GYNECOLOGY CASE PROTOCOL
Block G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang
General Data MP 34 years old G3P3 (3003) Married, housewife Roman Catholic Cabuyao, Laguna
Chief Complaint menorrhagia
Past Medical History No previous illnesses
(-) HPN, DM, PTB, BA, goiter No previous surgeries No known allergies to food or drugs
Family Medical History (-) HPN, DM, PTB, BA, goiter No relative with similar symptoms as the
patient
Personal/Social History High school graduate Currently a housewife Non-smoker, non-alcoholic beverage
drinker, does not use illegal drugs
Sexual History First coitus at 17 years of age 1 non-promiscuous sexual partner (+) OCP use from 1992-1996 (-) previous IUD use (-) previous STD’s
Menstrual History Menarche at 13 years old Regular monthly intervals 3-4 days’ duration Consuming 3-4 pads/day (+) occasional mild dysmenorrhea LMP: 1/20/2010 PMP: 12/22/2009 No previous Pap smear
Obstetric History G3P3 (3003)
G1 1986, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive
G2 1991, FT via SVD at home c/o hilot, F, AGA, (-) FMC, alive
G3 1997, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive\
History of Present Illness 3 months PTC
Increase in amount and duration of menses (3-4 pads per day 5-6 pads per, 3-4 days duration 10 days, with flow decreasing to 1-2 pads later)
(-) intermenstrual bleeding, hypogastric pain, bowel/urinary changes
(-) post-coital bleeding, dyspareunia, vaginal discharge, weight loss, anorexia and pallor
(-) consults done / medications taken
History of Present Illness 1 month PTC
Persistence of symptomsDuration increasing to 12 daysFlow decreasing to 1 pad/day later in the periodConsulted an Ob-Gyn in Laguna
○ TV UTZ done – unrecalled findings○ Patient lost to follow up
persistence of symptoms prompted this consult
Review of Systems (-) fever (-) malaise (-) cough (-) DOB (-) hemoptysis (-) chest pain (-) orthopnea (-) PND (-) easy fatigability (-) dizziness (-) nape pain
(-) weakness (-) polydipsia (-) polyuria (-) polyphagia (-) palpitations (-) abdominal pain (-) bowel changes (-) dysuria (-) decreasing urine
output Tea-colored urine
Physical Examination Awake, coherent, ambulatory, NICRD BP 120/80 HR 84 RR 18 Weight: 55kg Height: 152cm BMI: 23 HEENT: pink conjunctivae, anicteric sclerae, (-)
CLAD/TPC/ANM Lungs: equal chest expansion, clear breath
sounds, (-) crackles/wheezes Heart: (-) heaves/thrills, distinct heart sounds,
normal rate, regular rhythm, (-) murmurs
Physical Examination Abdomen: flabby, soft, normoactive
bowel sounds, nontender, (-) masses/organomegaly
Extremities: pink nail beds, full equal pulses, (-) cyanosis/clubbing/edema
Physical Examination Internal Examination:
Normal external genitalia; smooth, parous vagina; cervix smooth, closed, firm; corpus small; (-) adnexal masses/tenderness
Rectovaginal Examination:Good sphincter tone, intact rectovaginal
septum, smooth and pliable parametria, (-) fullness in the cul de sac, (-) intraluminal masses, (-) blood per examining finger
Assessment Abnormal uterine bleeding probably
secondary to adenomyosis, r/o endometrial pathology
Plan Diagnostics
CBC, Pap smear, Transvaginal ultrasound Therapeutics
FeSO4 325 mg/tab OD Others
Increase OFI, full body bath + perineal hygiene dailyMenstrual calendarFor endometrial biopsy with endocervical curettage
once with ultrasound results
Results CBC: WBC 9.7, Hgb 117, Hct 0.379, Plt 359,
Neut 0.76, Lym 0.23 Transvaginal Ultrasound
The uterus is anteverted with smooth contour and homogeneous echopattern, measuring 8.1x5x4.5cm, the cervix measures 3.4x3.2x2.8cm, the left ovary measures 1.9x2x1.6cm. There is no free fluid in the cul de sac
IMPRESSION: thickened endometrium, r/o endometrial pathology, normal ovaries
Results Endometrial Biopsy and Endocervical
Curettage was doneFinal Histopathologic Diagnosis:
○ Endometrial polyp○ Secretory phase endometrium○ Chronic endocervicitis
Guide Questions What is abnormal uterine bleeding (AUB)? How
is this different from dysfunctional uterine bleeding?
Differentiate menorrhagia, metrorrhagia, polymenorrhea, and menometrorrhagia.
How is this diagnosed? What are the possible causes of AUB? What other diagnostics may be ordered for the
patient?
Guide Questions What are the possible methods of medical
management for AUB? What are the possible methods of surgical
management of AUB? What is an endometrial polyp? What is endocervicitis? How should this patient be managed?