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분야
pptChief complaint
Present illness
Obstetric History
Past History (cont.)
Review of system
Physical examination(cont.)
Physical examination
Pelvic examination
Problem List
Impression
Diagnostic Plan
Laboratory Test
TV Ultrasonography
Diagnostic assessment
Therapeutic Plan
Operation Record
Final Diagnosis
Definition
Epidemiology
Site and Incidence
Risk Factors
Symtoms and signs
Diagnosis 2 (1)
Diagnosis 2 (2)
Treatment (1) - Medical
Treatment(2) – surgical
Reference
Cervix : vaginal spotting
no active bleeding
no erosion
motion tenderness
Adnexa : nonspecific
Parametrium : nonspecific
R/O Ectopic pregnancy
(#1, #2, #3, #4, #10 )
R/O PID
(#2, #3, #4, #6, #7 )
R/O Ovarian torsion
(#2, #3, #6)
R/O Surgical abdomen
(#2, #8)
Skipped mense
RLQ – Td/RTd +/+
Rt. Flank pain
Vaginal spotting
Cold sweating
Nausea, vomiting
Dysuria
S/p D&C
S/p appendectomy
smoking
Operation Record
Operation date : 2010. 05. 18
Preoperation Diagnosis: R/O Rt. Tubal pregnancy
Findings : 1. Pelvic adhesion (+)
2. Uterus : 7cm size -> non specific
3. Both adnexa
Rt.: ectopic focus at ampulla
Lt : fimbrio obstruction
Operation name : Laparoscopic Rt. Salphingotomy, Lt. fimbrioplasty, adhesiolysis
p. 238-256
2. Berek & Novak’s GYNECOLOGY 14Th
edition, Jonathan S. Berek, LWW,
p. 602-637
