CLINICAL DIAGNOSIS: CERVICAL ADENOCARCINOMA STAGE IB1

PROCEDURE PERFORMED: RADICAL HYSTERECTOMY

BILATERAL SALPINGO-OOPHORECTOMY
BILATERAL PELVIC LYMPHADENECTOMY
The patient is Angelita Tomita, 46 year oldest Gravida 9 Para 5 (5045) post radi
cal hysterectomy on February 18,2011 who came in due to feeling of urinary reten
tion associated with hypogastric pain few hours after discharged. The patient wa
s discharged one day prior to consult with indwelling foley catheter and was dra
ining well. At present, the patient has no vaginal bleeding, no vaginal discharg
e, and hypogastric pain, and foley catheter is draining well.
Review of systems: no fever, no headache, no blurring of vision, no nausea nor v
omiting, no difficulty of breathing, no epigastric pain, no diarrhea nor constip
ation, nor dysuria.
Past medical history: (+) hypertension- maintained on Amiodipine 5 mg, 1 tablet
once a day. No diabetes mellitus, bronchial asthma. Allergy to dust, pollen and
change in temperature/weather conditions. s/p breast implantation-1992, s/p Remo
val of breast implantation-1994, s/p suction curettage (for elective abortion in
Japan)-1989, 1990, 1991,2000
Family history: Patient's mother has hypertension, diabetes mellitus, bronchial
asthma, goiter and stroke.
Personal and social history: non-smoker, not alcoholic beverage drinker, no illi
cit drug use.
Menstrual history: Menarche at age 13/ regular interval/ 7 days duration/ consum
ing 4 maternity pads/day / with occassional dysmenorrhea
OB history: G9P5 (5045)
G1- 1979, delivered a live term male via svd, no fetomaternal complications
G2- 1980, deliverd a live term female via svd, no feto maternal complications
G3- 1981, delivered a live term female via svd, no feto maternal complications
G4- 1989, Elective Abortion s/p suction curretage
G5- 1990, Elective Abortion s/p suction curretage
G6- 1991, Elective Abortion s/p suction curretage
G7- 1994, delivered a live full term female via svd no feto maternal complicatio
ns
G8- 1999, delivered a live full term female via svd no fetomaternal complication
s
G9- 2000, Electo Abortion s/p suction curretage
Gynecological History
Oral contraceptive pill use- 1980s for two years

Allergic to drug: Co-amoxiclav : causes diarrhea

Feb 3 2011 at 1400h(110/80 , 89, 29, 36.7 fc=80 ml)
1200h ( 140/70, 67, 19,36.3, fc=350 ml)
Recieved patient conscious, coherent with ongoing foley catheter draining to uri
ne bag. no contraptions noted. urinalysis already taken and sent via aerocom whi
le patient is at examination room; may transfer to room.
urinalysis result still not in.
VS
1600H
TEMP
120/80
18
36.9
70
2000H
intake
am 700 --- fc 780 bm-0
Pm shift

ND#4: RISK FOR INFECTION

r/t traumatized tissue
ND#3: DISTURBED BODY IMAGE
r/t removal of female reproductive organs
as evidenced by _______
ND#5: READINESS FOR ENHANCED URINARY ELIMINATION
ND#1: ACUTE PAIN
r/t tissue trauma and
as evidenced by pain scale of 3/10.
ND#2: IMPAIRED TISSUE [INTEGUMENTARY] INTEGRITY
r/t radical hysterectomy
as evidenced by abdominal incision