婦產部 範例一
Uterine myoma/adenomyosis
Present illness #1 with symptoms
A XX-year-old woman, gravida X para X, presented to our outpatient department with
pelvic pain, dysmenorrhea, menorrhagia, and hypermenorrhea. The past medical
history was significant for uterine myoma and menorrhagia that has been worsening
over the previous several years, with resultant iron-deficiency anemia. The patient had
visited the outpatient clinic several times for complaints of pelvic pain, dysmenorrhea,
menorrhagia and hypermenorrhea. Medical management did not alleviate the
symptoms, and surgery was being considered after correction of the anemia. The
patient had had no prior surgery. She was a nonsmoker and denied alcohol or illicit
drug use. Current medications included nonsteroidal anti-inflammatory drugs and iron
supplements. Bimanual pelvic examination revealed a tender, enlarged, lobulated
uterus with the fundus at the level of umbilicus.
Present illness #2 without symptoms
A XX-year-old primigravida was found to have a fundal, subserous uterine myoma (?
x ? x ? cm) on routine ultrasonography. She had no previous symptoms of this large
fibroid. The patient was counseled about the possible risks and options and a decision
for expectant management was taken.
住院治療經過:
Routine preoperative evaluations, including electrocardiography (ECG), chest
radiography, serum electrolytes, blood urea nitrogen, and creatinine did not show any
preexisting pathology except for microcytic anemia, with hemoglobin (Hb) of X.X
gm/d. In anticipation of the surgery, 2 units of packed red blood cells were transfused
to correct the anemia. A laparoscopic-assisted vaginal total hysterectomy/abdominal
total hysterectomy/subtotal hysterectomy was carried out the following day without
complications. The patient was discharged on hospital day X after an uncomplicated
postoperative course.
婦產部 範例二
This 64 y/o female patient, G5P5A0, has had a bearing down sensation for
twenty years, and a solid protruding vaginal mass for 6 months. The vaginal mass
became more protruding when laughing, coughing and standing. She also complained
of incomplete emptying sensation. The feeling of incomplete voiding can be relieved
when protruding vaginal mass was pushed back.
Other urinary storage symptoms are as followed: stress urinary incontinence (-)
during laughing, cough, sneezing, incontinence without specific event (-), frequency
(-), daytime(-), urgency(-), urge incontinence(-), nocturia (-), sleep disturbance (-),
bed wetting (-). Other voiding-related symptoms were listed below, voiding difficulty
(+), strain to void (+), incomplete emptying (+), poor stream (+), urine retention (+),
unable to void (-), loss of sensation to void (-). Precipitating events and risk factors
were listed as below, multiparity (+), difficult labor course (-), labor work (+),
menopause (-) chronic abdominal straining (+), chronic cough (-), COPD (-).
She visited our outpatient Urogynecology clinic. Pelvic examination using POP-Q
system revealed Aa: +3, Ba: +8, C:+8/ GH: 8, PB: 3, TVL: 8/ Ap: +2, Bp: +2, D: -3.
The cough stress test and pad test were negative 0.07 g (voided volume 350 ml).
Urodynamic study results were as followed: 1. Uroflowmetry showed a low maximal
flow rate (9 ml/sec) with prolonged voiding time. 2. The flow pattern was strained
with intermittent type. 3. Cystometry + Electromyography showed stable detrusor
with coordinate urethral sphincter EMG. 4. Pressure flow study showed normal
voiding Pdet and abdominal straining and able to sustain until the end of flow. 5.
Urethral pressure profile (UPP) & stress UPP showed equalized pressure transmission
ration without urine leakage during cough provocative test. 6. Bladder outlet
obstruction was impressed. Therefore under the impression of uterine prolapse stage
IV, cystocele stage IV, rectocele stage III without occult urodynamic stress
incontinence, she was admitted for surgical treatment: transvaginal pelvic floor
reconstruction with tension-free vaginal mesh (TVM) techniques (Gynecare Prolift
System).
Imp:
Uterine prolapse stage IV with cystocele stage IV,
rectocele stage III without
urodynamic stress incontinence
Plans: 1. Pre-operative evaluation; 2. transvaginal pelvic floor reconstruction with
tension-free vaginal mesh (TVM) techniques (Gynecare Prolift System)
婦產部 範例三
High risk pregnancy
主訴
Intermittent regular low abdominal pain at home since yesterday afternoon
現病史
This 31 y/o female patient, G3P0AA2, EDC: 98-05-01, is 34+5 weeks pregnant. She
has been receiving regular prenatal care at our hospital, with all exam results being
normal except for elevated levels in GDM but subsequent normal OGTT. The
patient had been previously admitted on 98/02/26 at 31 weeks gestation with preterm
labor. MgSO4 was used for tocolysis and Rinderon (12mg QD x 2 doses) was
prescribed for lung maturation. Vaginal culture showed a heavy growth of bacteria
and Pentrexyl (500mg) 1# Q6H PO was prescribed. The patient was subsequently
discharged on 98/03-02 under stable condition
However, intermittent regular low abdominal pain and tightness sensation in low
abdomen has been noted again since 22:00PM last night. The patient also
complained of abundant yellowish vaginal discharge, but no vaginal bleeding or
watery discharge was seen. There was no fever, diarrhea or cough episodes recently.
As the symptoms persisted, it prompted the patient to come to our ER. She was
admitted to our DR through the ER for further evaluation. Pelvic exam revealed
cervical os dilatation: fingertip; effacement: poor; station: floating. Mild, yellowish
discharge was noted. Transabdominal sonography revealed a singleton fetus with
vertex presentation and visible fetal heart beats. Estimated fetal body weight was
about 2500 gm, which was compatible with gestational age. The fetal monitor
showed good fetal heart rate variability, but regular uterine contraction was observed
with contraction interval every 5 minutes, intensity of 60-80 mmHg. Subligual Adalat
(5mg x 4 doses) every 15 minutes was given every 15 minutes, but the contractions
persisted (interval: 5-7 mins, intensity: 60 mmHg). So this time, under the
impression of preterm labor at 35+4 weeks, she was admitted for tocolysis.
.