LOCATION: Inpatient, Hospital
PATIENT: Elaine Snow
PHYSICIAN: Andy Martinez, M.D.
ADMITTING DIAGNOSIS: Endometrial hyperplasia and postmenopausal bleeding.
1. Adenomatous endometrial hyperplasia.
2. Intramural and subserosal leiomyomata.
PROCEDURE PERFORMED: Total abdominal hysterectomy with bilateral salpingo-oophorectomy carried out.
COMPLICATIONS: Bleeding from small bowel mesentery, oversewn by Dr White at the time of procedure.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old woman who had been seen with complaints of postmenopausal bleeding. Dilation and curettage had been carried out and showed evidence of endometrial polyp along with simple endometrial hyperplasia without atypia. Due to the hyperplasia, Elaine was started on high dose Progesterone therapy with 20 mg daily. Unfortunately, she developed very heavy irregular bleeding on this and therefore elected to undergo definitive therapy in the form of total abdominal hysterectomy with bilateral salpingo-oophorectomy.
HOSPITAL COURSE: The patient was admitted on January 19, and I performed her total abdominal hysterectomy with bilateral salpingo-oophorectomy. During the course of the procedure, there was some bleeding noted from the small bowel mesentery. Dr. White was consulted intraoperatively, and he oversewed the bleeding area using figure-of-eight suture. The procedure was otherwise uncomplicated, and estimated blood loss was 350 cc.
The patient had then a completely uncomplicated postoperative course. By the second postoperative day she was feeling well enough to go home.
She was eating and passing flatus and ambulating on her own. She had adequate pain control with Ibuprofen alone.
DISCHARGE INSTRUCTIONS: The patient was instructed to avoid abdominal and pelvic strain for six weeks. She was to return to clinic in one week for staple removal.
Pathology report subsequently showed adenomatous hyperplasia of the endometrium and multiple intramural and subserosal leiomyomata.
DISCHARGE MEDICATIONS: 1. Ibuprofen 600 mg p.o q 6 to 8 hours p.r.n. 2. Ferrous sulfate 325 mg p.o tid. 3. Peri-Colace 200 mg p.o q h.s. p.r.n.