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[의학] Case-Vaginal Bleeding

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    [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

    #Vaginal#CaseVaginal#Case#Bleeding#의학