Pre-Operative Rounds

OBCC SAMSON
• L.M.
• 63/F
• MARRIED
• FILIPINO
• DATE OF ADMISSION: 03/13/24
 CHIEF COMPLAINT

Postmenopausal Vaginal Spotting

HISTORY OF PRESENT ILLNESS

1 year PTA 4 months PTA

 Occasional vaginal spotting once a  Increased frequency of vaginal
week spotting to 3x a week
 Not associated with tenderness  Consuming 2-3 moderately soaked
 1 fully soaked pad per day pads per day
  No other signs and symptoms noted.
No vaginal discharge noted.
  No consultation done.
No other signs and symptoms noted.
  No weight loss as claimed.
No consultation done.
HISTORY OF PRESENT ILLNESS

1 month PTA
 Sought consult at Western Visayas Medical Center due to
increasing frequency of vaginal spotting.
 Scheduled for transvaginal, transabdominal ultrasound.
 Results
returned and was then advised to undergo office
endometrial biopsy and manual vacuum aspiration.
 Transabdominal, Transvaginal Ultrasound
(02/06/24)

 Cervix
 2.0 x 2.5 x 2.4cm
 No Nabothian cyst. Homogenous stroma. Distinct cervical canal.
 Uterine Corpus
 4.1 x 3.4 x 4.3cm
 Volume = 31.3ml
 Retroverted uterus
 Subserous myoma (FIGO-7) postero-fundal, 2.9 x 2.8 x 2.4cm
 Transabdominal, Transvaginal Ultrasound
(02/06/24)

 Endometrium
 18mm (1.8cm)
 The endometrium is hyperechogenic, midline echo not defined with
regular endomyometrial junction.
 No intracavitary fluid. There is minimal color flow (Score-2)
 Adnexae
 Right ovary: 1.9 x 0.9 x 1.3cm
 Left ovary: 1.6 x 1.1 x 1.3cm
 Transabdominal, Transvaginal Ultrasound
(02/06/24)

 Others
 No free fluid in the cul de sac. No adnexal mass.
 The urinary bladder is unremarkable.
 IMPRESSION
 Retroverted normal sized uterine corpus
 Thick endometrium as described
 Subserous myoma nodule.
 Unremarkable cervix
 Atrophic ovaries. No adnexal mass.
 Please correlate clinically
Surgical Pathology Report
(02/20/24)

Histopathologic Diagnosis:
Endometrial Curettage, Manual Vacuum
Aspiration
ENDOMETRIAL CARCINOMA,
ENDOMETRIOID TYPE, FIGO GRADE 2
Surgical Pathology Report
(02/20/24)

 Gross Description:
 Received specimen labeled “Endometrial Curettings” are several brown-
black admixed with cream-white, soft to friable, irregular tissue fragments
with an aggregate diameter of 4.0 cm with mucoid portions. Entire
specimen for embedding.
 Surgical Pathology Report
(02/20/24)

 Microscopic Description:
 Histologic sections disclose a neoplasm composed of compactly arranged
proliferating malignant endometrial glands in a back-to-back pattern and
villoglandular growth with absent intervening stroma. These glands are lined by
a stratified, mildly, pleomorphic cells, with round to oval nuclei, prominent
nucleoli, vesicular chromatin pattern and a moderate amount of eosinophilic
cytoplasm. Mitotic activity is observed at 8-10 mitotic figures in ten consecutive
high power fields. Acute and chronic inflammatory cell infiltrates are seen
infiltrating the malignant glands. Wide areas of hemorrhage are seen in the
background
HISTORY OF PRESENT ILLNESS

3 weeks PTA
Sought consult with a private physician
Referred to IDH OPD for definitive
management.
 HISTORY OF PRESENT ILLNESS

 10 days PTA
 Patient came in to IDH OPD and was referred to a gynecologist oncologist for management.
 Scheduled for PFC with EHBSO possible BLND.
 Requested 2U PRBC/FWB
 Referred to IM for co-management and risk stratification.
 For ECG 12L, chest xray PA view, CBC, urinalysis, S.K, S. Creatinine, FBS, Protime, Blood
typing, 2D echo, HbA1C, lipid profile.
 To come back once with reply.
HISTORY OF PRESENT ILLNESS

8 days PTA
 Patient came back with lab results.
 For 2D echo, Lipid Profile
 LABORATORIES (03/05/24)

Complete Blood Count

Hemoglobin 149 120-150
Hematocrit 0.45 0.35-0.49
RBC 5.18 3.8-5.2 Blood Indices
WBC 7.52 4.5-11 MCH 28.80 26-34
Differential Count MCV 87.20 80-100
Segmenters 0.63 0.5-0.7 MCHC 33.00 32-36
Lymphocytes 0.27 0.22-0.4
Eosinophils 0.05 0.01-0.04
Monocytes 0.05 0.03-0.08
 LABORATORIES (03/05/24)

Protime Clinical Chemistry

Control 86.21% 73-107 Serum Sodium 141.00 mmol/L 136-145
Patient 13.13 sec 11.5-15.5 Serum 4.12 mmol/L 3.5-5.1
Activity 100% >69.9 Potassium
Ratio 0.97 <1.21 FBS 6.48 mmol/L 41.-5.9
Sensitivity Index 1.04 - Serum 63.31 umol/L 49-90
Creatinine
Normalized Ratio 0.97 <1.21
 LABORATORIES (03/05/24)
Complete Urinalysis
Clinical Examination
Macroscopic Examination Sugar (-)
Color Pale straw Bilirubin (-)
Transparency Hazy Ketone (-)
pH Level 7 Blood (-)
Reaction Acidic Albumin (-)
Specific gravity 1.01 Urobillinogen (-)
Nitrite (-)
Leukocytes (-)
LABORATORIES (03/05/24)
Complete Urinalysis
Range Grade
WBC Pus Cells 0-3/hpf Occasional
RBC 0-2/hpf Occasional

Epithelial Cells
Squamous Cells Few
Crystals
Amorphous Urates Occasional
LABORATORIES (03/05/24)

IMPRESSION:
• Left Paracardiac Fibrosis vs
Subsegmental Atelectasis
• Mild Cardiomegaly
• Atherosclerotic Aorta
• Thoracic Hypertrophic Degenerative
Osteoarthritic Changes and Mild
Dextroscoliosis
LABORATORIES (03/05/24)

IMPRESSION:
• Lateral Wall Ischemia
HISTORY OF PRESENT ILLNESS

3 days PTA
 Patient came back with the remaining lab results
LABORATORIES (03/08/24)

ADULT ECHOCARDIOGRAPHY REPORT

Conclusion:
 Normal left ventricular dimension with good systolic
function and stage I diastolic dysfunction
 Aortic and Mitral sclerosis with Mild Mitral regurgitation
 Tricuspid regurgitation, Trivial
 Normal pulmonary arterial pressure
LABORATORIES (03/07/24)

Lipid Profile
Cholesterol 6.84 mmol/L Up to 5.2
Triglyceride 2.58 mmol/L Up to 1.7
HDL-Cholesterol 2.28 mmol/L >0.9
LDL-Cholesterol 3.39 mmol/L <3.5

HbA1c Normal Value

5.6% <7.0%
HISTORY OF PRESENT ILLNESS

3 days PTA
 For repeat FBS and lipid profile after 2 months.
 Atorvastatin 40mg/tab, 1 tab OD
 Fenofibrate 160mg/tab, 1 tab OD
 Carvedilol 6.25mg/tab, 1 tab BID
 Trimetazidine 35mg/tab, 1 tab BID
 Cleared for proposed procedure
HISTORY OF PRESENT ILLNESS

 On the day of admission

 Patient came in for proposed procedure.
PAST MEDICAL HISTORY

 (+) HYPERTENSION; Amlodipine 5mg/tab 1tab OD

 (-) DIABETES MELLITUS
 (+) BRONCHIAL ASTHMA; last attack on January 2024
 (-) EXTRAPULMONARY TUBERCULOSIS
 (-) FOOD AND DRUG ALLERGY
 (-) OPERATION
 (-) HOSPITALIZATION
FAMILY HISTORY

PATERNAL MATERNAL
HYPERTENSION - +
DIABATES - +
MELLITUS
BRONCHIAL - +
ASTHMA
MALIGNANCY - -
PERSONAL AND SOCIAL HISTORY

 Retired government employee

 Non-alcoholic beverage drinker
 Nonsmoker
 No history of illegal drug use
 Diet: Rice, vegetables, meat, fish
 Exercise: Gardening
SEXUAL HISTORY

COITARCHE: 20 years old

PARTNER: 1, monogamous
HISTORY OF STI: none
FAMILY PLANNING: none
 OBSTETRIC HISTORY

G3P3 (3003)
DATE AOG TYPE OF PLACE OF DELIVERY COMPLICATION
DELIVERY
G1 Full term NSVD Lapaz Maternity Cinic None
01/23/1988
G2 Full term NSVD Lapaz Maternity Cinic None
08/21/1992
G3 Full term NSVD Lapaz Maternity Cinic None
02/02/1994
MENSTRUAL HISTORY

MENARCHE 10 years old

INTERVAL Regular
DURATION 3 days
AMOUNT 3 fully soaked pads/day
SYMPTOMS Abdominal pain
LAST MENSTRUAL PERIOD Menopause at 55 years old
PAST MENSTRUAL PERIOD N/A
PHYSICAL EXAMINATION
GENERAL SURVEY

Patient was seen and examined at the

triage, ambulatory, awake, alert,
oriented to time, place, and person, and
not in cardiopulmonary distress.
 VITAL SIGNS AND ANTHROPOMETRIC
DATA

Results Normal Range Interpretation

Temperature 36.8 36.5 – 37.5 Normal
Heart Rate 94 60 – 100 bpm Normal
Respiratory Rate 20 12 – 20 cpm Normal
Blood Pressure 120/80 <120/<80 Normal
Oxygen Saturation 98% >95% Normal
VITAL SIGNS AND ANTHROPOMETRIC
DATA

Results Interpretation
Weight 71 Underweight = <18.5
Height 155 Normal = 18.5 - 22.9
Overweight = ≥23
BMI 29.6
At Risk = 23 - 24.9
Obese I
Obese 1 = 25 - 29.9
Obese 2 = ≥ 30
 SKIN HEENT CHEST

INSPECTION •Fair complexion •Hair is black •(-) chest deformities

•Skin turgor <2s •Anicteric sclerae •(-) rashes, lesions, chest
•CRT <2s •Pinkish conjunctiva deformities
•(-) active lesions •(-) facial asymmetry
•(-) pruritus •(-) cyanosis
•(-) pallor •Intact extraocular muscles
•(-) cyanosis •Moist lips and oral mucosa
•(-) jaundice •Non-hyperemic tonsils
•(-) hematoma

PALPATION •Warm to touch •(-) cervical lymphadenopathy •Symmetrical chest expansion

•(-) thyroid enlargements •Equal Tactile fremitus
•(-) masses

PERCUSSION •Resonant on all lung fields

AUSCULTATIO •Bronchovesicular breath sounds

N on all lung fields
 CARDIOVASCULAR

INSPECTION • Adynamic precordium

PALPATION • Point of Maximal Impulse at 5th Intercostal space

Midclavicular Line
• (-) Heaves & thrills

AUSCULTATIO • Normal cardiac rate and regular rhythm

N • S1 heard at the apex, S2 heard at the base
 ABDOMEN

• Soft abdomen
INSPECTION
• No active lesions noted

AUSCULTATION • Normoactive bowel sounds

PERCUSSION • Tympanitic on all quadrants

• Soft abdomen
PALPATION
• No tenderness on all quadrants
 PELVIC EXAM

• Pubic hair is evenly distributed in an

inverted triangle
INSPECTION
• (-) masses, erythema, vulvar lesions,
discharges at introitus

• (-) Palpable mass

PALPATION • (-) Tenderness
• (-) Lymphadenopathies
 PELVIC EXAM

•Smooth vaginal walls

•Pinkish, parous cervix
SPECULUM
EXAM •No masses
•No nodularities
•No discharges

•Introitus admits 2 fingers with ease

•Cervix closed
BIMANUAL EXAM •Uterus is below the level of the symphysis pubis
•No adnexal masses or tenderness palpated
•No discharges
 PELVIC EXAM

•Good sphincter tone

RECTOVAGINAL •No blood and stool on examining finger
EXAM •Intact rectovaginal wall
•No masses, no nodularities
 OTHERS

EXTREMITIES Grossly normal extremities

NEUROLOGICA
No sensory or motor deficits.
L
 Endometrial Endometrial
PATIENT Vaginal Atrophy Malignancy
Polyps Atrophy

Age (63) ✅ ✅ ✅ ✅
Postmenopausal
✅ ✅ ✅ ✅
Bleeding
Ultrasound Findings ❌ ❌ ❌ ✅
Biopsy Result ❌ ❌ ❌ ✅
Family History ❌ ❌ ❌ ❌
ADMITTING DIAGNOSIS

G3P3 (3003) Endometrial Carcinoma,

Endometrioid Type FIGO Grade 2,
Hypertensive Cardiovascular Disease,
Bronchial Asthma not in Acute Exacerbation
 PLAN

 For Peritoneal Fluid Cytology, Extrafascial Hysterectomy with Bilateral

Salpingo-Oophorectomy, possible Bilateral Lymph Node Dissection
(3/15/24)
Preoperative Plan

 Appraise the patient of the possible risks and consequences of undergoing the operation.
 Set the schedule for operation and inform the OR.

UPON ADMISSION
 Secure informed consent
 Medical clearance and co-management with Internal Medicine
 Secure 2U FWB/PRBC of patient’s blood type with crossmatching
 Inform anesthesiologist.
THANK YOU