OB-GYN Studies

DISCHARGE SUMMARY

A 24-year-old white female, single, admitted as an emergency case for exploratory laparotomy for possible tubal pregnancy with delayed menses, positive serum hCG x2, and a pelvic ultrasound showing empty uterus with bilateral adnexal masses, the right larger than the left.

She underwent dilatation and curettage, exploratory laparotomy with excisional biopsy of growths on both right and left ovaries, drainage of right ovarian cyst.  Frozen section diagnosis of benign ovarian cystadenoma.

Her hCG was done with quantitative analysis on day 1 postoperatively with subsequent results of 298.

Her final pathology report on the ovarian tissues showed benign serous surface papillomas (adenofibroma) with benign secretory endometrium with deciduoid reaction.

Her final hemoglobin postoperatively was 12.1.  To be followed in the office for the remainder of her postoperative care.  She did have a cystitis that was present prior to surgery, and this responded to ampicillin orally.

FINAL DIAGNOSES

1. Benign serous surface papillomas (adenofibroma) of both right and left ovaries.

2. Follicular cyst, right ovary.

3. Cystitis.

SURGERIES PERFORMED

Exploratory laparotomy.  Excisional biopsy, right and left ovaries.  Drainage of right ovarian cyst.

FOOTNOTE

Lines 9, 18.  Alternative:  HCG (human chorionic gonadotropin).

Line 14.  The redundant word right was deleted.

Lines 30-34.  The Final Diagnoses were enumerated.