Tugano-Ventigan

GENERAL INFORMATION

CC: “masakit ang puson, likod, at ovary ”

CHIEF COMPLAINT

3 years PTA: post-coital bleeding: “pulang-pula”; blood

stain on sheets about 5” in diameter; lasts for 1 day, would resolve spontaneously

(+) dysuria, gross hematuria, (-) dyspareunia

(+) malaise, mood swings, perineal pruritus upon sexual intercourse

These prompted patient to palpate her vaginal canal – “hindi pantay ang kwelyo”.

2.5 years PTA: Symptoms persisted and patient consulted at

Labor Hospital in Quezon City Patient had an UTZ and she was told that she

had myoma. Pap smear – unknown results Advised to undergo biopsy of an

undetermined area, but she refused Hemostan 2x/day for 2 weeks – cessation of

bleeding. Amoxicillin – 2x/day for 1 month. Advised to refrain from sexual intercourse no sexual contact since then.

2.5 years – 9 months PTA: (-) abnormal vaginal bleeding, associated

symptoms9 months PTA: Alternating episodes of prolonged vaginal

bleeding (3 weeks) and yellowish discharge (1 week)

Bleeding – “buo-buo, mabaho, maitim” Discharge – yellowish, watery, “malansa”

9 months PTA: Lower back pain: “kumikirot”, 6/10, no

radiations, persistent, aggravated by strenuous work (paglalaba)

Suprapubic pain: “kumikirot”, 6/10, radiation to perineum; perineal pain was described as “tinutusok”

Pain relieved by mefenamic acid, 2x/day Paresthesia from knees up to gluteal area

4 days PTA: consult at a medical mission in Tanay, was

advised to undergo “Echocardiography, Uterus”

Upon consult: Pain has become worse (9/10), same areas Bleeding also has become worse (1-2 small

diapers/day)

(+) Ectopic pregnancy (1985), underwent right oophorectomy

(-) Other hospitalization & surgery, known allergies

(-) Heart problems, kidney diseases, PTB, DM

(+) Chicken pox, mumps and measles

(+) Gunshot on the face (unrecalled exact date), healed, no complications

2009: Rashes in extremities which lasted for 1-2 months – consulted an albularyo, treated with “luyang dilaw at langis”

High blood sugar: 140, using glucometer (July 24, 2010)

(-) DM, asthma, cancer, TB, heart problemsGenogram as follows:

4744

3017 7

2nd to 6th 8th to 12th

d. 105 85

Intimate Relationships

Adopted 3

HTN

Legend:

Baduyem Family Genogram, July 2010

6

Unknown Cause

Ectopic Pregnancy

Abortion

Vaginal Bleeding(Suspected Cervical CA)

Patient

Household Members

(+) Cigarette smoking ½ pack per day (12.5 pack years), started aged 21 y/o, stopped 2009

Occasional alcoholic drinker (-) Illicit drug use Unemployed, occasionally works as a

laundry woman (“tagalaba”) 5 sexual partners, monogamous (-) contraception

M: 12 y.o., I: regular, D: 3 days, A: 3 pasador/day, S: Dysmennorhea (3/10), no meds taken

G3P1 (1021)> 1 ectopic pregnancy> 1 abortion (2 mos.)> normal delivery, full term, at a hospital

LMP: June 21, 2010 – patak-patak May 2010 : bleeding for 3 weeks, heaviest on the 3rd day then the rest was spotting (“patak-patak”)

General: Weight loss (150 lbs about a year ago), chills

Skin: occasional erythematous patches/plaques/wheals (“pantal”); cystic mass (1 cm dm.), non tender, in the dorsum of the left foot (20 y duration, non changing in appearance) Eyes: Uses reading glasses; occasional cloudy/hazy sight “maulap”; (-) eye pain, erythema; (+) dimming of vision (nandidilim ang paningin) Ears: good hearing; (+) occasional dizziness Nose: (+) sinusitis, occasional nasal obstruction (just last year); (-) epistaxis Mouth and Throat: (-) dysphagia, sores, gum bleeding; loss of two front teeth (upper)

Respiratory: (+) occasional chest pain during coughing (started 3 months ago); “hingalin” and easy fatigability; (-) productive cough Cardiology: (+) occasional chest tightness; (-) PND, edema, claudication GI: (+) occasional heartburn (this year), gas (“kabag”), allegedly “green” stools, decreased frequency of bowel movements Endocrine: Drinks 2-3 glasses of water, (-) cold/heat intolerance, polydipsia, polyphagia, polyuria MSK: (-) Limitation of motion, intact reflexes Psychiatric: (-) irritability, anxiety

Awake Alert Ambulatory Speaks in sentences

BP 110/80 PR = 100 bpm RR = 18 /min. T = 36.9 C

Pale conjunctivae Slightly icteric sclerae Bilateral 1-cm fixed nontender masses near

the angle of the jaw Distinct S1 and S2 No S3 and S4, no murmurs

Clear breath sounds, no adventitious breath sounds

Breast exam: 3 cm x 1 cm clearly demarcated, smooth, fixed and nontender mass - upper right quadrant of left breast

Flat, nontender epigastric and periumbilical areas of the abdomen

Tenderness on light palpation in the hypogastric area

(-) Inguinal LAD

Grossly normal external genitalia Multiple pea-sized nodular masses around

the vaginal wall (posterior and lateral walls) Cervix also with multiple nodular masses (+) Blood on examining finger (Bleeding

started upon IE)

D/Dx R/I R/O

Cervical CA Vaginal bleedingMultiple masses in cervix and vaginal wallHx of multiple sexual partnersWeight loss

Cannot be ruled out

Myoma uteri MenorrhagiaMasses

Bleeding continuous, not merely cyclical

Abnormal Uterine Bleeding

Vaginal bleeding

D/Dx R/I R/OCervical CA Vaginal bleeding

Multiple masses in cervix and vaginal wallHx of multiple sexual partnersWeight loss

Cannot be ruled out

Myoma uteri MenorrhagiaMasses

Cannot be ruled out

Abnormal Uterine Bleeding

Vaginal bleeding

TB lymphadenopathy

CLAD, weight loss, prevalence

Cannot be ruled out

Cervical CA, t/c metastasis, myoma uterii R/o TB lymphadenopathy

Refer to GYNE Monitor vital signs – possible ER admission Refer to patho for biopsy– definitive

diagnosis for TB lymphadenopathy Order FBS

Clinical Staging: FIGO stage IIIA (preliminary)◦ Involvement of lower 1/3 of the vagina◦ Evaluate further w/ DRE for lateral pelvic wall

involvement (upgrades to stage IIIB)◦ Consider MRI as additional modality

Histopathology: determine prognosis, treatment◦ CLAD – biopsy may rule out metastasis

Treatment: Chemoradiotherapy (for stage IIB and above)

WHO Comprehensive Cervical Cancer Control: A guide to essential practice

Harrison’s Principles of Internal Medicine 17th ed. Novak’s Gynecology 14th ed. ACR Appropriateness Criteria: Staging of Invasive Cancer of

the Cervix. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/InvasiveCanceroftheCervixDoc5.aspx