Bison, Francis Romeo P.

San Beda College

Case Presentation

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 HistoryG3P3(3003)

Year NSD/CS Pre/Full term

Hospital Complication

G1 1999 NSD Full Kamuning

G2 2001 NSD Full Kamuning

Sepsis

G3 2004 NSD Full Sorsogon Placental Remission (ICU)

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

(+)Pallor, Anicteric sclerae, Pale palpebral conjunctiva, No cervical lymphadenopathies

Heent

Cardiovascular: Adynamic precordium, NRRR, no murmurs

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

Thorax

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 erosionsNo discharge

Cervix: short

FirmClosed

Uterus: Asymmetrically enlarged to 20 weeks size

Non-tender on deep palpation

MovableDoughy

 

Admitting Diagnosis

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

Course in the Wards   April

25April 26

April 28

April 29

May 02

Hgb 40 53 74 89 110

Hct 0.17

0.22

0.27 0.31 0. 38

WBC

5.6     10. 8  

*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 FactorAGE

AFRICAN-AMERICAN

RACE

EXPOSURE TO ESTROGEN

FHX

DIET

Advancing age

African american women develop earlier and more symptomatic

Early menarche,ObesityNulliparityOcp’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

MenorrhagiaAnemiaInfertility

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: 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

Thank You