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Case Study: Hydrosalpinx, Adnexal Mass, Status post Appendectomy

Case Study: Hydrosalpinx, Adnexal Mass, Status post Appendectomy

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Published by Chedan B. Ceriaco
A case study on hydrosalpinx, adnexal mass, and appendectomy of an OB patient.
A case study on hydrosalpinx, adnexal mass, and appendectomy of an OB patient.

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Published by: Chedan B. Ceriaco on Sep 19, 2009
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11/17/2012

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SAINT LOUIS UNIVERSITYCOLLEGE OF NURSING
Baguio City
Case Presentation:
Hydrosalpinx, Acute appendicitis
 
Presented to:Mrs. Melody D. Baliang, RNPresented by:Ayugat, RolandAlcantara, NadineCeriaco, ChedanGonzales, BiancaMacayan, KatrinRayray, CiaraDate: June 17, 2008
 
PATIENT PROFILE
Name: Mrs. M. T. M. (Initials for anonymity) Age: 42 years oldCitizenship:FilipinoBirth date: September 15, 1965Religion:Roman CatholicBirth Place:Baguio City, Philippines Address:San Vicente, Baguio CityEducational Attainment: High School Graduate Admitting Physicians:Dr. Bibat,Dr. Catalan Attending Physician:Dr. MalinitDate and Time Admitted:June 13, 2008; 11:10AMRoom and Bed Number:Pay ward, 025Impression Diagnosis: Adnexal Mass, Left, to consider ectopic pregnancy, G
7
P
6
 (6016)Operations performed:SalpingectomyElective Appendectomy(Both done last June 14, 2008)Final Diagnosis:Hydrosalpinx, Left, s/p sapingectomy, G
7
P
6
(6016), Acuteappendicitis, congestive s/p Appendectomy
HISTORY OF PRESENT ILLNESS
Patient’s condition started one month before admission, when she experienced profusevaginal bleeding with discharge amounting to approximately two fully soaked diapers and had beendiagnosed of threatened abortion 10 weeks AOG. She had then undergone completion curettagelast May 08, 2008 at the Sto. Nino Hospital, Baguio City. The bleeding was controlled but resumeda few days after the curettage with discharge amounting to approximately 1 to 2 minimally soakedpads. The patient had not taken any medications and verbalized to have no associated abdominalpain, dysuria, or fever accompanying her existing condition.Six days prior to admission, the patient complained of experiencing abdominal pain with anintensity of 5 out of 10 and no radiation. No medications were taken and there had been noaccompanying symptoms such as fever, dysuria, nausea and vomiting.About two days before admission, patient’s condition persisted, prompting her to seekadvice from a private physician. A complete blood count, urinalysis and pelvic ultrasound were thenrequested for further diagnosis. The complete blood count revealed no significant healthdeviations, while the urinalysis suggested the presence of a urinary tract infection and the Pelvic
 
ultrasound showed left adnexal mass, suspicious for ectopic pregnancy, mild hydrosalpingitis. Dueto these findings, the patient was advised for admission, hence admitted.
PAST MEDICAL HISTORY
The patient verbalized to have been previously hospitalized at Sto. Nino Hospital for her completion curettage and named no other succeeding condition necessitating hospitalization apartfrom her present admission at Saint Louis University - Hospital of the Sacred Heart. She alsoclaimed to have no existing allergies to food and drugs and has had no previous intake of maintenance drug for any serious health complication.Furthermore, she has had no history of ovarian carcinoma, dysfunctional uterine bleeding,myoma, Hydatidiform mole, pelvic inflammatory disease, cervicovaginitis, or polycystic ovariansyndrome.
FAMILY MEDICAL HISTORY
The patient claimed to have no existing history of heredofamilial disease conditions suchas hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcedisease, hyperthyroidism, or arthritis. She has no family member with an existing contagiousdisease such as with pulmonary tuberculosis.
COURSE OF CONFINEMENT
This nursing care plan presents the case of Mrs. M. T. M., 42 year-old female, Filipino, aRoman Catholic, married, born on September 15, 1965, a resident of San Vicente, Baguio City,with a chief complaint of flank pain and vaginal bleeding. This was her second hospitalization, buthad been admitted for the first time in Saint Louis University - Hospital of the Sacred Heart lastJune 13, 2008 at 11:10 am by Dra. Catalan and Dra. Bibat, with an impression diagnosis of 
 Adnexal Mass, Left, to consider ectopic pregnancy, G 
(6016).
 The patient was admitted with the following diagnostic tests: hematology dated June 11,2008; complete blood count dated June 11, 2008; urinalysis dated June 11, 2008; whole abdominalsonogram dated June 11, 2008; and a specimen histopathology that had been reported last May18, 2008.During the second day of hospitalization, June 14, 2008, the patient had undergone thefollowing operations: Salpingectomy, Elective Appendectomy both with duly accomplished consentforms with proper pre-operative preparation.

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