Surgery Patient
IDENTIFYING DATA
HC is a 30 years old, female, married, Filipino, Roman Catholic, born on August 19, 1982, who resides in San Pablo City.
CHIEF COMPLAINT
Vaginal bleeding of 2
months duration
Source &
Reliability
Information was obtained from the patient and has
fair reliability (75%).
HISTORY OF PRESENT ILLNESS
The
patient consulted with a complaint of vaginal bleeding of two months duration. The
patient’s symptom began two months prior to admission, when she experienced a
sudden onset of vaginal bleeding during coitus. It was characterized as bright
red and spotting-like. No pain during
coitus was noted. No medications or consult done, and the symptom persisted.
Few
hours prior to admission, she sought consult at the UERMMMCI Outpatient
Department. In her internal examination,
an 8x5cm mass was palpated on the right aspect of the vaginal canal. She was subsequently admitted for further
observation and treatment.
PAST HEALTH HISTORY
In 2008, H.C. was
admitted in the Community General Hospital in San Pablo due to hematochezia,
constipation, and diarrhea of 6 months duration. She was said to have external
hemorrhoids and a rectal mass was found. A proctosigmoidoscopy and rectal mass
biopsy was done. She was then diagnosed with rectal adenocarcinoma, stage II
(T2N0M0). She was referred to UERMMMC
where she underwent an abdominal perineal resection with posterior vaginectomy.
In 2009, she
underwent chemotherapy and radiotherapy in UERMMMC. Later that year, she had a colonoscopy and CT scan, which revealed no recurrence of the cancer.
In 2010, she
again had a colonoscopy and CT scan. The tests were negative for recurrence but
showed that she had a fatty liver. She was also then diagnosed with
uncontrolled diabetes mellitus type 2 and was prescribed metformin, 500mg,
twice a day.
In 2011, she was admitted in UERMMMC due to bacterial vaginosis and cellulitis.
Family
History
H.C.
has a family history of hypertension and diabetes mellitus on both her maternal
and paternal parents.
SOCIAL AND
ENVIRONMENTAL HISTORY
H.C. is a college
graduate and has been working as a midwife for 4 years now. Most of their income comes from the family
business. She lives with
her husband, 5 year old daughter, and 2 others in a house in San Pablo. She eats 3 meals a day, and does not do any form of exercise. She
usually sleeps at 10pm and wakes up at 4am, averaging 6 hours of sleep per day.
She has no history of cigarette smoking,
alcohol intake, and illicit drug use
REVIEW OF SYSTEMS
General
She reported weight loss from 180lbs in December 2011, to her present weight of 163lbs.
Genitoreporductive
She had her menarche at the age of 13 (1995). Her last menstrual period was in 2009, and she has been taking medroxyprogesterone (Provera) since then. She reported post-coital bleeding two months prior to admission.
PHYSICAL
EXAMINATION (Upon admission)
General Survey
She is awake, coherent and ambulatory. She is not in cardiorespiratory distress or pain.
Eyes
Her conjunctivae are pinkish and sclera are anicteric. Her pupils are equally brisk and reactive to light. Extraocular muscles are full and intact.
Thorax and Lungs
Her breathing is effortless and her chest expansion is symmetrical. No tenderness or chest retractions. She has clear breath sounds. No adventitious sounds.
Breast
Her breasts are symmetrical. No discharge, masses, or tenderness.
Cardiovascular
She has an adynamic precordium, with distinct heart sounds. No murmurs.
Abdomen
Her abdomen is soft and flabby with normoactive bowel sounds. She has a colostomy bag on LLQ. No tenderness.
Genitoreproductive
She has a prominent firm pelvic wall with a vaginal mass on the right side.
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