11.06.

2018

Chief complaint: fleshy material protruding on vaginal area

Menopause for 4 years

Patient:

This is a case of ALMONTE, FAUSTINA 62-year old G5P5(5005), CP, Married, Roman Catholic, born
on April 14, 1957 admitted at VMMC OB-Gyn Ward 7 for the 1st time due to fleshy material protruding
on vaginal area and scheduled vaginal hysterectomy.

One year prior to admission, patient noticed a fleshy material protruding on her vaginal area,
approximately a 25-centavo coin in size, aggravated by urinating and reduces spontaneously. No other
associated symptoms such as vaginal discharge, vaginal bleeding, dysuria, hematuria, and sensation of
bladder fullness. No consult was done. No medications were taken.

During the interim, patient still has the above symptom. Still no consult done. No medications
taken.

4 months prior to admission, patient noticed an increase in size of the fleshy material on her
perineum approximately that of a size of a kiwi fruit. Now associated with difficulty in urinating, nocturia
(about 20 times per night), urinary frequency, and sensation of bladder fullness. No consult was done.
No medications taken.

2 months prior to admission, persistence of symptoms prompted consult at FEU NRMF were
transvaginal ultrasound was done with unrecalled result. Patient was said to have pelvic organ prolapse
and was advised to undergo surgery. Patient was then referred at our institution for cardiopulmonary
clearance and surgery.

1 month prior to admission, still with above symptoms, patient sought consult at another hospital
and revealed the same diagnosis.

Few hours prior to admission, still with above symptoms, patient sought consult at our institution
with laboratory results and clearance, hence admission.

PERTINENT NEGATIVES:
(-) difficulty in ambulation
(-) edema
(-) Dysuria
(-) abdominal pain
(-) bowel changes
(-) decreased stool caliber

Past Medical History:

(+) Hypertension (October 2018) maintained on Losartan 50mg/tab OD and Atorvastatin 40mg/tab OD
(-) Diabetes mellitus
(-) Bronchial Asthma
(-) Pulmonary Tuberculosis
(-) food/drug allergies
(-) previous blood transfusions
(-) previous surgeries
(-) previous hospitalizations

Family History

(-) Hypertension
(-) Diabetes Mellitus
(-) Pulmonary Tuberculosis
(-) Malignancy

Personal and Social History

Patient is a retired helper, non-smoker, non-alcoholic beverage drinker, denies any illicit drug use.

ROS
(-)irritability, (-) weight loss, (-) loss of appetite, (-)difficulty in initiating sleep, (-)headache, (-)dizziness,
(-) blurring of vision, (-)dysphagia, (-) hoarseness, (-) cough, (-)colds, (-)dyspnea, (-) orthopnea, (-)
shortness of breath, (-)chest pain, (-)chest heaviness, (+) hypogastric pain, (-)constipation, (-)joint pain,
(-)limitation of movement, (-)bipedal edema

Obstetrical and Gynecological history:

Patient had her menarche at 14 years old. Her menses were noted to be regular occurring every
28-30 days, at 3 days duration, and usage of 1-2 pads/day, and without symptoms of dysmenorrhea.
Patient is already menopause for 4 years.
Patient is a G5P5 (5005).
 1st pregnancy occurred last 1984 and she gave to birth to a live full term baby boy via normal
spontaneous delivery at home, assisted by a midwife, no fetomaternal complications noted.
 2nd pregnancy occurred last 1986 and she gave to birth to a live full term baby boy via normal
spontaneous delivery at home, assisted by a midwife, no fetomaternal complications noted.
 3rd pregnancy occurred last 1987 and she gave to birth to a live full term baby boy via normal
spontaneous delivery at home, assisted by a midwife, no fetomaternal complications noted.
 4th pregnancy occurred last 1990 and she gave to birth to a live full term baby girl via normal
spontaneous delivery at home, assisted by a midwife, no fetomaternal complications noted.
 5th pregnancy occurred last 1994 and she gave to birth to a live full term baby girl via normal
spontaneous delivery at home, assisted by a midwife, no fetomaternal complications noted.
She had her coitarche at 26 years old. She had a total of 1 sexual partner. There is no history of
dyspareunia nor postcoital bleeding. No methods of contraception used.

Physical Exam
General: Conscious, coherent, not in cardiopulmonary distress
Vital signs: BP 110/80 HR 91bpm RR 21bpm T 36.5 O2 sat 98%
HEENT: Anicteric sclerae, pale palpebral conjunctivae, no eye discharges, no nasoaural discharges, no
neck vein engorgement, no cervical lymphadenopathies
Chest/Lungs: symmetrical chest expansion, no retractions, clear breath sounds
Cardiac: adynamic precordium, normal heart rate regular rhythm, no murmur
Abdomen: flabby abdomen, normative bowel sounds, soft and nontender
Pelvic exam:
Inspection: fleshy material protruding on perineum, soft, tender, approximately 7x5 cm
Speculum:
Internal exam:
Extremities: (-) gross deformities, (-) edema, (-) cyanosis, full and equal pulses, CRT <2s

Admitting Diagnosis:
G5P5(5005) Pelvic Organ Prolapse St III Cervix, St II Bladder and rectum; Hypertension St II, Controlled

Plan:
>Patient is for admission
>For vaginal hysterectomy with anterior and posterior repair on November 6, 2018