Basicmedical Key

CONSULTANT: Andy Martinez, MD

This is a 62-year-old white female gravida 2, para (to bring forth) 2, 0, 0, 2, who is postmenopausal and is referred by Dr. Green to render an opinion regarding postmenopausal bleeding. Papanicolaou smear last year in July. Mammograms unknown.

REASON FOR THE VISIT: The patient has a chief complaint of postmenopausal bleeding.

Evaluation by Dr. Green, including pelvic ultrasound, demonstrates the uterus to be enlarged for age with multiple calcifications suggesting residuals of prior fibroid and thickened endometrium with what appears to be a 3.2 × 3.3 × 2.3-cm (centimeter) solid mass endometrium with some surrounding fluid.

Differential diagnoses are endometrial polyp, localized hyperplasia, and even malignancy. Endometrial sampling for further evaluation is highly recommended.

The right ovary is normal in size and texture. The left ovary is not well visualized, probably due to atrophy.

MEDICATIONS: Multivitamins and calcium

ALLERGIES: No known drug allergies

TOBACCO: None. ALCOHOL: None.

SOCIAL HISTORY: The patient is a retired bookkeeper.

The above was discussed with the patient.

FAMILY HISTORY: Positive for colon cancer, breast cancer, and heart disease. Negative for hypertension, cholesterol, diabetes, osteoporosis, and ovarian cancer.

REVIEW OF SYSTEMS: The patient is positive for eyeglasses, arthritis of the left shoulder, the above genitourinary symptoms, pelvic relaxation, stress urinary incontinence, and postmenopausal bleeding.

GYNECOLOGY EXAMINATION: Blood pressure is 110/68. Height 63½ inches. Weight is 138 pounds. Neck: Supple.

Nonpalpable thyroid. Breasts: Negative for masses, discharge, or tenderness. Breasts are symmetrical. Pelvic: Adult female genitalia, marital vagina, cervix multiparous, and uterus 6 weeks. Midline adnexa negative. Rectal: Deferred. Musculoskeletal, within normal limits.

IMPRESSION: Postmenopausal bleeding with abnormal pelvic ultrasound and symptomatic pelvic relaxation.

PLAN: Hysteroscopy with fractional D&C (dilation and curettage). Subsequent to the D&C, the patient will probably require a total abdominal hysterectomy with bilateral salpingo-oophorectomy and Burch urethrovesical neck suspension in conjunction with Dr. Sanchez (surgery) with possible staging for malignancy. The risks, benefits, indications, and alternatives to surgery have been discussed with the patient and her daughter. The patient gives informed consent and elects to proceed with surgery. The patient is scheduled for surgery 3 days from now. Dr. Green’s preoperative history and physical are reviewed, and he feels she is “okay” for anesthesia and procedure as planned. The patient does have advanced directives.

Written report was sent to Dr. Green by Dr. Martinez stating that, in his opinion, the patient will need hysteroscopy with a fractional D&C and possibly a total abdominal hysterectomy.

11-2A:

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): ____________________________________

11-2B Operative report, hysteroscopy

Dr. Martinez schedules a hysteroscopy for Gladys, which becomes a hysterectomy. During the hysterectomy procedure, it is found that Gladys has extensive gallbladder calcification. Dr. Sanchez is called into the operating room to assess the gallbladder, and he recommends that the gallbladder be removed during this operative session (Operative Report 11-2C). Before surgery, the patient had signed a consent form to proceed with the cholecystectomy if it were warranted. Report the services of Dr. Martinez for the following:

SURGEON: Andy Martinez, MD

PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding with abnormal pelvic ultrasound

POSTOPERATIVE DIAGNOSIS: Grade 1, stage I endometrial cancer and porcelain gallbladder

PROCEDURE PERFORMED: Hysteroscopy with fractional dilation and curettage by Dr. Martinez. Exploratory laparotomy with lysis by Dr. Sanchez. Total hysterectomy and bilateral salpingo-oophorectomy by Dr. Martinez. Cholecystectomy by Dr. Sanchez.

ANESTHESIA: General laryngeal mask

ESTIMATED BLOOD LOSS: 350 cc

URINE OUTPUT: 220 cc

FLUIDS: 2700 cc

COMPLICATIONS: Perforation of uterus at time of hysteroscopy and D&C (dilation and curettage)

PROCEDURE: The patient was prepped and draped in a lithotomy position under general laryngeal mask anesthesia. The weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The Kevorkian curet was then used to obtain endocervical curettings. There was thick brown mucous material present. The uterus then sounded to a depth of 8 cm (centimeter). The cervical os (opening) was then serially dilated to allow passage of a hysteroscope. The hysteroscope was then passed into the uterine cavity. With poor visualization of the uterine contents, it became apparent that there was a perforation (report accidental puncture during surgery based on this comment) in the posterior uterine cavity. The instruments were removed from the vagina. The patient was then placed in a supine position, and a Foley catheter was placed. The abdomen was prepped and draped. A vertical incision was made in the lower abdomen (this is where the procedure converted to a TAH [total abdominal hysterectomy]). The fascia was divided in the midline. The peritoneum was entered and the incision was extended vertically. Palpation of the abdominal cavity revealed an abnormally hard, fixed lesion in the right upper quadrant by the liver that was suspicious for metastatic malignancy. The incision was extended. The bowel was packed out of the operative field using a self-retaining retractor and laparotomy sponges. An adhesiolysis was required to mobilize the sigmoid off the posterior uterine wall. The uterus was grasped and elevated. The round ligaments were cross-clamped, divided, and ligated with 0 Vicryl suture ligature. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The ureters were attempted to be visualized bilaterally. The right ovary was adherent to the pelvic sidewall, and then the utero-ovarian ligament was clamped, divided, and ligated with 0 Vicryl suture ligature. The left infundibulopelvic ligament was doubly clamped, divided, and ligated with 0 Vicryl free tie and 0 Vicryl suture ligatures. The uterine vessels were skeletonized. The bladder was advanced from the operative field. The broad ligaments were stepwise fashioned down to the uterosacral-cardinal ligament complex using 0 Vicryl suture. The vaginal cuff was reapproximated using 0 Vicryl figure-of-eight sutures times three. The operative was inspected and was hemostatic. The right adnexa was then grasped, and adhesiolysis was performed to allow mobilization of the left adnexa. The infundibulopelvic ligament was then doubly clamped, divided, and ligated and then surgically excised from the pelvic sidewall. Operative sites were inspected and were hemostatic. The pelvis and abdomen were liberally irrigated. See Dr. Sanchez’s dictation for cholecystectomy. At completion of this procedure, hemostasis was observed in the operative site. The omentum was brought down anteriorly. The fascia and peritoneum were closed with 0 Vicryl internal interrupted retention sutures and 0 PDS continuous suture. The incision was irrigated. The skin was closed with staples. All sponges and needles were accounted for at completion of the procedure. The patient left the operating room in apparent good condition having tolerated the procedure well. The Foley catheter was patent and draining clear yellow urine at completion of the procedure.

Pathology Report Later Indicated: Grade I, endometrial cancer with minimal myometrial invasion. Focal areas of FIGO (International Federated Gynecological Oncology) grades 2 and 3 with focal invasion limited to the inner third of the myometrium.

11-2B:

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

11-2C Operative report, cholecystectomy

Dr. Sanchez removes the diseased gallbladder of this patient during the same operative session as the hysterectomy performed by Dr. Martinez. Report the services of Dr. Sanchez in the following:

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Porcelain gallbladder

POSTOPERATIVE DIAGNOSIS: Porcelain gallbladder

PROCEDURE PERFORMED: Open cholecystectomy

INDICATION: This is a 62-year-old female on whom Dr. Martinez had performed a hysterectomy. This was done in regard to endometrial cancer. Please see his operative note for specific details. Briefly, it had been a D&C (dilation and curettage) and hysteroscopy, but a perforation of the uterus had occurred. He then converted to an open procedure for the hysterectomy. During this time, on exploration of the abdomen, it was noted that she had a contracted, rock-hard porcelain gallbladder present. I was called in for evaluation of this. Please see my intraoperative consult dictation regarding this. I recommended removal of her porcelain gallbladder because of the potential malignancy being present.

PROCEDURE: The abdomen had already been opened through a vertical midline incision. This went from a little way above the umbilicus down to the pubic symphysis. To get adequate exposure of the gallbladder and liver, we had to extend the incision superiorly some. Then, with the use of a Balfour retractor and the upper arm, we were able to get good exposure. Laps were packed on top of the liver to bring it down. We were able to dissect out the neck of the gallbladder, the cystic duct, and the cystic artery. The cystic artery was ligated with 4-0 silks. It was then transected. We then dissected all the way around the cystic duct. We then took down the gallbladder out of the gallbladder fossa using cautery. We clamped the cystic duct just above the common duct. We identified the junction. It was transected and handed off the table as specimen. We doubly ligated the cystic duct stump then with 3-0 Vicryl. Hemostasis was achieved. Dr. Martinez then came back in to finish the closure of the wound. Again, this is an abbreviated dictation.

I met with the patient’s family member postoperatively and did discuss the removal of her gallbladder and the reason for the decision regarding this. Her questions were answered. She understood and was glad that the gallbladder was removed at this time.

Pathology Report Later Indicated: Extensive calcification of gallbladder, benign

11-2C:

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

11-2D Oncology consultation

Dr. Green requests that Dr. White, oncologist, provide his opinion about the patient’s uterine cancer.

CONSULTANT: Rapheal White, MD, Oncology

REASON FOR CONSULTATION: Endometrial uterine carcinoma

HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old white woman who had been seen at the beginning of May by Dr. Martinez for vaginal bleeding. Evaluation included D&C (dilation and curettage). She has had perforation of the uterus. Surgery of total abdominal hysterectomy had been performed for tumor of the uterus. Porcelain gallbladder had been found and this had been also removed. Postoperatively, she has recovered relatively promptly, started feeding, and has had bowel movements. She required fluid support and because of this she probably has developed tachycardia in the range of 175 with blood pressure dropped from 160 systolic to 120. She had been treated with digoxin and diltiazem and had been transferred to the surgical ICU (intensive care unit) and started on esmolol. Electrolytes also had been replaced. At this point, she gives no specific complaints. She feels somewhat depressed and scared by the whole situation.

PAST MEDICAL HISTORY: Past medical history has been insignificant. She has had no illnesses, injuries, or surgeries.

Her only medications have been multivitamins and calcium.

SOCIAL HISTORY: She is a retired bookkeeper. Lives together with her husband in Manytown. There is no history of tobacco abuse or alcohol abuse.

She has no known allergies.

FAMILY HISTORY: Notable above for colon cancer and breast cancer. There is also heart disease in the family. No significant history of dyslipidemia, diabetes, osteoporosis, or history of ovarian cancer.

REVIEW OF SYSTEMS: Except for the events in the hospital associated with tachyarrhythmia, she has had no chest pain, cough, shortness of breath, nausea, or vomiting. Constitutional: There is no history of any significant weight loss. Appetite has been good. There is no history of fevers. HEENT (head, ears, eyes, nose, throat): She uses glasses. No significant change in vision. No blurred or double vision. No change in hearing or swallowing problems. No new headaches. No new neck stiffness. She has arthritis of the left shoulder that has been present for a long time. Respiratory: She has had no history of exposure to tuberculosis. No pneumonia. No chronic history of any shortness of breath, cough, or expectoration. No hemoptysis. Cardiovascular: No significant prior history. No palpitations or chest pain. Gastrointestinal: No history of abdominal pain. No history of gastroesophageal reflux, regurgitation, peptic ulcer disease, or recent change significant of bowel habits. No melena or hematochezia. No mucus in the stool. Genitourinary: She has had complaints of stress urinary incontinence. Gynecologic: There is postmenopausal bleeding for which she had surgery. She is para (to bring forth) 2. She has had uncomplicated deliveries. She has a son and daughter who are living close by and essentially healthy. She has not been on hormonal replacement treatment. Musculoskeletal: She has complaints consistent with osteoarthritis, pain mainly in the left shoulder that had been present for a long time. Neurologic: No history of stroke, seizures, loss of consciousness, paresis, tingling, or numbness. Hematologic: No history of easy bruising or bleeding prior to the postmenopausal bleeding. No history of blood transfusions. Lymphatic: No history of lymph node enlargement. Endocrine: No history of polydipsia. No cold or heat intolerance. Immunologic: No history of hives or recurrent frequent infections. Psychiatric: No history of major depression or psychosis.

PHYSICAL EXAMINATION: She is alert and oriented times three; was in apparent distress while in the ICU. Blood pressure at present in the range of 122-150/70-80. Pulse is in the range of 79; it reaches 120-130 at times. Respiratory rate is 16. She is afebrile. Normocephalic and atraumatic. Eyes: PERRLA (pupils equal, round, reactive to light and accommodation). No jaundice. No extraocular muscle movement. No sinus tenderness. Clear oral and nasal mucosa. Tongue and uvula midline. No pharyngeal exudates, erythema, or thrush. The ear canals are clear. The neck is supple. No JVD (jugular vein distention). Trachea midline. Nonpalpable thyroid. No palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Lungs are clear to auscultation and percussion bilaterally. Heart: S1 (first heart sound) and S2 (second heart sound). No gallop or rub. No significant murmur. Breast exam: No palpable mass or nipple discharge. The abdomen is soft and nondistended. Bowel sounds are present, hypoactive. Difficult to examine, she has had recent surgery but no palpable masses or organomegaly. Extremities: There is no cyanosis, clubbing, or edema. Pulses are present. Neurologic: There are no focal motor, sensory, or cranial nerves II-XII deficits. Muscle tone and reflexes are grossly within normal range. She shows appropriate insight and judgment. Mood is somewhat depressed. Affect is grossly normal.

Her ECG (electrocardiogram) and monitor slips have shown episodes of V-tach (ventricular tachycardia), episodes of atrial fibrillation, and some slowed PR (pulse rate) intervals. Dr. Martinez has considered WPW (Wolff-Parkinson-White syndrome).

LABORATORY DATA: White blood cell 15.27, hemoglobin 12.4, hematocrit 35.2, platelets 186, and normal red cell indices. Differential: Increased neutrophils 88.6%, decreased lymphocytes 5.7%, monocytes 5%, eosinophils 0.6, and basophils 0.1%. Basic metabolic panel: potassium 3.5, glucose 123, and calcium 7.4. The rest is within normal range. PT/INR (prothrombin time/International Normalized Ratio) today has been 13 and 1.2. Magnesium was normal at 1.7, and phosphorus decreased to 0.3. Urine culture has been done but is not available yet. LDH (lactate dehydrogenase) was 143. Troponin had been 0.08. The pathology result from the surgery has concluded with endocervical curettings and benign endocervical mucosa; the uterus has shown endometrial adenocarcinoma endometrioid-type, predominantly grade 1 with focal areas of FIGO (International Federated Gynecological Oncology) grades 2 and 3 with focal invasion limited to the inner third of the myometrium. Left ovary, fallopian tube, no pathologic diagnosis. Multiple intramural and subserosal leiomyomata showing the myometrium, benign, right ovary and fallopian tube portion of benign ovary and fallopian tube. The gallbladder has shown extensive calcification.

ASSESSMENT: A 62-year-old patient has had recent surgery at this point and is in critical condition, namely because of cardiac arrhythmias probably related to fluid overload related also to medications. She has been started in the hospital on Peri-Colace, Zoloft, azithromycin, cefotaxime, and Zofran, and Tylenol has been given. In terms of the uterine cancer, the cancer seems to be early stage. As per the available data, the tumor is T1B, N0, M0, the stage is IB endometrioid carcinoma, low grade in most of the tumor. No evidence of any intravascular, perineural spread. These are also associated, most likely, with stress leukocytosis as well as electrolyte abnormalities. The patient at this point is still in critical condition in terms of her cardiac function. She has been monitored. Anticoagulation has been planned considering relatively prolonged hospital stay, and at this point she is bedridden in the ICU. Dr. Green has started replacement of electrolytes and anticoagulation. She has been kept n.p.o. (nothing by mouth) with consideration of possible ileus. Aside from this, her immediate problems, which will be managed by Dr. Green in terms of the uterine cancer, the only disturbing factor is the fact that there was perforation of the uterus during D&C, which may have caused some spilling of tumor cells in the pelvic area. Still this is not a justifiable consideration for any additional adjuvant treatment. The recommendation in her case would be after stabilization of her condition in several weeks to perform CT (computerized tomography) scans to evaluate for any pelvic, periaortic, possible adenopathy, which at her stage of cancer is not very likely. As there was tumor spilling, the risk for recurrence of such an early stage uterine cancer is minimal, and studies would be indicated in less than 10% over 5 years. Considering these facts, no additional treatment would be recommended; yet a cautious approach with obtaining of imaging studies, CT scan of pelvis and abdomen could be considered once she is stable, and if those are negative, further follow-up could be done on a clinical basis. The patient herself is not willing to proceed with any aggressive treatment, which again in her case is not recommended and most likely will not be needed in the future either. She will need regular gynecological follow-up as well as mammograms as per guidelines. I would be glad to follow up with her in 1 to 2 months when she would be able to have the CT scans done. I appreciate the opportunity to see this pleasant lady, who in terms of her uterine cancer would have very likely good prognosis.

11-2D:

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ___________________________________

ICD-9-CM DX CODE(S): _____________________________________

11-2E Discharge summary

PRIMARY CARE PHYSICIAN: Ronald Green, MD

1. Endometrial uterine adenocarcinoma

PRINCIPAL DIAGNOSES:

2. Porcelain gallbladder

POSTOPERATIVE DIAGNOSIS: Wolff-Parkinson-White syndrome

OPERATIVE PROCEDURE: Hysteroscopy with fractional dilatation and curettage converted to a total abdominal hysterectomy with bilateral salpingo-oophorectomy, open cholecystectomy, lysis of adhesions, open biopsy frozen section of ovary and fallopian tube, arterial line insertion, and postoperative fluid overload.

CONSULTANTS: Drs. Martinez, Sanchez, White, and Orbitz.

IDENTIFICATION HISTORY OF PRESENT ILLNESS: The patient had preoperative history and physical by Dr. Green.

PREOPERATIVE GYN NOTE: The patient is a 62-year-old white female, gravida 2, para (to bring forth) 2, who is postmenopausal with postmenopausal bleeding. Pap smear 11/03. Mammogram unknown.

REASON FOR THE VISIT: The patient had a chief complaint of postmenopausal bleeding. Evaluation by Dr. Monson (radiology), including pelvic ultrasound, demonstrates the uterus to be enlarged for age with multiple calcifications suggesting residuals of prior fibroid and thickened endometrium with what appears to be a 3.2 × 3.3 × 2.3-cm (centimeter) solid mass in the endometrium with some surrounding fluid. Differential diagnoses are endometrial polyp, localized hyperplasia, and even malignancy. Endometrial sample for further evaluation is highly recommended. The right ovary is normal size and texture. The left ovary is not well visualized, probably due to atrophy.

MEDICATIONS: Multivitamins and calcium

MEDICAL PROBLEMS: None

ILLNESSES: None

INJURIES: None

SURGERY: None

ALLERGIES: No known drug allergies

TOBACCO: None. ALCOHOL: None.

SOCIAL HISTORY: The patient is a retired bookkeeper.

FAMILY HISTORY: Positive for colon cancer, breast cancer, and heart disease.

REVIEW OF SYSTEMS: The patient is positive for eyeglasses, arthritis of left shoulder, the above genitourinary findings, pelvic relaxation, stress urinary incontinence, and postmenopausal bleeding.

EXAMINATION: Blood pressure is 110/68. Height: 63¹/₂ inches. Weight: 138 pounds. Neck is supple. Nonpalpable thyroid. Breasts negative for masses, discharge, or tenderness. Breasts are symmetrical. Pelvic: Adult female genitalia, marital clean vagina. Cervix multiparous. Adnexa negative. Rectal: Deferred. BUS (Bartholin’s, urethra, and Skene’s glands) within NORMAL LIMITS. Some pelvic relaxation is noted.

IMPRESSION: Postmenopausal bleeding with abnormal pelvic ultrasound and symptomatic pelvic relaxation.

HOSPITAL COURSE: During the hysteroscopy and D&C (dilation and curettage), it was noted that there was perforation of the uterus, at which time the procedure was converted to a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During that time there was noted to be a gelatinous mass posterior to the uterus, which was sent to pathology. At the time of frozen-section pathologic evaluation, it was determined that the endocervical curettings were benign endocervical mucosa. Uterus, left fallopian tube, and ovary resection with endometrial adenocarcinoma endometrioid-type: Predominantly grade 1 with focal areas of FIGO (International Federated Gynecological Oncology) grades 2 and 3 with focal invasion limited to the inner third of the myometrium. Left ovary and fallopian tube resection: No pathologic diagnosis. Multiple intramural and subserosal leiomyomata showing extensive hyalinization with focal calcification. Focal adenomyosis: Myometrium, benign. Right ovary and fallopian tube: Portion of benign ovary and fallopian tube. Gallbladder excision: Extensive calcification of the gallbladder. The cytologic washings returned atypical cells; cannot rule out malignancy.

The hospital course continued with the patient developing problems with fluid overload, at which time Dr. Orbitz (nephrology) was consulted, and he determined that the patient had Wolff-Parkinson-White syndrome, which was aggravated by the stress of surgery. The patient also had frequent episodes of atrial fibrillation and was anticoagulated, and he thought she should remain anticoagulated until she was further evaluated in 4 to 6 weeks. She was discharged on Toprol XL 100 daily, and he thought she should stay on the beta-blocker indefinitely. She should also have a Holter monitor done in 4 to 6 weeks. Then if she is in sustained sinus rhythm at that time, it would be reasonable to remove the anticoagulation. The patient was discharged postoperative day 8 with instructions to return to the clinic in 1 week for incision check and in 4 weeks for postoperative evaluation. A consultation was arranged with oncology, who felt that she would not require additional treatment; yet they recommend a cautious approach with obtaining imaging studies, CT (computerized tomography) scan of the pelvis and abdomen every 3 months times 1 year. The patient was not willing to proceed with any aggressive treatment at the time of discharge.

DISCHARGE MEDICATIONS:

1. Metoprolol 50 mg (milligram) q.12h.

2. Coumadin 1 tablet q.d. (every day) at 1 PM

3. Tylenol p.r.n. (as needed)

This narrative discharge summary is being sent to Dr. White to render an opinion regarding recommendations about further treatment for this cancer relative to perforation of the uterus at time of D&C hysteroscopy (tumor cells spilled into abdomen). We will also send copies of the cytology and slides for that evaluation. I spent a total of 45 minutes providing this discharge service for this patient.

11-2E:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): ______________________________________

A colposcope is illustrated in Figure 11-2 and is used to examine the vagina and cervix as illustrated in Figure 11-3. A colposcopy is an examination and/or biopsy of the vaginal and cervical areas and is most often an office procedure. A hysteroscope is a scope that is inserted through the vagina and cervix and into the uterus. A hysteroscopy is a procedure performed in an operating room because of the danger for possible uterine perforation and/or hemorrhage.

FIGURE 11–2 Office colposcope with beam splitter.

From the Trenches

“Never stop learning. Subscribe to clinical news to keep up with new procedures in your specialty. Read your coding journals and go to training sessions or monthly meetings through coding organizations. If you are self-motivated to keep abreast of current coding issues, you will succeed.”

Sheri

Pelvic pain

Pelvic pain is a common gynecologic complaint and can have many origins, for example, pregnancy-related pelvic pain, pelvic inflammatory disease (PID), dysmenorrhea (painful menstruation), endometriosis, and pelvic adhesions. The pelvic pain can also indicate a nongynecologic etiology, and so the OB/GYN physician is alert to differential diagnoses from other organ systems. Gastrointestinal-related pelvic pain could indicate appendicitis, irritable bowel syndrome, or inflammatory bowel disease. Urology-related pelvic pain could indicate urinary tract infection or renal stones. Musculoskeletal-related pelvic pain could indicate strain, contusion, fracture, or radiating pain from a herniated disc or arthritic condition of the spine.

CASE 11-3 11-3A History and Physical Examination 11-3B Operative Report, Ureteral Stents 11-3C Operative Report, Hysterectomy 11-3D Pathology Report 11-3E Discharge Summary

CASE 11-3

The patient in this case, Gloria Rhodes, has been experiencing pelvic pain and dysmenorrhea. She is admitted by Dr. Martinez for a hysterectomy.

11-3A History and physical examination