Professional Documents
Culture Documents
Pre Op Conference 23 May
Pre Op Conference 23 May
Pre Op Conference 23 May
IDENTIFYING DATA
D. J
44 Y/O
Married
Roman Catholic
Naga City, Cam Sur
Government
Employee
Informant- Patient
CHIEF COMPLAINT
Interim
FAMILY •
•
(+) HTN, Maternal
(+) DM, Maternal
HISTORY
• (+) CKD, Maternal
• (+) Cervical cancer, Maternal grandmother
2 2002 ✓ Hospital
3 2003 ✓ CS Hospital OB
4 2004 ✓ CS Hospital OB
5 2007 ✓ CS Hospital OB
Gynecologic History
Menarche 12 years old
HEENT: Anicteric sclerae, pink IE: Cervix closed, smooth uterus small
palpebral conjunctivae, no neck vein no adnexal mass nor tenderness,
distention, no cervical Minimal vaginal bleeding
lymphadenopathy
RVE: Tight sphincteric tone, empty
Chest/Lungs: Symmetric chest rectal vault
expansion, no retractions, Clear breath
sounds Extremities: No edema, Full equal
pulses, CRT < 2 seconds
Cardiovascular: Adynamic precordium,
normal rate, regular rhythm
REVIEW OF SYSTEM
General: (-) weight loss (-) appetite (-) irritability (-) weakness
Skin: (-) color changes (-) sores (-) itchiness
HEENT: (-) Headache (-) blurring of vision (-) loss of hearing (-) nasoaural
discharge (-) colds (-) hoarse voice (-) dysphagia
Respiratory: (-) cough (-) hematemesis (-) hemoptysis
Cardiovascular: (-) palpitations (-) chest tightess/pain (-) easy fatigability
(-) orthopnea
Gastrointestinal: (-) watery stools (-) melena (-) nausea/vomitin
Genitourinary: (-) dysuria (-) oliguria (-) hematuria
REVIEW OF SYSTEMS
CNS: (-) loss of consciousness (-) seizure (-) behavioral change (-)
balance or gait abnormality
Musculoskeletal: (-) paralysis (-) painful joints (-) frequent muscle aches
(-) bipedal edema
Hematologic: (-) easy bruising (-) bleeding episodes
Ancillary Tests • WBC: 6.74 NEU: 64.8
• RBC: 4.79. LYMP: 28.0
CBC (05/23/2023) • HGB: 137.00 MONO: 5.0
• HCT: 0.417 EOS: 1.8
• PC: 327 BAS: 0.5
Color: Straw
Character: Clear
pH: 6.0
SG: 1.005
Urinalysis (05/23/2023) Protein: Negative
Glucose: Negative
WBC: 0.72
RBC: 0.36
UTZ
The anterior cervix measures 2.5x1.2cm
and the posterior measures 2.4x0.8cm,
homogeneous stroma and distinct
endocervical canal. The endometrium is
hyperchoic with multiple cystic spaces
extending to the endocervical canal.
Exploratory Laparotomy,
EHBSO with Planned Function
Class Identification and
Bilateral Lymph Node
Dissection