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CASECASEHARRYHARRY PRIBADIPRIBADI07100770710077

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HistoryHistory

y Ms. M, a 57-year old female non-smoker,non-alcoholic beverage drinker P6A0

y admitted in Mabalacat on September 10,

2010y widowed for 11 years since her husband

had passed away because of LiverComplications.

y lives in Davao City. His nationality isFilipino and was born in Davao City onthe 7th of June, 1949

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y Ms. M graduated at a public high school andshe didnt continue his college level due tofinancial problem.

y

She believes in super natural forces andsuperstitious beliefs. The client seeks medicalhelp from a physician only for a serioushealth condition although she admits to seek

help from the Hoax doctor or the localalbolaryo who would prescribe alternativemedicine to relieve mild signs and symptomsand other bodily discomfort.

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y Ms. M having vaginal bleeding for about ayear.

y She asked neighbors and friends, they hadtold her it was a normal occurrencemenopause, she sought no furthertreatment.

y The bleeding, was not painful, aftersometime, the bleeding began to increase

afterward become heavy vaginal bleedingand body weakness every menstrualperiod that last almost a week

y Ms. M did not report her problem.

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y Present History

y Menopause at 53 years.

y

Start of Menses age 12.

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y Ms. M consuming 4 big cups of blackcoffee a day. She said that she doesntexercise

y FAMILY HEALTH-ILLNESSHISTORY

y

Hereditary disease in the family isUterine Myoma and Hypertension whichher mother, first sister had herselfpossessed.

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y HISTORY OF PAST AND PRESENT

ILLNESS

y Ms. M had hypertension took aspirin and

an anti-hyper medication to which she

could not recall the name of.

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y Physical Examination:

y VS: BP- 150/70, PR 76, BR 26, Temp

36

y Pink Conjunctiva, Anicteric Sclerae

y NRRR, (-) Murmurs, CBS, (-) Rales, (-)

Wheezes

y Globular, NABS, (-) Non Tender

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PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

y RR : 24, HR: 80, BP:120/70

y Height = 153 cm Weight = 70 Kg.y Head : Normocephalic

No abnormal mass

y

Hair and scalp Evenly distributed, Thick hair,

no infection and infestation

y Eyes :no anemic and no icteric

y Pupils : Black in color, equal in size 4mm indiameter

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y Chest and Lungs : Symmetric chest expansion, quiet, rhythmicand effortless respiration

y Heart : Cardiac rate of 80 , S1=S2, no murmur

y Abdominal

Audible bowel sound of 8 per minute

No palpable massy External genitalia

No discharges

No lesion

y Lower extremities

No edema, no deformities and can move freely

Capillary refill: 2 seconds

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DIFF

ERENTIALDIFF

ERENTIALDIAGNOSEDIAGNOSE

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Pelvic UltrasoundPelvic Ultrasound

Uterus: Size 6.1 x 4.9 x 5.9 cm, Anteverted,homogenous, No intermual/ subserousmyomatous growth

y Cervix: Size: 2.6 cm x 2.5 cm. Abnormalities: No

Focal lesionsy Endometrium: Endometrium is not delineated.

There is a round hyperechoic mass notedmeasuring 3.2 x 3.8 3.9 cm suggesting endometrial polyp vs. Submucous myoma

y Ovaries (Right) 1.7 x 2.4 x 2.4 cm lateral(Left) 2.1 x 2.0 x 2.6 cmAbnormalities: No pathologic ovarian lesionnoted

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DIAGNOSEDIAGNOSE

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P2A0P2A0 MYOMAMYOMAU

TERI +U

TERI +HYPERTENSIONHYPERTENSIONGRADE IIGRADE II

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WHAT ARE THE RISK

WHAT ARE THE RISK

FACTOR FOR THISFACTOR FOR THISPATIENTPATIENT

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y Predisposing Factors

y Age is a currently 57 years old.

y Heredity

y Early Menarche and Nulliparity The client had her menarche at 12 years ofage. Studies have suggested that an early start of menarche (less than theaverage age of 13) and nulliparity contribute to the development of a

uterine leiomyoma (still unknown mechainism) (Faerstein, 2001).y Precipitating Factors

y High Fat Diet &Obesity

y Anxiety/ StressStress causes adrenal gland exhaustion as well as reducedprogesterone levels. This tilts the estrogen to progesterone ratios in favorof estrogen.

y

Caffeine orCoffee intake - The client has an average consumption of at leastthree (tall) cups of coffee a day. Increase in coffee consumption. Caffeineintake from all sources is linked with higher estrogen levels regardless ofage, body mass index (BMI), caloric intake, smoking, alcohol, andcholesterol intake.

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y HGB (g/dL) : 140 n : 120-160 g/dl

y HCT (%) :43.1- n : 36.0 47.0

y Platelet Count : 246 : n :150 400

y (x10 9/L)

y WBC (x10 9/L) :9.1 n :4.8 10.8

y Differential Count:

Segmenters (%) : 40 (n:55-65%)

Lymphocytes (%) : 48 (n:25-35%)

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WORK

UPF

OR THISW

ORKU

PF

OR THISPATIENT ?PATIENT ?

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y Non medic work up: Low Salt, Low Fat

diet.

y Drugs :

Cefazolin Sodium : 1g/IV q 8

Nalbuphine Hydrochloride 10 mg / amp

PRN Opioid analgesics.

Amlodipine Besylate 5 mg / tab OD

Diclofenac Sodium 75 mg/deep IM

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y After obtaining a necessary

cardiopulmonary clearance as well as a

pelvic ultrasound (September 9, 2010), the

patient was immediately booked for atotal hysterectomy which was done on

September 11, 2010.

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THANKSTHANKS