Notes

* Final Report *
Progress Note *
Physician Note

Patient: ASMA ALI ALI KABI MRN: MBH-00031264 FIN: 015648096
Age: 34 years Sex: Female DOB: 23/8/1984
Associated Diagnoses: Unspecified ovarian cysts
Author: Dr.Shivani Seth Vohra

seen with dr Rehana
patient admitted with lower abdominal pain

she has history of pain since 2 months but now more since last 2 days
she went to NMC hospital was diagnosed with left ovarian cyst 6.1*5.9*4.9cm,had no insurance so came to Al Baraha hospital
she has periods for last 3 days
Pain is not Associated with Menstrual Cycle
TODAY she pain in epigastric region
she is NPO from night
No Dysuria / Bowel Complaints
No Nausea / Vomiting Associated With It

she had urine culture on 27/8/2018 that was normal
BHCG -negative
AFp- negative

Obstetrics History
P3 All Nvd , Last Delivery 2 Years Earlier In Nmc Hospital
Anc And Pnc Uneventful

Memstrual History
Menstrual Cycles Regular
5 Days / 30 Days
Lmp 15/9/18
Contraception Nil


US Pelvis Non-OB Limited of 10.09.2018:
" Urinary bladder is seen of average distension , normal wall thickness, no stones , masses or diverticulum formation .
" Uterus is seen AVF , normal size measures 10 x 5.7 x 3.4 cm , showing homogenous myometrium , with no focal lesion .
" Normal endometrial thickness measures 7.3 mm .
" Small cervical nabothian cyst measures 4.6 mm.
" Right ovary is seen normal size measures 3.2 x 2.3 cm with no focal lesion , containing small follicles .
" Left ovary is seen normal size measures 3.6 x 2.7 cm containing largest follicle measuring about 2.6 x2.1 cm .
" No adnexal solid masses or collections .
" No pelvic masses or collections .
IMPRESSION :-

" Essential normal study .



Today morning round 19/9/2018
patient is having mild pain in epigastric region

per abdomen-
soft
mild tenderness in epigastric region
rest abdomen soft

case discussed with dr wafa
-consult with medical for epigastric pain
- discahrge today and book patient for laparoscopic removal of ovarian cyst on 26.09.18



Health Status
Allergies:
Allergic Reactions (Selected)
Severity Not Documented
No Known Allergies- No reactions were documented.

Objective
Vital Signs
19/9/2018 06:00 AST
Temperature Oral
36.8 DegC

Peripheral Pulse Rate
82 bpm

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
101 mmHg

Diastolic Blood Pressure AA
60 mmHg

Mean Arterial Pressure, Cuff AA
74 mmHg

General: Alert and oriented.
Neurologic: Alert.
Psychiatric: Cooperative.

Review / Management
Results review
Condition: Stable.

Report
US Pelvis Non-OB Complete of 18.09.2018:
" Urinary bladder is seen of average distension , normal wall thickness, no stones , masses or diverticulum formation .
" Uterus is seen AVF , normal size measures 9.3 x 6.3 x 3.8 cm , showing homogenous myometrium , with no focal lesion .
" Normal endometrial thickness measures 3 mm .
" Right ovary is seen normal size measures 3.6 x 1.8 cm with no focal lesion , containing small follicles .
" Left ovary is seen enlarged by evidence of well defined simple cystic lesion measuring about 6.3 x 4.6 cm , showing thin regular wall and clear anechoic content .
" No adnexal solid masses or collections .
" No pelvic masses or collections .
IMPRESSION :-

" Left ovarian simple cyst , as above described .



Impression and Plan
Diagnosis: Left Ovarian cyst (ICD10-CM N83.20, Admitting, Medical).
PLAN
-CA 125, HIV and LDH awaited
-patient to be discharged today
-book for laparoscopy on 26.09.18
-consult medical for epigastric pain
-inform if any concern

Patient councelled regarding her condition and need for laparoscopic surgery for ovarian cyst removal
in case of pain, vomitting ,fever,dizziness, blackout or sudden severe pain come to emergency

Result type: Progress Note-Physician
Result date: 19 September, 2018 10:03 AST
Result status: Auth (Verified)
Result title: Progress Note *
Performed by: Dr.Shivani Seth Vohra on 19 September, 2018 10:13 AST
Verified by: Dr.Shivani Seth Vohra on 19 September, 2018 10:13 AST
Encounter info: 015648096, MBH Al Baraha, Inpatient, 17/9/2018 -