소개글
[의학] Case-Vaginal Bleeding에 대한 자료입니다.
목차
Identifying Data
Chief Complaint
Present Illness
Obstetric history
Past History 1
Past History 2
Review of System 1
Review of System 2
Review of System 3
Review of System 4
Physical Examination 1
Physical Examination 2
Pelvic Ex.
Problem List
Impression
Diagnostic Plan
Lab. Findings
Ultrasonography1
MRI
PET
Diagnosis
Therapeutic Plan
Operation record
PATHOLOGY FINDING
Endometrial Cancer
1. Endometrial Cancer
2. Risk Factors
3. Symptoms
4. Diagnosis
5. Pathology
6. Staging
6. Staging (FIGO)
6. Staging(Cont.)
7. Treatment
7. Cancer Treatment: Surgery
8. Prognosis
Reference
본문내용
Chest / Lung
Breathing Sound : Clear Breathing Sound
Regular Heart Beat without Murmur
Abdomen
Soft & Flat, Normoactive Bowel Sound
mass(-)
Tenderness (-) Rebound Tenderness (-)
Back & Extremity
Deformity (-) CVA Tenderness (-/-)
Clubbing (-) Pretibial Pitting Edema (-/-)
Paresthesia(-)
Cervix: non specific finding
but bleeding from Cervix canal
Ut & adn: n/s finding
Date : 2010. 04. 15
OP name
- TLH, LSO, RS, washing cytology
OP finding
- Uterus & Both adnexa :
smooth & regular surface
- EM material : average 1.0cm sized
Postoperative diagnosis
- Endometrial Cancer
*Uterus, total hysterectomy ;
1. Endometrioid adenocarcinoma, grade 1, 2.0x1.5cm, residual, endometrium with
1) confinement to endometrium
2) no lymphatic/vascular tumor invasion
3) clear resection margin
2. Adenomyosis
3. Chronic cervicitis with squamous metaplasia
*Salpinx, right, salpingectomy ; Chronic salpingitis
*Ovary, left, salpingo-oophorectomy ; Cystic follicle
*Salpinx, left, salpingo-oophorectomy ; Chronic salpingitis
*Peritoneal washing, cytology;
Negative for malignancy
참고문헌
Berek & Novak’s GYNECOLOGY 14Th edit., Jonathan S. Berek, LWW, p. 1137-1170