NAME HPI
Buayaban, Ailene Conde 7 years PTA, patient
M-17 underwent surgery for
uterine myoma measuring ~8-
10cm. No medication/ work-
up after.
3 months PTA, patient noted
decrease in urinary stream
with patient having to strain
to start the urination.
Symptoms associated with
numbness of the right leg
consult done with an
obstetrician where TVS
showed and enlarged uterus
meas. 9.1 x 10 x 11 cm with 3
hyperechoic circumscribed
uterine mass largest
measuring 8.1 x 7.9 x 8.5 cm
left anterior wall subserosal
less than 50% intramural
(grade 5). Patient was
however lost to follow up
condition tolerated.
5 days PTA, patient noted
inability to void thus sought
consult at a private hospital
where straight catheterization
was done drawing 2 L urine.
Patient was discharged but
still unable to void.
4 days PTA, condition
persisted thus return to the
private hospital where
catheterization again was
done drawing 2 L of urine
again.
3 days PTA, condition
persisted thus sought consult
PE
PE: examined patient awake,
alert, conscious, coherent
BP: 120/80 mmhg
HR: 85bpm
RR: 19cpm
Temp: 36.5 C
Wt: 62.5 kg
Ht: 160cm
Skin: fair, warm to touch,
good turgor
HEENT: anicteric sclerae, pink
palpebral conjunctiva, no
naso-aural discharges
Breast: nontender
Chest and lungs: clear breath
sounds
CVS: Distinct heart sounds
Abdomen: Flabby, soft,
nontender, (+) midline
infraumbilical surgical scar
Spec exam: Not done
BPE- not done
Rectovaginal- tight sphnicter
tone, (+) 14 weeks size
retroverted uterus, firm
Extremities- strong peripheral
pulse, CRT <2 secs
Neuro- within normal limits
 where FBC was induced and
advised surgery referred to
charity.
Pacilan, Madel Ramirez 2 years PTA, patient had
M-24 onset of dysmenorrhea (PS
8/10) sought consult with a
gynaecologist where
ultrasound of the whole
abdomen showed a right
ovarian mass measuring _ as
claimed. Patient was
prescribed unrecalled
medication with temporary
relief of pain.
1 year PTA, patient had
sudden onset of severe
hypogastric pain. Consult
done at a local hospital where
ultrasound of the whole
abdomen showed a 12 cm
ovarian mass thus underwent
surgery with a final diagnosis
of Borderline mucinous
tumor, right ovary, stage 1c.
Follow up check up with
CA125 and CA 19-9 every 3
months were within normal
limits.
3 months PTA, patient had
her routine gynaecologic
check-up where CT scan of
the whole abdomen showed a
well-defined non-enchancing
cyst m. 3.1 x 2.2 cm of the left
internal iliac region. TVS
showed a normal sized
retroverted uterus with
intact hyperechoic
endometrium m. 1.1 cm;
PE: examined patient awake,
alert, conscious, coherent
BP: 100/80 mmhg
HR: 86bpm
RR: 21cpm
Temp: 36.2 C
Wt: 75 kg
Ht:
Skin: fair, warm to touch,
good turgor
HEENT: anicteric sclerae, pink
palpebral conjunctiva, no
naso-aural discharges
Breast: nontender
Chest and lungs: clear breath
sounds
CVS: Distinct heart sounds
Abdomen: Flabby, soft,
nontender, (+) midline
surgical scar
Spec exam: Not done
BPE- not done
Rectovaginal- tight sphnicter
tone, no mass palpated,
minimal pain over the R and L
lower quadrant in palpation
Extremities- strong peripheral
pulse, CRT <2 secs
Neuro- within normal limits
adherent to the posterior
uterus is a biloculated cystic
structure m. 6 x 6.6 x 3.6 cm
with minimal color flow on
color Doppler studies, with
B:M f..... by IOTA, advised
surgery