Notes

* Final Report *
Admission Notes
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 Razia Zafar Ali

MRP:Dr Wafa

seen with dr Samreen

Basic Information
Admit information: Left ovarian cyst .
Source of history: Self.
Present at bedside: Family member.
Referral source
History limitation

Chief Complaint
came with complains of pain abdomen ,started 2 months ago but now more since last 2 days

History of Present Illness
came with complains of pain abdomen ,started 2 months ago but now more since last 2 days,pain is moderate in intensity
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 2 days
Pain is not Associated with Menstrual Cycle
No Dysuria / Bowel Complaints
No Nausea / Vomiting Associated With It

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

Cervical Smear :Negative for intraepithelial lesion or malignancy

Medical History Nil Significant

Surgical History Nil Significant

urine culture:negative
HVS:negative


Review of Systems
Constitutional: Negative.
Genitourinary: Negative.
Neurologic: Alert and oriented X4.

Health Status
Allergies:
Allergic Reactions (All)
Severity Not Documented
No Known Allergies- No reactions were documented.
Current medications.
Histories
Past Medical History:
Resolved
Negative (387926014): Resolved.
Family History:
Entire family history is negative.
Procedure history:
none and no hospitalization history.
Social History



Educational needs
Following Assessment done


The patient’s and family’s beliefs and values
Their literacy, educational level, and language
Emotional barriers and motivations
Physical and cognitive limitations
The patient’s willingness to receive information



Physical Examination
Vital Signs
17/9/2018 22:02 AST
Temperature Oral
37 DegC

Peripheral Pulse Rate
87 bpm

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
98 mmHg

Diastolic Blood Pressure AA
53 mmHg LOW

General: Alert and oriented.
Gastrointestinal: Soft, Non-tender.
Pain assessment:
Self-reports pain
The location is: Abdomen .
The quality is: aching, sharp.
The duration is: 2 days.
Numeric rating: 5 / 10 on the severity scale.
The time pattern is: intermittent.
Aggravating factors: none.
Alleviating factors: none.
.
Integumentary: Warm.
Neurologic: Alert, Oriented.
Cognition and Speech: Oriented.
Psychiatric: Cooperative, Appropriate mood & affect.
PA:abdomen soft,left lower quadrant fullness and tenderness present,bladder ful
PV:patient refused

Review / Management
Results review: All Results
27/8/2018 11:47 AST
Hgb
12.40 gm/dL

Platelet
286.00 x10(3)/mcL

Sodium Lvl
136 mmol/L

Potassium Lvl
3.90 mmol/L

Chloride Lvl
104 mmol/L

Total Protein
76 gm/L

Albumin Lvl
37.5 gm/L

Bili Total
6.7 umol/L
27/8/2018 11:42 AST
High Vaginal Culture
See Result

Urine Culture
See Result
.
Radiology results: 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
.

Impression and Plan
Orders

Diet plan enetered
Diagnosis
Left Ovarian cyst (ICD10-CM N83.20, Admitting, Medical).
Orders
Orders
Laboratory:
CA 125 (Order): Blood, Routine collect, 17/9/2018 23:18 AST, Once, Stop date 17/9/2018 23:18 AST, Lab Collect, Left Ovarian cyst, Print Label By Order Location
AFP (Order): Blood, Routine collect, 17/9/2018 23:18 AST, Once, Stop date 17/9/2018 23:18 AST, Lab Collect, Left Ovarian cyst, Print Label By Order Location
BhCG Quantitative (Order): Blood, Routine collect, 17/9/2018 23:18 AST, Once, Stop date 17/9/2018 23:18 AST, Lab Collect, Left Ovarian cyst, Print Label By Order Location
CBC w/ Auto Diff (Order): Blood, Routine collect, 17/9/2018 23:17 AST, Once, Stop date 17/9/2018 23:17 AST, Lab Collect, Left Ovarian cyst, Print Label By Order Location.
inj perfalgan given in emergency
observation
give analgesia if needed
send blood for investigations

Education and Follow-up:
Counseled: Patient, Regarding diagnosis, Regarding treatment, Regarding medications, observation,to give analgesia,if pain persists then for ovarian cystectomy .
Discharge Planning: Plan to discharge ( In 2 days ).

plan of care discussed with patient and family

interdisciplinary plan charted

Result type: Admission Note-Physician
Result date: 17 September, 2018 23:04 AST
Result status: Auth (Verified)
Result title: Admission Notes
Performed by: Dr Razia Zafar Ali on 17 September, 2018 23:14 AST
Verified by: Dr Razia Zafar Ali on 17 September, 2018 23:25 AST
Encounter info: 015648096, MBH Al Baraha, Inpatient, 17/9/2018 -