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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 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 • 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 History G3P3(3003)
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
Heent (+)Pallor, Anicteric sclerae, Palepalpebralconjunctiva, No cervical lymphadenopathies
Thorax • Cardiovascular: Adynamicprecordium, NRRR, no murmurs • Lungs: Symmetrical chest expansion, no retractions vesicular breath sounds over both lung fields
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 erosions No discharge Cervix: short Firm Closed Uterus: Asymmetrically enlarged to 20 weeks size Non-tender on deep palpation Movable Doughy
Admitting Diagnosis G3P3 (3003) Abnormal Uterine Bleeding Probably Secondary to Myoma Uteri, Anemia Secondary
Course in the Wards *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 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
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 Menorrhagia Anemia Infertility
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