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Case Presentation. Bison, Francis Romeo P. San Beda College. General Data. MD 40y.o Married Admitted last April 25 2010. Chief Complaint. Hypogastric Pain. History of Present Illness. 10 monts PTA Hypogastric Pain described as shearing 9/10 pain Associated with intermenstrual bleeding

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Case Presentation

Bison, Francis Romeo P.

San Beda College


General Data

  • MD

  • 40y.o

  • Married

  • Admitted last April 25 2010


Chief Complaint

  • Hypogastric Pain


History of Present Illness

  • 10 monts PTA

    • Hypogastric Pain described as shearing 9/10 pain

    • Associated with intermenstrual bleeding

    • Uses 2 diaper and 1 napkin for the whole day

    • Hot compress  temporarily relieved her symptoms

    • No consult was done


  • 8 mos PTA

    • Persistent intermenstrual bloody discharge and hypogastric pain

    • Consulted QMMC Gyne

    • Fractional Curettage was done due to thick endometrial lining

    • Biopsy showed proliferative endometrium

    • Advised to come back for a week


  • 1 week PTA

    • Intermittent hypogastric pain with generalized body weakness

    • Consulted at Amang Rodriguez

    • Ultrasound and other labs was done

    • Diagnosed “myoma uteri”, and was advised for surgery

    • Patient then opted to transfer to another hospital for second opinion, hence consult at QMMC OB-ER.


Review of Systems:

  • Unremarkable


Past Medical History

  • Unremarkable

    • Occasional cough and colds

  • Fractional curettage was done at qmmc(2009)

  • No known food and drug allergy


Personal and Social

  • Housewife

  • Nonsmoker

  • Non-alcoholic

  • Denies drug abuse


Family History

  • Maternal

    • Hypertension

  • Paternal

    • Pott’s disease


Ob-Gyne History

G3P3(3003)


Menstrual History

  • M-14 y.o

  • I- Regular

  • D- 5-7 days

  • A- 3 pads per day

  • S- Dysmnorrhea (7/10)


Sexual History

  • Coitarche at age 21

  • Had 2 Sexual partner

  • Last coitus was last month


Physical Examination

  • General appearance: awake, conscious, coherent, ambulatory, not in cardiorespiratory distress

    Vital Signs

  • BP=100/60

  • HR=81/min

  • RR=20/min

  • Temp: 36.5oC


Heent

(+)Pallor, Anicteric sclerae, Palepalpebralconjunctiva, No cervical lymphadenopathies


Thorax

  • Cardiovascular: Adynamicprecordium, NRRR, no murmurs

  • Lungs: Symmetrical chest expansion, no retractions vesicular breath sounds over both lung fields


Abdomen

  • Globular

  • Soft

  • Doughy mass measuring 16 x 18 cm

  • Movable

  • Non-tender


Extremities

  • Pale nail bed

  • No edema


SPECULUM EXAM

IE

Cervix pink

Smooth

No erosions

No discharge

Cervix: short

Firm

Closed

Uterus: Asymmetrically enlarged to 20 weeks size Non-tender on deep palpation

Movable

Doughy


Admitting Diagnosis

G3P3 (3003) Abnormal Uterine Bleeding Probably Secondary to Myoma Uteri, Anemia Secondary


Course in the Wards

*Transfused with 4 units of pRBC properly typed and crossmatched


Medications

  • Tranexamic acid

  • Ferrous sulfate

  • Vitamin C tablet


  • Referred to CardioPulmonary service for clearance prior to the procedure.

  • On the 10th hospital day, patient was scheduled for hysterectomy.


Definition

Uterine leiomyoma are benign monoclonal neoplasm arising from smooth muscle cells in the myometri


Classified by location:

  • Submucosal – lie just beneath the endometrium.

  • Intramural – lie within the uterine wall.

  • Subserosal – lie at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.


Prevalence

Age

  • 20% to50% of reproductive age

  • Incidence increases with advancing age

  • Rare before puberty

  • 25-35y/o: 0.31 per 1000

  • 45-50y/o: 6.20 per 1000


Risk Factor

AGE

AFRICAN-AMERICAN RACE

EXPOSURE TO ESTROGEN

FHX

DIET

Advancingage

African american women develop earlier and more symptomatic

Early menarche,Obesity

NulliparityOcp’s

1st degree relatives with 2.5x more likely develop fibroids

Red meat, Alcohol,Smoking


Etiology-Unknown

Estrogen

Progesterone

  • Most common during reproductive years, rare before puberty, decrease size after menopaus

  • Increases the mitotic activity of fibroids in women


Complication

Menorrhagia

Anemia

Infertility


Diagnostic Approach

  • Pregnancy test should be obtained in all women

  • Suggested by symptoms and physical examination

  • Usually confirm by transabdominal or transvaginal ultrasound


Treatment Approach

  • Tx of Symptomatic fibroids depends on:

    • Desire for future pregnancy

    • General health

    • Size and location


Medical

  • Goal: relieve or reduce symptoms

  • No definitive medical treatment exist

  • GnRh agonist- induces hypogonadism through pituitary desensitization, down regulation of receptors and inhibition of gonadotropins


Surgery

  • Hysterectomy- most common and the only definitive treatment

  • Myomectomy- preserves fertility, risk for reccurence


Current Status of Pt.

  • At 10:35 pm of May 6, BP: O, RR:O, HR:O. ECG showed asystole. Patient pronounced dead at 10:35 pm by IM ROD. Post-mortem care rendered.

    CBC

  • Hgb: 134Hct: 0. 46WBC: 30. 2

    PT, PTT:

  • PT: 21. 1PT % Activity: 32. 8aPTT: 47. 7

    Blood Chemistry and Serum Electrolytes

  • CK- MB: 165(inc)Potassium: 4

  • Crea: 102. 83Chloride: 105

  • Sodium: 134 (dec)

  • Troponin I; positive

    Cause of death:

  • Sudden cardiac death secondary to acute myocardial infarction; hypoxic encephalopathy, s/p arrest; s/p subtotal hysterectomy/CLEB+GETA


Thank You


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