ADMITTING DIAGNOSIS:

G2P2 (2001) To consider Double Primary Malignancy

Endometrioid adenocarcinoma, endometrium; Poorly Differentiated Malignancy
(Lymphoma vs Neuroendocrine tumor vs High grade sarcoma vs Poorly differentiated
carcinoma)
s/p endometrial sampling (3/15/2024 PJG)
s/p wound debridement s/p Incision biopsy Left lower quadrant abdomen (2/09/24)
Acute Kidney Injury
Anemia severe secondary to chronic disease
Hypertension stage II
Urinary tract infection
CVA (May 9, 2023)
Menopause x 12 years

GENERAL DATA
BA, 54 year-old, female, born on January 5, 1970; residing in Sta. Rosa, Nueva Ecija;
married, Gravida 2 Para 2 (2002), and was admitted for the 2 nd time in our institution last
May 4, 2024.

CHIEF COMPLAINT:
Bipedal Edema

HISTORY OF PRESENT ILLNESS:

16 months prior to admission, the patient had prolonged and heavy vaginal bleeding
consuming 8 fully soaked pads per day lasting for 1 month. She consulted at the OPD
of our institution where in TVS was requested and done revealing a myoma uteri,
intramural with subserous component, endometrial mass consider neoplastic process.

14 months prior to admission, she the patient underwent endometrial sampling at the
OPD, which revealed endometrial adenocarcinoma. Since then, the patient was lost to
follow up.

Until 4 months prior to admission, the patient noticed an enlarging foul smelling
carbuncle on the left lower abdomen with pain on palpation measuring about 4 x 3 cm.
Hence, she sought consult at our institution and was admitted under the general surgery
service, and was managed as a case of sepsis secondary to infected woud. Wound
debridement was done for 1 month. The patient was discharged there after and was
advised follow up consult after 1 month.

2 months prior to admission, the patient came in at the OPD for follow up consult under
general surgery service. Wound care and dressing were done and the patient was given
co-amoxiclav 625 mg/tab PO BID for 7 days as take home medications. The patient did
not complain of any symptoms since then.
Until 1 week prior to admission, the patient suddenly noticed having bipedal edema,
which caused her to have difficulty in walking. Persistence of symptoms. Hence, the
patient was admitted

PAST MEDICAL HISTORY:

The patient has a known case of endometrioid carcinoma since March 15, 2023.
She is Hypertensive for 2 years now since 2022, with a history of cerebrovascular
accident (CVA) last May 2023. She has been maintained on Losartan 100 mg/tab PO
OD, Carvedilol 25 mg/tab PO OD, Amlodipine 10mg/tab PO ODHS.
She was admitted last February 2024 in our institution under general surgery
service as a case of sepsis secondary to infected wound, wherein wound debridement
was done for 1 month.

FAMILY HISTORY:
Both the mother and the father of the patient have hypertension

PERSONAL AND SOCIAL HISTORY:

The patient is a ___ graduate, __ among ___ siblings. She is a non-smoker, a non-
alcoholic beverage drinker, and denies illicit drug use. The patient does not have any
food preferences as well

OBSTETRICS AND GYNECOLOGIC HISTORY:

She had her menarche at 15 years old with regular interval of 28 to 30 days, lasting for
5 days, consuming approximately 4 moderately soaked pads per day, with no
dysmenorrhea. She has been menopause for 12 years now. She had her coitarche at
__ years old with __ sexual partners. She denies any post coital bleeding, nor
dyspareunia. No papsmear was done to the patient yet.

The patient is a gravida 2 para 1 (2001). Both gravidities were delivered vaginally at
term. With her first child on 1st month of life due to neonatal pneumonia.

REVIEW OF SYSTEMS:

PHYSICAL EXAMINATION: