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Name: Ros Zalina Ahmad

RN: HSNZ00298798
Age: 49
Address: Kuala Berang
Occupation: Housewife
DOA: 19/10/14
DOC: 27/10/14
CC: this patient is a known case of cervical cancer and she is postoperative (post Wertheim
hysterectomy and BSO) of D7 for stage lla CA cervix.
HOPI:
Preoperative:
This patient is a 49 yo Malay woman, married at 17 yo for 32 year, G9P6+3, who was previously
well until 4 months ago (before puasa) had abnormal bleeding per vagina (intermenstrual
bleeding, postmenopausal bleeding) or irregular menses (twice in one month, duration 4-15days)
Blood was fresh red in colour and watery (malodorous), 5 partially soaked pads used
She thought these to be the symptoms of perimenopause.
In August Postcoital bleeding 2 times
Immediately went to private clinic
1st pap smear was done and result was abnormal, she was then referred to HSNZ O&G clinic
In September she want to see O&G specialist and colposcopy was done and cervical biopsy was
taken she was diagnosed with cervical cancer. She was scheduled for next visit. During second
visit, CT scan and chest X ray were done she was informed that it was stage lla cancer. she was
offered and counseled regarding the surgical therapy
In October, the surgery was done in HSNZ and the whole tissue that was removed was sent to
the lab for histopathological examination and the result will be out after one month to
determine whether she can be treated with chemotherapy (cisplatin)
Postoperative:
She presents well postoperatively with no vaginal bleeding, no abdominal distension and
discomfort, no fever, no scar discharge. She is passing out urine through the catheter and orally
well.

No LOW/LOA
No fever/pain
No vaginal discharge
MH:
LMP=21.9.14
AOM=15yo
irregular cycles, every month
no dysmenorrhea
no menorrhagia
Sexual history: (risk factors can put in HOPI)
HPV infection is transmitted by skin contact during sexual intercourse
Early age of coitus, grandmultiparous, multiple sexual partner (ask about husband)

PGH:
No gynaecological problem, no taking OCP (if use ocp then wont use condom), total 3 Pap
smear done, no STI/PID
POH:
Full term vaginal delivery, uneventful
Miscarriage
1. 2months-complete
2. 8months-complete (dont remember the cause)
3. 4months-D&C done

PMH:
No medical illness (immunocompromised-diabetes)
DH:
currently taking analgesics and antibiotic
Vitamin C bought from pharmacy
FH:
No significant medical illness, no family history of breast, endometrial, colon cancer (not
cervical), children are all healthy
SH:
Husband businessman, both of them do not smoking, moderate financial status (low
socioeconomic status)
Summary:
This 49yo female patient is at post op day 7, appears well and uneventful. Before operation, she
presented with abnormal bleeding per vagina
PE:
Vital signs:
BP=120/78
PR=76
BR=20
T=37
Pain score=0
General:

CVS:
Resp:
Abdominal:

Transverse suprapubic scar about 16cm


Incisional hernia

Resp:
CVS:
Ddx
Endometrial cancer
Atrophic vaginitis
**referral d/t CA cervix
Stage 3b uremic symptoms limb swelling, sob, renal failure dialysis
Stage 2a operable because not involve parametrium
HPE-specimen
Wertheim hysterectomy for cervical ca stage 2a
Lymph nodes-common iliac, internal iliac, external iliac
Chest x-ray
CT pelvis
CT abdomen
Echo resting 12 leads
Med:
Adm
Cefuroxime 500? Inj
Sodium bisphosphate 16%
Midazolam 7.5mg tablet
Pre op
Celecoxib 200mg capsule
Heparin 5000 IU/ml inj
Post op
Tramadol 50mg capsule
Paracetamol 500mg tablet
Cefuroxime axetil 250mg tablet