Gynecologic Census for Month of March 2024

Gynecologic Cases

1. Gyne Endorsement

2. February 27 2024 ‹#› Consultant On Call: Dr. Residents on Duty: Dr.

3. ‹#› GYNECOLOGY DTR Admission 2 ER Admission Co-management 1 Consult February 27 2024

4. ‹#› Name Age/Parity Chief Complaint Admitting Diagnoses Plan B.P. 42 /G 1P1 ( 1001 ) palpable abdominal mass G 1P1(1001) Abnormal Uterine Bleeding secondary to Adenomyosis Pelvic Endometriosis Laparoscopic Right Salpingo-oophorectomy with Frozen Section, Left Salpingectomy possible Adhesiolysis possible Open possible Intrauterine Device Insertion 3/26/2024 5AM DTR #1 February 27 2024

5. ‹#› Name Age/Parity Chief Complaint Admitting Diagnoses Plan D.B. 39/G1P0 (0010 ) heavy menses G 1P0(0010) Abnormal Uterine Bleeding secondary to Endometrial Polyp Uterine Myoma FIGO Grade 4 Operative Hysteroscopy Transcervical Resection of Polyp, Curettage 3/26/24 3PM DTR # 2 February 27 2024

6. ‹#› Name Age/Parity Chief Complaint Admitting Diagnoses Plan S.E. 32 / nulligravid dysuria Nulligravid T/C Endometriosis Polycystic Ovarian Syndrome For TVS in AM CM #1 January 21, 2024

7. DTR #1 B.P. 42 years old Single Filipino G1P1(1001) palpable abdominal mass ‹#› February 27 2024

8. Medical History ‹#› February 27 2024 x Hypertension x Diabetes Mellitus x Bronchial Asthma x Cardiac Disease x Renal Disease / Hypothyroidism ( on Levothyroxine 100mcg OD & Calcium+VitD3 1 tab BID ) x Neurologic Disease

9. Previous Hospitalizations/Surgeries ‹#› S/P PCS for Cephalopelvic Disproportion (2001) S/P Total Thyroidectomy for Multinodular Goiter (2022) 2003- Acute Gastroenteritis 2022- Acute Gastroenteritis, Hypocalcemia February 27 2024

10. Family History ‹#› x Hypertension X Diabetes Mellitus X Cancer x Bronchial Asthma X Cardiac Disease X Renal Disease X Thyroid Disease X Neurologic Disease X Tuberculosis February 27 2024

11. Social-Personal History X Smoker X Alcoholic beverage drinker X Drug use / Food and Drug Allergies ‹#› Allergies: shrimp, eggplant, Tramadol, Ketorolac Occupation: Physician February 27 2024

12. OB History ‹#› Gravida 1 Para 1 (1001) Pregnancy order Pregnancy outcome Year Present status G1 PCS:CPD , full term, male , 7.3lbs 2001 Living February 27 2024

13. Gynecologic History Menarche 12 y.o. Menstrual cycle Regular, 5 days, 4 PPD Dysmenorrhea ( +), takes NSAIDs LMP - PMP - Menopause N/A Coitarche - Sexual partners 1 OCP use 2001-2003 DMPA 2003-2008 Diane 35 2016-2018 Yaz STI None Pap smear - HPV vaccine - ‹#› February 27 2024

14. History of Present Illness 2 years PTA Patient noted onset of profuse vaginal bleeding (7-10 days duration with 6 pads per day) with increasing dysmenorrhea. TVS revealed adenomyosis. GnRH 11.25 given with relief of symptoms. After 3 months, shifted to Dienogest for 6 months but due to persistent spotting, shifted to Qliara and was maintained on the medication. ‹#› February 27 2024

15. History of Present Illness 5 months PTA Patient palpated a cystic abdominal mass measuring 10x10cm, associated with bloatedness. TVS revealed a 13cm endometriosis cyst with adenomyoma. CA125 was normal. GnRH 11.25mg IM given for 2 doses. Repeat TVS revealed 15cm mass thus patient opted for surgery. ‹#› February 27 2024

16. Transvaginal UTZ (3/2/24) I. UTERUS : 9.0 x 6.0 x 3.9 cm; Anteverted with smooth contour and inhomogenous echopattern. Within the posterior myometrium is a heterogeneous structure with ill-defined border and linear shadowing suggestive of an adenomyoma encroaching into the endometrial cavity measuring 3.4 x 3.4 x 2.8 cm (previously 3.4 x 3.4 x 2.8 cm) II. ENDOMETRIUM: 0.26 cm Findings: no mass Echogenicity: hyperechoic Midline: linear Endomyometrial junction: intact Intracavitary fluid: none Color flow: color score - 1 (no color) ‹#› February 27 2024

17. Transvaginal UTZ (3/2/24) ‹#› February 27 2024 III. ADNEXAE: No normal ovarian tissue is visualized. Posterosuperior to the uterus is a septated smooth-walled cystic structure with ground glass echoes and minimal color flow within the wall suggestive of an endometrioma measuring 15.1 x 11.9 x 9.4 cm (volume=890.53ml) (previously 13.7 x 9.2 x 8.5 cm (volume=564.99ml). No shadowing is noted. IV. CERVIX: 3.1 x 2.8 x 1.8 cm, homogeneous, Nabothian cyst: present V. OTHERS: Scanty clear free fluid in the cul-de-sac. (+) sliding sign surrounding the uterus The right kidney measures 11.8 x 9.8 x 5.4 cm with a central cystic area measuring 9.0 x 6.7 x 3.8 cm and an echogenic structure measuring 0.9 x 0.8 x 1.1 cm. Incidental finding of cystic structures within the right kidney to consider hydronephrosis versus multiple renal cysts aggregately measuring 9.0 x 6.7 x 3.8 cm. Within the cystic area is an echogenic structure with color flow measuring 1.9 x 0.8 x 1.1 cm.

18. Transvaginal UTZ (3/2/24) ‹#› February 27 2024 IMPRESSION: NORMAL-SIZED ANTEVERTED UTERUS WITH INTACT HYPERECHOIC ENDOMETRIUM POSTERIOR ADENOMYOMA OVARIAN CYST, PROBABLY AN ENDOMETRIOMA BY PATTERN RECOGNITION, LATERALITY CAN NOT BE DETERMINED SCANTY CLEAR CUL-DE-SAC FLUID INCIDENTAL FINDING OF A CYSTIC RIGHT KIDNEY (HYDRONEPHROSIS VERSUS RENAL CYSTS)

19. Physical Examination General Survey Awake, coherent, not in respiratory distress Vital signs BP: 120/80 mmHg HR: 7 6 bpm RR: 19 cpm Temp: 36.0 C Pain Score: 0/10 Weight, Height, BMI Weight: 59 . 7 kg Height: 1 51.7 cm BMI: 25.9 kg/m 2 (Obese Class I) ‹#› February 27 2024

20. Physical Examination Skin Warm, good mobility and turgor HEENT Anicteric sclerae, pink palpebral conjunctivae, (+) 3X5 cm mass neck midline, firm, movable, nontender Breast Symmetric, nontender, no masses, no nipple discharge Chest & Lungs Equal chest expansion, Clear breath sounds CVS Distinct and regular heart sounds, no murmurs Extremities Strong peripheral pulses, CRT <2s Neurologic exam Within normal limits ‹#› February 27 2024

21. Physical Examination Abdomen Flabby, normoactive bowel sounds, soft, nontender, (+)pelvoabdominal mass m. ~13cm from symphysis pubis, firm, movable, nontender Speculum exam: C ervix deviated to the right, m oderate bloody discharge Bimanual pelvic exam Introitus: parous Cervix: 1 cm open cervix, deviated to the right, (+)0.5cm endocervical firm mass at 11 o’clock position Uterus & Adnexae: (+) pelvoabdominal mass m. ~13cm from symphysis pubis, firm, movable, nontender Discharge: moderate bloody discharge Rectovaginal exam intact rectovaginal septum, tight sphincter tone, no nodulations ‹#› February 27 2024

22. Admitting Diagnosis G1P1(1001) Abnormal Uterine Bleeding secondary to Adenomyosis Pelvic Endometriosis ‹#› February 27 2024

23. Plan Laparoscopic Right Salpingo-Oophorectomy with Frozen Section, Left Salpingectomy possible Adhesiolysis possible Open possible Intrauterine Device Insertion 3/26/24 5AM ‹#› February 27 2024

24. DTR #2 D.B. 39 years old Single Filipino G1P0(0010) heavy menses ‹#› February 27 2024

25. Medical History ‹#› February 27 2024 x Hypertension x Diabetes Mellitus x Bronchial Asthma x Cardiac Disease x Renal Disease x Thyroid Disease x Neurologic Disease

26. Previous Hospitalizations/Surgeries ‹#› 2017 - Manila - Laparoscopy cystectomy - Benign 2022 - CDUH - Dengue, Typhoid Sept 2923 - CHHF - Migraine/Vertigo February 27 2024

27. Family History ‹#› / Hypertension (paternal) X Diabetes Mellitus X Cancer / Bronchial Asthma (maternal) X Cardiac Disease X Renal Disease X Thyroid Disease X Neurologic Disease X Tuberculosis February 27 2024

28. Social-Personal History X Smoker X Alcoholic beverage drinker X Drug use X Food and Drug Allergies ‹#› Allergies: none Occupation: account specialist February 27 2024

29. OB History ‹#› Gravida 1 Para 0 (0010)) Pregnancy order Pregnancy outcome Year Present status G1 Incomplete abortion (3 mos) S/P completion curettage 2005 – February 27 2024

30. Gynecologic History Menarche 12 y.o. Menstrual cycle Regular, 3-4 days, 5-6 ppd Dysmenorrhea None LMP 3/20/24 PMP 2/18/24 Menopause N/A Coitarche 19 Sexual partners 4 males, 4 females OCP use None STI Non e Pap smear None HPV vaccine None ‹#› February 27 2024

31. History of Present Illness 14 months PTA Noted heavy menses, consuming 2-3 fully soaked overnight pads per day, lasting 5-6 days, associated with dysmenorrhea. PS 8/10. No changes in bowel/bladder habits, or dizziness. Sought consult. TVS revealed endometrial polyp, unrecalled size. Prescribed unrecalled pills for 3 months, but discontinued after 2 months due to headache. Noted normal menses thereafter. ‹#› February 27 2024

32. History of Present Illness 10 months PTA Patient noted recurrence of heavy menses, lasting 5-6 days, consuming 3 moderately soaked diapers per day, associated with hypogastric pain PS 8/10. No consult done. Took buscopan venus with partial relief. ‹#› February 27 2024

33. History of Present Illness Interim Noted persistence of symptoms. No consult done. ‹#› February 27 2024

34. History of Present Illness 1 month PTA Persistence of symptoms with same characteristics prompted consult. TVS revealed normal-sized retroverted uterus m. 9.1x6. 5x15.2cm, with thick intact isoechoic endometrium m. 1.08cm, uterine myoma m. 1.2x1.2x1.2cm figo grade 4, endometrial polyp m. 1.8x1. 9x1.5cm, unremarkable ovaries and no cul-de-sac fluid. Advised contemplated procedure, hence this admission. ‹#› February 27 2024

35. Transvaginal UTZ (1/3/24) CLINICAL DATA: LMP = 01/20/2024 I. UTERUS: 9.1 x 6.5 x 5.2 cm; Retroverted with smooth contour and inhomogenous echopattern. There is a well-circumscribed heterogenous mass at the anterior, midcorpus measuring 1.2 x 1.2 x 1.2 cm (volume = 0.93 ml), suggestive of an intramural myoma (FIGO Grade 4). II. ENDOMETRIUM : 1.08 cm; Findings: Within the endometrial cavity is an echogenic mass measuring 1.8 × 1.9 x 1.5 cm (volume = 2.83 ml), with color score 2 (minimal) with multiple non-branching vessels. Echogenicity: isoechoic Midline: linear, interrupted Endomyometrial junction: intact Intracavitary fluid: none Color flow: color score - 1 (no color) ‹#› February 27 2024

36. Transvaginal UTZ (1/3/24) III. ADNEXAE: Right Ovary: 2.8 x 1.8 x 1.7 cm (volume = 4.45 ml), lateral to the uterus Left Ovary: 2.7 x 1.7 x 1.3 cm (volume = 3.14 ml), lateral to the uterus Both ovaries appear unremarkable. No adnexal masses seen. IV. CERVIX: 2.6 x 2.4 x 2.3 cm, homogenous, Nabothian cyst: present V. OTHERS: No free fluid in the cul-de-sac. ‹#› February 27 2024

37. Transvaginal UTZ (1/3/24) IMPRESSION ： NORMAL-SIZED RETROVERTED UTERUS WITH THICK INTACT ISOECHOIC ENDOMETRIUM UTERINE MYOMA FIGO GRADE 4; ENDOMETRIAL MASS, TO CONSIDER AN ENDOMETRIAL POLYP UNREMARKABLE BILATERAL OVARIES NO CUL-DE-SAC FLUID ‹#› February 27 2024

38. Transvaginal UTZ (1/3/24) ‹#› February 27 2024

39. Transvaginal UTZ (1/3/24) ‹#› February 27 2024

40. Laboratories (3/25/24) ‹#› February 27 2024 CBC Hgb 11.6 Hct 35.9 WBC 5.63 Plt 379 Prothrombin time Patient 13.5s Activity 101 INR 1.00 Control 13.6s Crea 0.6 mg/dl SGPT 22 U/L

41. Physical Examination General Survey Awake, coherent, not in respiratory distress Vital signs BP: 1 3 0/80 mmHg HR: 92 bpm RR: 20 cpm Temp: 36. 4 C Pain Score: 0/10 Weight, Height, BMI Weight: 78.3 kg Height: 1 58 cm BMI: 31 .4 kg/m 2 (Obese Class II) ‹#› February 27 2024

42. Physical Examination Skin Warm, good mobility and turgor HEENT Anicteric sclerae, pink palpebral conjunctivae Breast Symmetric, nontender, no masses, no nipple discharge Chest & Lungs Equal chest expansion, Clear breath sounds CVS Distinct and regular heart sounds, no murmurs Extremities Strong peripheral pulses, CRT <2s Neurologic exam Within normal limits ‹#› February 27 2024

43. Physical Examination Abdomen Flabby, normoactive bowel sounds, soft, nontender, no palpable masses Speculum exam: closed cervix, minimal active bleeding Bimanual pelvic exam Introitus: nullparous Cervix: closed, smooth, no cervical motion tenderness Uterus : non-enlarged A dnexae: nontender, no palpable masses Discharge: minimal bloody discharge ‹#› February 27 2024

44. Admitting Diagnosis G1P0(0010) Abnormal Uterine Bleeding secondary to Endometrial Polyp Uterine Myoma FIGO Grade 4 Obese Class II ‹#› February 27 2024

45. Plan Operative Hysteroscopy Transcervical Resection of Polyp, Curettage 3/26/24 3PM ‹#› February 27 2024

46. CM #1 S.E. 32 years old Married Filipino Roman Catholic Nulligravid Chief Complaint: dysuria ‹#› February 27 2024

47. Medical History x Hypertension x Diabetes Mellitus X Bronchial Asthma X Cardiac Disease X Renal Disease X Thyroid Disease X Neurologic Disease ‹#› February 27 2024

48. Previous Hospitalizations/Surgeries ‹#› none February 27 2024

49. Family History ‹#› x Hypertension x Diabetes Mellitu s X Cancer X Bronchial Asthma X Cardiac Disease X Renal Disease X Thyroid Disease X Neurologic Disease X Tuberculosis February 27 2024

50. Social-Personal History X Smoker / occasional a lcoholic beverage drinker X Drug use X Food and Drug Allergies ‹#› Allergies: none Occupation: BPO February 27 2024

51. OB History ‹#› Nulligravid Pregnancy order Pregnancy outcome Year Present status G - - - February 27 2024

52. Gynecologic History Menarche 1 3 y.o. Menstrual cycle regular, 5-7 days, 2-3 moderately to fully soaked overnight PPD Dysmenorrhea Occasional LMP 3/5/2024 PMP 1/30/2024 Menopause N/A Coitarche 19 years old Sexual partners 5 OCP use None STI None Pap smear None HPV vaccine None ‹#› February 27 2024

53. History of Present Illness 4 days PTA Onset of dysuria. No fever or hematuria. No consult done. ‹#› February 27 2024

54. History of Present Illness 1 day PTA Persistence of dysuria now associated with bilateral flank pain, PS 8-9/10 thus sought consult at ER and subsequently admitted. ‹#› February 27 2024

55. Physical Examination General Survey Awake, coherent, not in respiratory distress Vital signs BP: 1 10 / 7 0 mmHg HR: 89 bpm RR: 19 cpm Temp: 36. 3 C Weight, Height, BMI Weight: 75.1 kg Height: 1 63 cm BMI: 2 8.3 kg/m 2 (Obese I ) ‹#› February 27 2024

56. Physical Examination Skin Warm, good mobility and turgor HEENT Anicteric sclerae, pink palpebral conjunctivae Breast Symmetric, nontender, no masses, no nipple discharge Chest & Lungs Equal chest expansion, Clear breath sounds CVS Distinct and regular heart sounds, no murmurs Extremities Strong peripheral pulses, CRT <2s Neurologic exam Within normal limits ‹#› February 27 2024