Dalian Municipal Central Hospital
Dept.: gynecology ward
Bed No.: 2209
Admission No.: 564278
Age: 12 years old
Admission No.: 564278
Admission date: January 18, 2017 14: 06: 46 Discharge date: January 23, 2017
Admission status (brief history of illness, positive sign, relevant laboratory and instrument examination results): female, 12 years old. Because of her failure to have menses one week ago, the patient accepted gynecological ultrasonography in an obstetrics and gynecology hospital, prompting: the diameter of the cyst mass in pelvic cavity is about 200px. Later when she accepted reexamination in the First Affiliated Hospital of Dalian Medical University, the mass still preserved but the patient has no symptoms. 3. Body examination on admission: T: 36.4℃; P: 99 times/m R: 20 times/m BP: 124/80 mmHg, clear mind, no obvious abnormality during heart and lung auscultation, soft abdomen, no tenderness and rebound tenderness, not touching mass, and limb-free. Gynecology examination: refuse to check. Ultrasonography done in the First Affiliated Hospital of Dalian Medical University on January 18, 2017: anteversion of of uterus. Its size is about 38*35*24mm with clear outline and regular shape. The intima is 4mm, and the liquid dark area close to the left ovary is 89*90*78mm, no blood.
Admission diagnosis: pelvic cavity mass, parovarian cyst?
Diagnosis and treatment progress: complete relevant examination after admission, results report: routine blood and urine test, coagulogram, biochemical hepatorenal function, blood glucose, ion and tutor marker are basically normal. The hepatitis virus, syphilis, and HIV are all negative. No abnormality is seen in the electrocardiogram and chest radiography. On October 20, 2016, the “Laparoscopic nuclear removal of left fallopian tube mesangial cyst” was operated smoothly. After the operation, the antibiotic was given to prevent infection and rehydration therapy for the disease was carried out. At present, the general state of patient is good. Now after consulting the superior physician, the patient was allowed to leave the hospital. The pathology results after operation will be reported later.
Discharge condition: the patient now is in good general state and has no discomfort complaints. The urine is normal. The gas has been exhausted but she has not defecated yet. The abdominal incision stitches are not removed.
Discharge diagnosis: left fallopian tube mesangium cyst
Discharge doctor’s advice: 1. Have a good rest, prevent infection and strengthen nutrition.
2. To see a doctor at any time when abdominal pain, fever or other abnormal situation occur.
3. After 1 month, come to hospital to be diagnosed and reviewed by specialist Zhou Fanchen of gynaecological clinic on Wednesday afternoon.
4. No bath in a tub for a month.
5. After discharge for a week, return hospital to check pathology condition and take out stitches.
6. Our department will have follow-up clinic.
The registration number of outpatient appointment: 114 www. dlzxyy.com 84440555 84442555
Physician signature: Yu yongai attending physician: /Yang Yiming
Seal of record room of Dalian Municipal Central Hospital (sealed)