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Case Presentation

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

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  1. Case Presentation Bison, Francis Romeo P. San Beda College

  2. General Data • MD • 40y.o • Married • Admitted last April 25 2010

  3. Chief Complaint • Hypogastric Pain

  4. 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

  5. 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

  6. 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.

  7. Review of Systems: • Unremarkable

  8. Past Medical History • Unremarkable • Occasional cough and colds • Fractional curettage was done at qmmc(2009) • No known food and drug allergy

  9. Personal and Social • Housewife • Nonsmoker • Non-alcoholic • Denies drug abuse

  10. Family History • Maternal • Hypertension • Paternal • Pott’s disease

  11. Ob-Gyne History G3P3(3003)

  12. Menstrual History • M-14 y.o • I- Regular • D- 5-7 days • A- 3 pads per day • S- Dysmnorrhea (7/10)

  13. Sexual History • Coitarche at age 21 • Had 2 Sexual partner • Last coitus was last month

  14. 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

  15. Heent (+)Pallor, Anicteric sclerae, Palepalpebralconjunctiva, No cervical lymphadenopathies

  16. Thorax • Cardiovascular: Adynamicprecordium, NRRR, no murmurs • Lungs: Symmetrical chest expansion, no retractions vesicular breath sounds over both lung fields

  17. Abdomen • Globular • Soft • Doughy mass measuring 16 x 18 cm • Movable • Non-tender

  18. Extremities • Pale nail bed • No edema

  19. 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

  20. Admitting Diagnosis G3P3 (3003) Abnormal Uterine Bleeding Probably Secondary to Myoma Uteri, Anemia Secondary

  21. Course in the Wards *Transfused with 4 units of pRBC properly typed and crossmatched

  22. Medications • Tranexamic acid • Ferrous sulfate • Vitamin C tablet

  23. Referred to CardioPulmonary service for clearance prior to the procedure. • On the 10th hospital day, patient was scheduled for hysterectomy.

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

  25. 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.

  26. 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

  27. 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

  28. Etiology-Unknown Estrogen Progesterone • Most common during reproductive years, rare before puberty, decrease size after menopaus • Increases the mitotic activity of fibroids in women

  29. Complication Menorrhagia Anemia Infertility

  30. Diagnostic Approach • Pregnancy test should be obtained in all women • Suggested by symptoms and physical examination • Usually confirm by transabdominal or transvaginal ultrasound

  31. Treatment Approach • Tx of Symptomatic fibroids depends on: • Desire for future pregnancy • General health • Size and location

  32. 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

  33. Surgery • Hysterectomy- most common and the only definitive treatment • Myomectomy- preserves fertility, risk for reccurence

  34. 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

  35. Thank You

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