Complaining of postmenopausal bleeding.
The patient is a 69-year-old gravida 3, para 2. AB 1, female whose last menstrual period was 15 years ago, She originally came to the gynecologist’s office complaining of postmenopausal bleeding. As an outpatient, she had an endometrial biopsy that revealed poorly differentiated adenocarcinoma with clear-cell features of the endometrium. Today the patient was admitted to the hospital for an open total abdominal hysterectomy and related surgery as deemed necessary by the surgeon during the hysterectomy. Her medical history includes ongoing treatment for hypertension, anxiety disorder, postsurgical hypothyroidism with a history of thyroid cancer. and type 2 diabetes mellitus. The surgery performed was a total abdominal-hysterectomy, including the uterus and cervix. The patient failed to mention that her fallopian tubes and ovaries had been removed in the past as a fail-safe method of birth control. There was no evidence of metastasis into other pelvic organs. A consultation with an oncologist was performed prior to discharge. The patient had an uneventful recovery from the surgery and was discharged on day three to follow up with her gynecologist and oncologist in the next two weeks. Principal Diagnosis:
Secondary Diagnoses
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