05 March 2019
Dr Gerald Gernad
Dear Dr Gernad
Re: Ms Kesan Charm, aged 44
I am referrig Ms Charm who requires you assessment and management for possible endometrial Cancer.
Ms Charm presented initially on 3/3/2019 with irregular menstruation along with, painful micturation. She also has complaints of painful intercourse and general body malaise. She was commenced on paracetamol twice daily. She was advised to TFT,TVS, complete blood test along with hystroscopy.
Following day, she complained of foul smell in the vaginal discharge, constiaption, bleeding in stool and hematuria. On examination, she had signs of ascites and lymph aedena was noted. Her blood results showed a rise in WBC, drop in haemoglobin and electrolytes imbalance. A PAP test and biopsy was advised.
Today, she was brought to clinic by her son with signs of shock due to profused bleeding. MRI, CT scan and X-ray was performed and results are awaiting along with biposy report. Her PAP test shows abnormal growth of cells.
In segments to her personal history she lives with her husband and son. She smokes 10-12 cigarattes per day and drinks. His mother died with uterine cancer.
Based on aforementioned information, your critical assessment and treatment would be highly appreciated.
If you required further information, please do not hesitate to contact me.
Bromechinix Health Clini