PRAC 6552 Week 7 Assignment 2: FNP Students OB Episodic Visit: Focused Note

(PRAC 6552 Week 7 Assignment 2, PRAC 6552 Week 7 Assignment 2)

Chief Complaint 

post op visit

History of Present Illness

Patient is a 52 yo G1P0010 with a hx of enlarged left ovary on recent MRI, concerning for possible malignancy. Patient reports symptoms of abdominal bloating with associated symptoms of early satiety. Patient states that for the last month she has been experiencing abdominal bloating, patient thought that maybe she had a hernia. The initial work up included an MRI which demonstrated a 17 x 14 x 10 cm, described as cystic with multiple septations with both solid and cystic components. They also noted multiple uterine fibroids largest being 5.1 x 5.1 cm involving the uterine fundus. [1]

Treatment Summary

04/15/21: MRI of pelvis demonstrating a left ovarian mass measuring 17 x 14 x 10 cm described as having both cystic and solid components with multiple septations. There are also multiple uterine fibroids, largest measuring 5.1 cm involving the uterine fundus, likely subserosal.

04/23/2021: Initial appointment with Dr. Hoffman

04/28/2021: Exploratory laparotomy. Left salpingo-oophorectomy with frozen section. Total abdominal hysterectomy with right salpingectomy. Stage IA endometrial adenocarcinoma, endometrioid type, FIGO grade 1

Interval History

Patient reports discomfort under her right rib cage with onset in the evening. Patient reports difficulty with deep inhales and feels short of breath at times. Patient reports she attempts to perform deep breathing exercises at home but is uncertain if she is performing this correctly. She reports experiencing blurry vision at least once a week post op. She reports this occurs first thing in the morning and it normally resolves spontaneously after a few minutes. She denies other vision concerns and reports an eye exam about 4 weeks prior to surgery. She reports doing well otherwise. She reports her pain has been minimal. She denies fever, chills, chest pain, abnormal vaginal discharge or bleeding.

Review of Systems

Constitutional: no fever, no chills, no sweats, no weakness. Fatigue no, appetite strong, hot flashes absent.

Eye: occasional blurry vision, no visual disturbances. Skin: no Jaundice, no rash, no lesions, no petechiae.

ENMT: no ear pain, no sore throat, no congestion, no hoarseness.

Respiratory: no shortness of breath, no cough, no orthopnea, no wheezing, no exertional dyspnea.

Cardiovascular: no chest pain, no palpitations, no edema.

Gastrointestinal: no nausea, no vomiting, no diarrhea, no GI bleeding, no constipation, no bloating, no pain, no heartburn.

Genitourinary: no dysuria, no hematuria, no discharge, no pain. no frequency, no urgency, no incontinence.

Gynecological: no pelvic pain no bleeding, no discharge _ _ _, no vulvar lesions, no dyspareunia, no post coital bleeding.

Musculoskeletal: no back pain, no trauma, no edema, no neuropathy, no joint pain. Neurologic: no headache, no dizziness, no numbness, no weakness.

Psychiatric: no sleeping problems, no irritability, no mood swings/depression

Heme/Lymph: no bleeding tendency, no bruising tendency, no petechiae, no swollen nodes

Allergy/Immunologic: no seasonal allergies, no food allergies, no recurrent infections, no impaired immunity.

Additional ROS info: Except as noted in the above Review of Systems and in the History of Present Illness all other systems have been reviewed and are negative or noncontributory……….. Continue