DATE GS ENT URO ORTHO/PEDIA/OPTH/NEURO

OB/DR CARDIO THORACIC OPD

MONDAY21

Cancio/Perdigon

Aguila/Dela Cruz

Cadiente/Andres-Lim

Cua De Jesus /Relucio

Menor Balaoing Que

TUESDAY22

Dy/Ruiz Ramirez/Umali

Carag-Lim/Tria-Ramos

Pidlaoan

Estrellas,I/Saquing

Pacis Monje Ranin

WEDNESDAY23

Carvajal/Reyes,C.

Motas/Ramirez

Doronila/Victorino

Inciong Gervasio/Sumayo

Sison San Andres

Santos,N

THURSDAY24

Estrellas,T/Reyes,R.

Guerero/Motas

Florendo/Bustos

Acosta Marzo/Tan

VArgas Alcantara Solis

FRIDAY25

Gargalican/Santos, G.

DelaCruz/Figuerres

Grageda/Cadiente

Limark Montecillo/Uichanco

Estrera Balaoing Tinglao

SATURDAY26

Laborte/Sinamban

Umaii/Aguia

La’o/Carag-Lim

Flores Palaganas/Abesamis

Lim,A. Monje

SUNDAY27

Pelayo/Snatos,S

Motas/Ramirez

Lazaga/Florendo

Mamaril Nagtalon/Berdan

Sison San Andres

SS Cases

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Excision of Mastoid Osteoma

Take down Colostomy

Mammoguided needle oc poss MRM

ACDF C4-C7 using IBG c cervical pate underIOSM/SSEP

Take down colostomy

Exlap

MRM,L Hemorrhoidectomy

Mastectomy, L Take Down Colostomy

ASDF C4-C7

TKA,R ORIF, L PSAPP Excision of R poplitea area mass

AUB 2˚ SIMPLE ENDOMETRIAL

HYPERPLASIA WITHOUT ATYPIA

PRESENTOR: Florence Fatima C. Bucsit, M.D.REACTOR: Ma Gregoria Grace Abesamis, DPBA, M.D.MODERATOR: Romel Almoro, DPBA,M.D.

GENERAL DATA

N.M.42 year old FemaleManilaRoman Catholic

CHIEF COMPLAINT

Vaginal Spotting

HISTORY OF PRESENT ILLNESS4 months PTC

• Vaginal SpottingConsult at SLMC-OPD OB-GyneImpression: AUB prob 2º endometrial pathologyUTZMx: D&C under TIVAHistopath Finding: Simple Hyperplasia without atypia , endometrium

2 months PTC

• Intermenstrual bleeding for 4 days• No consult was done

1 month PTC

• No menses• Consult done with SLMC- OPD OB-Gyne

A> G4P3 (2112); Simple Hyperplasia without atypia s/p D&C (Aug 2011)P> For Repeat D&C

REVIEW OF SYSTEMS(-) weight loss

(-) cough, colds, fever

(-) nausea, vomiting

(-) headache

(-) chest pain, easy fatigability, orthopnea, PND

(-) bowel, bladder disturbance

(-) back pain

(-) bleeding tendencies

MEDICAL HISTORY• (+) Rheumatic Heart Disease, Severe

Mitral Stenosis (2000), not in failure• Chronic AF with controlled ventricular

response• Chronic CVD infact, L frontal with no

residual (07/2010)

MEDICAL HISTORY(-)Bronchial Asthma

(-) Hypertension

(-) Diabetes Mellitus

(-) Cardiac Disease

(-) Liver Disease

(-) Bleeding Disorder

(-) Seizure Disorder

(-) Allergies

Current Medications

• Penicillin G 1.2 mn IM every 28 days• Warfarin 5 mg, 1/2 tab OD• Carvedilol 6.25 mg OD• Lanoxin 2.5mg OD• Simvastatin 20mg ODHS

FAMILY HISTORY

(+) Hypertension, father

(+) Cholelithiasis, father

(+) CVD, grandfather

(+) Nephrolithiasesm grandmother

(-) Diabetes Mellitus

(-) Cancer

SOCIAL HISTORY

Non smoker

Non alcoholic beverage drinker

SURGICAL / ANESTHETIC HISTORY

• S/p D&C (08/2011)

under general anesthesia- IV

no known complications

PHYSICAL EXAMINATION• conscious, coherent, ambulatory• BP: 120/80 mmHg • CR: 58bpm • RR: 18 cpm • Temp:Afebrile• Weight: 43.5 kg • Height: 151 cm • BMI: 19.1 ( ideal weight)

AIRWAY ASSESSMENTMOUTH OPENING >2 FINGERS

THYROMENTALDISTANCE

>3 FINGERS

MALLAMPATI I

FULL NECK EXTENSION YES

MISSING TEETH NO

LOOSE TEETH NO

DENTAL CROWNS/BRIDGES/BRACES NO

• HEENT: Pink palpebral conjunctivae, anicteric sclera, no

nasoaural discharge, no neck vein engorgement, no palpable

cervical lymph nodes

• CVS:Adynamic precordium, irregular rate and irregular

rhythm, AB L 6th ICS anterior axillary line,(+) gr. 3/6 diastolic

murmur heard best at the AB

• Chest and Lung:Equal chest expansion, no retractions, clear

breath sounds

• Abdomen:Flat, normoactive bowel sounds, soft, no

tenderness

• Extremities:Full pulses, no edema

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION• GCS 15• Oriented to 3 spheres• All CN (2,3,4,5,6,7,8,9, 10, 11 and 12)

assessed are intact• Sensory: No sensory deficits noted as

to pain, pressure and light touch on all 4’s

• Motor: 5/5 on all 4’s • (-) Babinski’s

LABORATORIESCBC 01/17/12

Hgb 13.3

Hct 42.3

WBC 5,970

Plt 194,000

Coagulation Studies(1/27/2012)

PTT

PT 12.9/15.5/53%

INR 1.29

BIOCHEMISTRY 01/17/12

Na 139

K 4.5

GLU

BUN

Crea 0.92

Ancillary

• CXR (12/05/2011)– Cardiomegaly with

multichamber enlargement

• ECG (01/17/2012)

• AF- slow ventricular response

• ST and/or T wave changes suggests ischemia,lateral

Diagnostic TEE

• RHD, mitral stenosis• Mitral valve area of 0.49 cm2• Peak gradient of 18 mmHg• Eccentric LVH with adequate wall

motion and contractility• Dilated Left atrium• Normal main pulmonary artery

SALIENT FEATURES

42 year old female ASA II Mallampati I Simple Endometrial HyperplasiaRHD, Severe MSChronic AFChronic CVD infarct

SURGICAL PLAN

D&C

Approach to Anesthetic Planning

ANESTHETIC CONSIDERATION

• SEVERE MS• CHRONIC AF• CHRONIC CVD Infarct