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. .