Myoma Uteri OB-GYN Rotation Quirino Memorial Medical Center. Lazaro, Tonyrose C. San Beda College of Medicine. General Data. A.E. 44 y/o female G3P3 Admitted for the second time at QMMC - June 13,2011. Chief Complaint. Vaginal Bleeding. History of Present Illness. 2yrs PTA
Lazaro, Tonyrose C.
San Beda College of Medicine
Myoma Uteri (intramural with submucosal component)
Proliferative Endometrium with necrosis and chronic inflammation
The uterus is anteverted with smoothe contour and heterogenous echopattern measuring 14.8x12.8x13.1cm. There is a well-circumscribed heterogenous mass seen at posterior wall measuring 12.3x12.9x10.4cm (intramural with submucosal.) Cervix measures 3.40x2.12x2.35cm. Endometrium is hyperechoic measuring 0.4cm.
The left ovary measures 3.11x2.63x2.72cm. the right ovary not seen.
Impression: Myoma Uteri (intramural with submucous component); Normal Left Ovary
Gross and Microscopic Description:
Specimen consists of several tan brown soft irregular tissue fragments aggregately measuring 3.0x2.5x0.5cm. All tissues processed.
Section discloses irregularly shaped endometrial glands lined by tall columnar cells having aligned cigar shaped nuclei surrounded by a fibrous stroma infiltrated by lymphocytes and plasma cells and focal areas of necrosis.
Diagnosis: Proliferative Endometrium with necrosis and Chronic Inflammation.
HEENT: anicteric sclera, slightly pale palpebral conjunctiva
Chest/Lung: symmetrical chest expansion, clear breath sound, no retractions
Heart: adynamic precordium, normal rate and rhythm, no murmur
Extremities: full pulses, pink nailbeds
Abdomen: urgencyglobular, uterus enlarged to 18x18x10 cm, doughy, slightly movable, non-tender
Speculum Exam: pink and smooth cervix, no erosions, no discharge
Internal Exam: cervix short, firm, closed; uterus asymmetrically enlarged, non-tender on deep palpation, doughy, slightly movable.
COMPLETE BLOOD COUNT (6/13/2011)
BLOOD CHEMISTRY (6/15/2011) urgency
COAGULATION PANEL (6/15/2011) urgency
CHEST X-RAY (6/15/2011) urgency
Abnormal Uterine Bleeding Secondary to Myoma Uteri,
Proliferative Endometrium, S/P CS 3x Malpresentation
and Repeat, Bilateral Tubal Ligation, DM Type II Controlled
TAHBSO + ADHESIOLYSIS/GEA
Abnormal Uterine Bleeding Secondary to Myoma Uteri, Proliferative Endometrium, S/P CS 3x Malpresentation and Repeat, Bilateral Tubal Ligation, DM Type II Controlled.
decrease the blood supply to the fibroid, thereby causing ischemic necrosis, degeneration, and reduction in fibroid size
Thank You.. urgency