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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
Case Presentation

Bison, Francis Romeo P.

San Beda College

general data
General Data
  • MD
  • 40y.o
  • Married
  • Admitted last April 25 2010
chief complaint
Chief Complaint
  • Hypogastric Pain
history of present illness
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
slide5

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
slide6

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
Review of Systems:
  • Unremarkable
past medical history
Past Medical History
  • Unremarkable
    • Occasional cough and colds
  • Fractional curettage was done at qmmc(2009)
  • No known food and drug allergy
personal and social
Personal and Social
  • Housewife
  • Nonsmoker
  • Non-alcoholic
  • Denies drug abuse
family history
Family History
  • Maternal
    • Hypertension
  • Paternal
    • Pott’s disease
ob gyne history
Ob-Gyne History

G3P3(3003)

menstrual history
Menstrual History
  • M-14 y.o
  • I- Regular
  • D- 5-7 days
  • A- 3 pads per day
  • S- Dysmnorrhea (7/10)
sexual history
Sexual History
  • Coitarche at age 21
  • Had 2 Sexual partner
  • Last coitus was last month
physical examination
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
Heent

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

thorax
Thorax
  • Cardiovascular: Adynamicprecordium, NRRR, no murmurs
  • Lungs: Symmetrical chest expansion, no retractions vesicular breath sounds over both lung fields
abdomen
Abdomen
  • Globular
  • Soft
  • Doughy mass measuring 16 x 18 cm
  • Movable
  • Non-tender
extremities
Extremities
  • Pale nail bed
  • No edema
slide19
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
Admitting Diagnosis

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

course in the wards
Course in the Wards

*Transfused with 4 units of pRBC properly typed and crossmatched

medications
Medications
  • Tranexamic acid
  • Ferrous sulfate
  • Vitamin C tablet
slide23

Referred to CardioPulmonary service for clearance prior to the procedure.

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

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

classified by location
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.
slide26
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
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
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
Complication

Menorrhagia

Anemia

Infertility

diagnostic approach
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
Treatment Approach
  • Tx of Symptomatic fibroids depends on:
    • Desire for future pregnancy
    • General health
    • Size and location
medical
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
Surgery
  • Hysterectomy- most common and the only definitive treatment
  • Myomectomy- preserves fertility, risk for reccurence
current status of pt
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: 134 Hct: 0. 46 WBC: 30. 2

PT, PTT:

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

Blood Chemistry and Serum Electrolytes

  • CK- MB: 165(inc) Potassium: 4
  • Crea: 102. 83 Chloride: 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