS / LABORATORIES / PROCEDURE & OR FINDINGS / ENDORSEMENTS
New Referrals: 1
ROOM / NAME / DIAGNOSIS / REFERRAL / DIET & MEDS / LABORATORIES / PROCEDURE & OR FINDINGS / ENDORSEMENTS

MAIN:

ROOM / NAME / DIAGNOSIS / REFERRAL / DIET & MEDS / LABORATORIES / PROCEDURE & OR FINDINGS / ENDORSEMENTS
109A
10D00026
06-43-30
DOB: 9/3/86
DOA: 4/2/10
Dr. MT Dee
IIC: Tin
CIC: Denise / Myla Villanueva
23 y/o, nulligravid, 3rd year nursing student
198 Magsaysay St., Tondo, Manila
3537183
Ht: 150cm Wt 65.5kg BMI 29.1
LMP: March 15-20, 2010, G0P0
CC incidental finding of ovarian mass on Ultrasound / Serous Cystadenoma, Left
Ext genitalia: no gross lesion
SE: cervix pink smooth with minimal whitish discharge, directed anteriorly
IE: Cervix firm, long, closed
Uterus: normal sized, anteverted pushed anteriorly
R adnexae: no mass non-tender
L adnexae: (+) 9x9x8cm, cystic, nontender, slightly movable pushing the uterus anteriorly
RVE: lower pole of the mass palpated / Anes / Soft diet
Postop meds:
Cefuroxime
Mefenamic acid / 3/9 TVS: normal-sized uterus and right ovary, secretory endometrium, ovarian cyst left, poss. Endometrial vs. dermoid
Other findings: culdesac: minimal fluid; left ovary 9.93x10.2x10.16 cm cystic, unilocular, smooth inner wall, thick-walled (0.34cm), no septa, containing low level echoes, no solid areas, negative color flow
4/2 CBC hgb 132 hct 0.40 wbc 7.90 plt 401 seg 0.67,lym0.31, eo 0.02; Blood type B+
U/A yellow slt turbid pH6.0 spgr 1.015 alb (-) sugar(-) rbc 3-8/hpf pus 0-3/hpf SC + Bact few MT ++
4/8 Na 139.85 K 4.19 / OR done: Left salphingo-oophorectomy w/ FS & Ovarian drilling R ovary under spinal anesthesia
OR Findings: On opening, no peritoneal fluid was noted. Proceeded to doing peritoneal washing and specimen collected for possible cytology. The uterus, R fallopian tube was grossly normal. The R ovary was normal in size but polycystic in appearance. The L ovary was noted to be cystically enlarged to about 10 x 11 x 9 cm with smooth glistening capsule located in the cul de sac. Proceeded w/ L salphingo-oophorectomy and specimen sent for frozen section. Ovarian drilling was likewise done on the R ovary. EBL: 200 cc / SPDP
109B
10D00126
02-81-88
DOB:
DOA: 04/06/10
Dra. Gamilla
IIC: Melai
CIC: KD / Teodelyn Garcia
21/F G3P3 (3003), Unemployed
1073 Paquita St.Sampaloc Manila
7331241
09184314853
Ht 5’3 Wt.:63 BMI:24
LMP: July 3, 2009
CC:abdominal enlargement / Mucinous Cystadenoma (FS), Left ovary
SE: Cx pink, smooth, minimal blleding oer os, IUD string in place
IE: Cx firm, long closed
Uterus: normal sized, anteverted, deviated to the right
(+) pelvoabdominal mass measuring 29x27cm extending up to 3 fingerbreadths below the umbilicus the lower border of which cannot be palpated, cystic, movable, nontender, anterosuperior to the uterus
RVE: tight sphincteric tone, smooth rectal mucosa, no pararectal tenderness, lower pole of which cannot be palpated / Anes / Soft diet
Post-op meds:
Celecoxib
Cefuroxime / 4/5: CBC:hgb 119, hct 0.25, plat 315, WBC 7.1, seg 0.61, lymph 0.37, eos.01. Blood type O
U/A: Yellow , slightly turbid, ph 6.5, 1.010, (-) sugar, RBC 1-2/hpf, pus 2-4/hpf, sq.cells mod, mucus few. Na 143, K 3.65
4/6: Na 143.29 K 3.23
4/7 Na 137.81 K 3.39 / OR done: Adshesiolyis with LSO under GETA (4/7/10)
OR findings:
On opening, there was straw colored free peritoneal fluid. Specimen was collected for possible cytology. There was a 30x27x10cm cystic mass which on further exploration was noted to be the left ovary. The left fallopian tube was stretched over the left ovary. There were adhesions over the omentum and anterior superior surface of the left ovary. Proceeded to do adhesiolysis followed by left salpingooophorectomy. Specimen was sent for frozen section. The liver, subdiaphragmatic area, the paracolic gutters, and paraaortic area were smooth.
On cut section of the ovary, it exuded chocolate brown fluid. There were 2 yellow irregular masses measuring 15x14x6cm and 6x5x2.5cm _____ with finely granular surface. Also noted are multilobulated cyst measuring 1.5 to 7cm in widest diameter with smooth inner wall and containing clear fluid. EBL: 250cc / SPDP
109C
10D00104
06-44-52
DOB: 01/02/65
DOA: 04/05/10
Dra. C. Fernandez
IIC: Venice
CIC: Aeyzl / Marlyn De Guzman
45/F G6P5(4115), Vendor
#99 Malakas St. La Loma, Quezon City
9532567
Ht 161.5cm Wt. 141 lbs BMI 24.8
LMP: March 27-31, 2010
CC: Gross Hematuria / Myoma Uteri, Endocervical polyp, Endometrial Polyp s/p Biopsy, HPN St. 2, PTB V
Flabby abdomen 13 x 13 cm firm, nodular, nontender midline mass
Ext. genitalia: no gross lesion
Spec Exam: cervix pink, smooth with minimal clear mucoid non-foul smelling discharge
IE: cervix firm, short, parous, uterus enlarged nodularly to 4 mos size, more to the right, adnexae cannot be assessed. / CV Med
Pulmo / GLEMCD
Post-Op Meds:
Tramadol
Metoclopramide
Nalbuphine
Metoprolol
Cefuroxime
Mefenamic acid / 12/29/09 TVUS Neg LUB sonography, Uterine myoma, intramural-subserous, solitary, thickened endometrial stripe, nabothian cysts, multiple, adnexae clear
1/26/10 TVUS Uterine myoma, intramural-subserous, solitary, thickened endometrial stripe, nabothian cysts, multiple, s/p oophorectomy R (?)
3/8/10 enlarged uterus with intramural myoma w/ submucus component 8.36 x 8.48 x 7.74 cm midposterior wall extending to the thickened endometrium 1.97 cm, normal sized uterus, 3/9 3/9/10 Endometrial biopsy: (+) Endometrial Polyp
3/22/10 Hgb 133, Hct 0.39, WBC 11.70, Neu 0.62, Lym 0.34, Mono 0.01, Eos 0.03, Plt 287 / OR done: TAH under spinal anesthesia (4/7/10)
OR Findings:
On opening, no free peritoneal fluid was noted. The uterus was nodularly enlarged to four (4) months size. Both ovaries and the left fallopian tube was grossly normal. The right fallopian tube is surgically absent. Proceeded to do total abdominal hysterectomy. O n cut section of the uterus, the endometrium was smooth. There is a 0.5 cm fleshy mass on the endocervical canal. There is a 10x13x9cm nodular mass on the posterior surface of the uterus which on cut section showed whorled cut surface. EBL 500-600 cc
109D
10D00103
06-44-51
DOB: 06/01/66
DOA: 04/05/10
Dra. C. Fernandez
IIC: Venice
CIC Dave / Marilou Alvarez
43/F G3P3(2012), unemployed
250 Anchores San Roque, San Pedro, Laguna
5204292
Ht. 156cm, Wt 70 kg, BMI:28.8
LMP: March 23-29, 2010
CC: Abdominal Enlargement / Leiomyoma(FS), Endometrial Polyp s/p Biopsy, myoma uteri (utz), HPN St. 1
Flabby abdomen, NABS, soft, nontender, 23 x 24cm, firm, slightly movable mass which is superior the uterus
Ext. Genitalia, no gross lesions
SE: Cervix pink, smooth with whitish discharge
IE: Cervix firm, long, parous, uterus normal sized, anteverted, (+) 24 x 25 cm firm, slightly movable mass which is superior the uterus
RE: Tight sphincteric tone, smooth rectal mucosa, lower border of the mass not appreciated / Onco
CV
Pulmo / NPO
Pre-Op Meds:
Metoprolol
Omeprazole
MSO4
Tramadol
Ketoroloac
Metoclopramide
Nalbuphine
Celecoxib
Ranitidine
Cefazolin / Jan 2010 TVS: Normal sized anteverted uterus with menstrual endometrium: Myoma nodules as described. Solid mass, R adnexa as described prob representing solid ovarian tumor vs huge subserous myoma. Doppler studies described suggestive of non-benign nature, Pls correlate clinically. (solid hypoechoic, irregularly shaped mass measuring 15.15 x 19.20 x 10.77 cm), no normal ovarian tissue noted representing solid ovarian tumor vs huge subserous myoma)
4/6 CXR: FF-up study when comared to the one done on 3/4/10 exam shows a nodular opacity in the retrocardiac area measuring 1.7 cm in diameter. Suggest chest CT scan with contrast for confirmation. Heart top normal in size.
4/7: Na 142.09 K 3.78 / OR done: TAH, RSO (4/8/10)
OR findings: leiomyoma (FS)
109E
10D00108
06-43-65
DOB: 12/06/88
DOA: 04/05/10
Dr. Gonzales
IIC: Venice
CIC: Dong / Richelle Domingo
21/F/nulliparous, student
142 Unit 11 Dalaya Townhomes 15th Ave. Cubao, Quezon City
9132050
Ht 163 cm Wt 45.5 kg BMI 17
LMP: March 18- 24, 2010
CC: Hypogastric Pain / Pelvic Inflammatory Disease, r/o acute appendicitis
Ext. genitalia: no gross lesion
Spec Exam: cervix pink, smooth with yellowish foul smelling discharge
IE: cervix long, soft, closed, uterus normal in size, adnexae not palpable, no masses, (+) direct and rebound tenderness / GS / Soft Diet
Levofloxacin
Metronidazole / 4/4 Hgb 120, Hct 0.35, WBC 12.10, Plt 289, Neu 0.74, Lym 0.25, Eos 0.01, UA: yellow, slightly turbid, pH 6.5, SG 1.020, No albumin, sugar, 0-2/hpf rbc, 25-30/hpf pus cells, +++ sq cell, + Bact,, + mucus threads, +++ amorphous urate, Grams stain: small pleomorphic gram variable bacilli occurring singly and in pairs +++, Gram (+) cocci in pairs Few, Pus cells ++++, epith cells ++, None found for trichomona vaginalis
4/5 Hgb 120, Hct 0.35, WBC 12.10, Neu 0.74, Lym 0.25, Eos 0.01 / MGH
109G
10D00114
06-35-93
DOB: 03/07/72
DOA: 04/06/10
Dra.P.Punsalan
IIC: Melai
CIC:Jo / Cheryl Coderis Dacir
38/F G0P0 unemployed
3rd yr nursing student
301 Amber Bldg Rosewood points Levi Mariano Ave Taguig City
LMP: March 19-22,2010
CC: Menorrhagia / Endometrioma, Left
Myoma Uteri,intramural
Abnormal Uterine Bleeding secondary to endometrial pathology s/p Right oophorectomy / DAT / 4/6/10 CBC hgb 102, hct 0.32, plat 324, WBC 9.30, seg 0.61, lymph 0.38. / For Possible Cystectomy, Left and TAH with Left Cystectomy / LSO
For OR on Monday

REFERRALS:4 Co-managed: 0

SURGERY: 3 MEDICINE: 0 PEDIA: 0 PSYCH: 1
ROOM / NAME / DIAGNOSIS / REFERRAL / DIET & MEDS / LABORATORIES / PROCEDURE & OR FINDINGS / ENDORSEMENTS
218 B (CC)
10C000053
06-30-37
DOB 5/18/1970
DOA 3/3/10
DOR 3/14/10
Dr Moreno
IIC Ghie
CIC Tin / ALFONSO, Liza
39 y/o single nulligravid
9 St. Simon st., Don Bosco Village, Paranaque City
Tel # 8240736 (Contact: mother)
Wt 57kg Ht 157cm
LMP 2/24/10 – 3/2/2010
CC: prolonged menses (since 3/4/10, but no more bleeding since 3/28) / AUB probably secondary to endometrial pathology
Obsessive-Compulsive disorder
Abdominal exam: flabby, NABS, soft, nontender, no palpable mass
Pelvic exam not done / Main:
Psychiatry / DAT
Nozimar
Haloperidol
Benadryl
Olanzapine
Ferrous sulfate
Dyphenhydramine / 03/04 CBC hgb 129 hct 0.38 wbc 12.2 seg 79 lympho 21 plt 260
FBS 111.94 TC 145.77 TG 57.56 HDL 72.68 LDL 68.6
Crea 0.77 SGPT 20.88 Na 142 K 3.9
ECG Sinus tachycardia, complete right bundle branch block
03/14 CBC hgb 104 hct 0.31 wbc 14.9 seg 70 lympho 27 eos 3 plt 270
03/16 hgb 103 hct 0.32
4/6: CXR Normal chest / For observation
For possible TRS
Perineal hygiene 2-3x/day
WOF ↑ amount of bleeding
304E
10B00134
06-18-33
DOB: 01/31/1962
DOA: 02/05/2010
AMD: Dr. R Enrile
IIC: Erwin
CIC: Justin / BERONILLA, Eva
48 G6P4 (4024)
18 Bentley St. Village, East Executive Homes
3963833
LMP: Jan 20-24, 2010
CC: vaginal discharge / Spinal cord compression, L1 lesion secondary to L1 burst fracture
Papillary thyroid CA withextramedullary spinal cord metastasis (follicular variant)
No gynecologic pathology at the time of examination
SE: cervix pink, smooth, with whitish mucoid discharge
IE: cervix firm, long closed, normal-sized uterus, no adnexal mass or tenderness / Main:
NeuroSx
Referral:
Endo
Rehab
Rad Onco
Uro
Gyne / Full diet
Celecoxib
Lactulose
Pregabalin
Metoclopramide / 02/08 Histopath: metastatic papillary thyroid cancer, follicular variant
02/21 CBC: Hgb 114 Hct 0.34, plt 389, WBC 10.70, Seg 0.74, Lymhpo
0.23, Mono 0.01 eo 0.02
02/20 Na 136.97 K 3.75
02/17 TSHI: 1.68, FT4 RIA 19.1
02/08 Hgb 112 HCt 0.33
03/22 TSH 1.41
U/A yellow, turbid, pH 5.0, sp gr 1.020, alb (-), sug (-), pus 50-60/hpf SC few Bact ++++
03/24 Urine CS: (+) E. coli > 100,000 cfu/ml Sensitive to Cefazolin,
Gentamycin, Piptazo, Imipenem, Nitrofurantoin, Ciprofloxacin,
Norfloxacin, Meropenem
3/31 TSH 1.41
4/5 UA: Light yellow, slightly turbid urine pH 5.0, SG 1.015, Neg albumin and sugar, 50-60/hpf RBC, 30-40/hpf pus cell, ++ sq cell, Few renal cell, + Bact, + Mucus, + Amorph urates, + Ca oxalate / s/p laminectomy for decompression and debulking of extramedullary tumor T12-L2 with pedicular screw and rod placement (2/5/10)
s/p total thyroidectomy (2/22/10)
s/p 10 cycles RT / No gyne intervention needed
Endo: plan for 200mci RAI once with consent
Uro: plan to do urodynamic studies
For possible home (NSx)
306H
DOB: 9/26/53
DOA: 4/7/10
Dr.
IIC: Jane
CIC: EJ / Evangelista Ligaya
56 y/o, G3P3 (3003), housewife
#1929 Daang Bakal Tayuman Tondo, Mla
255-0463
Ht 145 cm Wt 66 kg BMI: 31.4
Menopause: 51 y/o
CC: RLQ pain / Acute Appendicitis
Cannot rule out gynecological pathology
Ext. genitaliaL no gross lesion
SE: cervix pink smooth with no discharge
IE: cervix firm, short, closed
Uterus and adnexa cannot be assessed due to guarding / GS (main)
CV / GL to progressive diet once tolerated
Arcoxia
Celecoxib / 4/7: CBC Hgb 133 Hct 0.40 Plt 275 WBC 14.5 Neutro 0.8 Lympho 0.2
U/A dk yellow, sl turbid, 6.0, 1.025, 0-2 RBC, 0-1 us, trace protein, neg sugar, (+) AU, (+) sq cell, +# MT, +3 bact / s/p Appendectomy
OR Findings:
308 C
10C00523
06-38-98
DOB: 7/18/1996
DOA: 3/23/2010
DOR: 3/22/2010
Dr. Bongala
IIC: Venice
CIC: Rix / NIIM, Annaliza, N.
13 y/o, single, nulligravid
Zapote Road, Everlasting Street, Caloocan City
09306546805
Ht 165 cm Wt 42 kg BMI 15.4
CC: RLQ pain / Acute Ruptured Appendicitis w/ localized peritonitis
Vaginal Candidiasis
No palpable gynecologic pathology at time of examination
Cannot totally rule out other gyne pathology
SE: pink, smooth cervix with curdlike vaginal discharge
IE: firm, long closed cervix, (-) CMT; uterus N sized, retroverted; left adnexa no mass, no tenderness; right adnexa cannot be assessed due to muscle guarding / Main:
Pedia-Surg
Referral
Gyne
Pedia / DAT
Dolcet
Omeprazole / 03/22 Hgb 125, Hct 0.39, WBC 12.4, Seg 0.79, Lympho 0.18, Bands
0.01, Mono 0.02, Plt ct 340; Blood Typing: “A+”
U/A: yellow, sl. Turbid, pH 6.0, s.g. 1.030, sugar neg, alb
trace, RBC 1-2, PC 3-6, EC mod, MT mod, bact few, AU few,
cast none / s/p ‘E’appendectomy (03/23/10) / MGH (since 3/27)

DISCHARGES : 1

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