Name: Norfizah Binti Mohd Sharif

SB no :SB299727
Age 52 years old
Race Malay
Sex Female
Address Subang Jaya
Parity 3 + 2
Last Menstrual Period 2nd of April 2013
Date of Admission 4th of April 2013
Date of Clerking 6th of April 2013
Chief complaint
Heavy and painful bleeding 10 days
History of Present Illness
My patient, Puan Norfizah has developed heavy menses 10 days prior to
admission at Hospital Sungai Buloh. Previously, she stated that her menstrual cycle
lasted for about 28 days with bleeding lasting for 5 days. She usually experience
peak flow on day 2 and day 3 and she had to use 3 pads per day. About 10 days
prior to admission, she experience heavy menstrual bleed, from day 1 to day 6 of
her menses. She had to use 10 12 pads per day and she claimed that it was fully
soaked. The bleeding was fresh blood associated with blood clots. The bleeding was
associated with localized suprapubic pain, which occurs throughout the menses but
is not relieved by Panadol. Patient gave a pain score of 9 over 10 and she was
unable to sleep due to severe pain.
Subsequently, the patient experience gradual onset of shortness of breath.
The shortness of breath was progressively worsening. Initially patient developed
shortness of breath during doing her daily chores but subsequently the shortness of
breath occurs at rest. It was associated with lethargy, palpitation and lightheadedness. As such, she was referred to Hospital Sungai Buloh by Klinik Kesihatan
Subang.
She gave no history of mucousal bleed, unexplained bruising, per rectal
bleed, malaena, haematuria, joint selling, fever, arthralgia and myalgia. There were
no history of taking the anticoagulant or family history of bleeding disorder.
Past Gynaecololgy and Menstrual History
She attained menarche at the age of 12. Her menstrual cycle was 28 to 30
days with bleeding at day 1 to day 7. The peak flow was on day 1 to day 3. The
cycle was regular until this current admission where she experience heavy flow. She
experienced dysmenorrhoea almost every month after being diagnosed to have
uterine fibroids and had to take analgesic to relieve her symptoms.
There were no history of intermenstrual bleeding, post-coital bleed and
dyspareunia

Past Obstetrics history

She is married 35 years ago and was blessed with 3 children. All of her
children was born at full term vuia spontaneous vaginal delivery at HUSM with
birthweight ranging from 2.8 3.0 kg. She claimed that her antepartum,
intrapartum and postpartum was uncomplicated. She breastfed all of her children
for 2 years
Patient had history of miscarriage 2 times. First miscarriage was 11 years ago
at 17 weeks of period of amenorrhoea. She had another miscarriage at 9 weeks of
period of amenorrhoea 6 years ago. Dilatation and curettage was done for both
miscarriages.
Past Medical and Surgical History
There are no diabetes mellitus, hypertension, bronchial asthma or heart disease and
she never underwent any surgical intervention before.

Family History
Both her father and mother has hypertension. All her siblings were well. There were
no history of chronic disease running in the family and no family history of
congenital abnormalities

Social history
The husband name is Ahmad and he works as a lorry driver while she is a
housewife. She lives with her youngest daughter and her husband. Her eldest
daughter and second daughter currently working and support her financially. She
does not consume alcohol and does not smoke.

Drug history
Currently patient was on antacids and non-steroidal anti inflammatory drugs.
She gave history of allergic to penicillin antibiotics, which she developed
erythematous and itchy skin rashes upon ingesting the drugs

Diet history

Patient was on normal adult diet. There were no history of allergic to any
foods

Systemic review
General system

No loss of weight
No loss o appetite

Respiratory system

No runny nose
No sore throat
No cough

Cardiovascular system
1. No chest pain
2. No leg swelling
Genitourinary system

No dysuria
No frothy urine
No frequency

Central nervous system

No headache
No altered consciousness
No syncope

Summary
Puan Norfizah, a 52 years old Malay female was admitted to Hospital Sungai Buloh
with complain of dysmenorhoea and menorrhagia.

PHYSICAL EXAMINATION

General inspection
Patient was lying comfortably in supine position supported by 1 pillow. She
was alert, conscious and well oriented to time place and person. She was not in pain
but in respiratory distress evidence by using accessory muscle to breath and
respiratory rate of 26 breaths per minute. She looks pallor. Her hydrational and
nutritional status looks clinically adequate. There was no obvious deformity or
abnormal movement noted. There was intravenous cannula attached to the dorsum
of her left hand connected to intravenous normal saline.
Vital sign
Pulse rate
Blood pressure
Temperature

: 110 beats per minute (normal volume, regular rhythm)

: 110/70 mmHg
: 37 C

Gross parameters
Height 158 cm
Weight 72 kg
Body Mass Index 28 kg/m2
General examination
Hands
Palms were cold, dry and pale
No wasting of thenar and hypothenar muscle
No koilonychias
No peripheral cyanosis
Capillary refilling was good (< 2 sec)
Arms
No bruising
No scratch mark
Face

Conjunctivae were pale

No yellowish discoloration of the sclera
Oral hygiene was good
The tongue was moist and not coated
No presence of central cyanosis

Neck
Jugular venous pressure was not elevated.


Leg

Cervical lymph nodes were not palpable

No pitting edema
Palpable dorsalis pedis and posterior tibialis on both side

Specific abdominal examination

Inspection
Abdomen was flat and moves symmetrically with each respiration
Umbilical was centrally located and inverted
Overlying skin was normal
No dilated vein
No visible peristalsis
Palpation
Abdomen was soft and non tender
Uterus size was 16 weeks , asymmetry (more on right iliac fossa), firm,
smooth surface, regular margin, mobile in horizontal direction, globular in
shape and non tender
No hepatoslenomegaly
Both kidneys were not ballotable
Percussion
Resonance Traubes space
No shifting dullness
Auscultation
Bowel sound present
No renal bruit

Uterus size 16 weeks,

mobile, smooth surface,
regular margin and non
tender

Specific examination of the respiratory system

Inspection
Chest wall moved symmetrically during each respiration.
There was no chest wall deformity, skin discolouration, surgical scar, dilated
veins and visible pulsation seen in this patient.
Palpation
Trachea was centrally located and no tracheal tug present.
Chest expansion was equal on both sides.
Vocal fremitus was equal and of normal intensity on both sides
Percussion
All zones were resonance on both sides
Auscultation
Vesicular breath sound with normal intensity was heard over both lungs
Vocal resonance was equal and of normal intensity on both sides
Specific examination of cardiovascular system
Inspection
There was no chest wall deformity, precordial bulge, skin discolouration,
surgical scar, dilated veins or visible pulsation noted in this patient
Palpation
Apex beat was palpable at left 5th intercostal space, 1 cm medial to midclavicular line
There was no parasternal heave and no thrill palpable over mitral, tricuspid,
pulmonary and aortic area
Auscultation
1st and 2nd heart sounds present and there was no murmur heard over mitral,
tricuspid, pulmonary and aortic area

Problem List and Diagnosis

Problem Lists in this patient

Symptoms
Age 52 years old
Underlying uterine fibroids not progressively enlarge
Secondary dysmenorrhoea the pain lasted throughout the menses
Menorrhagia
Symptomatic anaemia
2 previous miscarriages
Signs
Obesity BMI 28 kg/m2

Signs of anaemia
Uterus size of 16 weeks , asymmetry (more on right iliac fossa), firm, smooth
surface, regular margin, mobile in horizontal direction, globular in shape and
non tender

Provisional Diagnosis
Provisional diagnosis
Uterine fibroids with
symptomatic anaemia

Positive findings
Symptoms
Risk factor age more
than 30 years old
Secondary
dysmenorrhoea
Menorrhagia
Symptomatic anaemia
Underlying uterine
fibroids which was not
progressively enlarged
Signs
Risk factor - Obesity
BMI 28 kg/m2
Signs of anaemia
Uterus size of 16 weeks
, firm, smooth surface,
regular margin, mobile
in horizontal direction,
globular in shape and
non tender

Negative findings

No compressive
symptoms such as
urinary frequency (not
all uterine fibroids have
this symptoms)
No other risk factors in
this patient nulliparous
or positive family history
No problems with
spontaneous conception
(subfertility was
associated with
subfertility)

Differential Diagnosis
Provisional diagnosis
Leiomyosarcoma
with symptomatic
anaemia

Endometriosis
with symptomatic
anaemia

Endometrial
carcinoma

Adenomyosis

Positive findings
Symptoms
Secondary
dysmenorrhoea
Menorrhagia
Symptomatic anaemia
Signs
Signs of anaemia
Uterus size of 16 weeks ,
firm, smooth surface,
regular margin, globular
in shape and non tender
Symptoms
Risk factor uterine
abnormality (uterine
fibroids) and long
duration of menstrual
flow previously (> 7 days)
Secondary
dysmenorrhoea
Menorrhagia
Symptomatic anaemia
Signs
Signs of anaemia
Mass per abdomen
Symptoms
Risk factor age more
than 35 years old
Secondary
dysmenorrhoea
Menorrhagia
Symptomatic anaemia
Signs
Risk factor - Obesity BMI
28 kg/m2
Signs of anaemia
Mass per abdomen
Symptoms
Risk factor age more
than 30 years old and
previous history of
dilatation and curretage

Negative findings

The uterus was mobile

in horizontal direction
Underlying uterine
fibroids which was not
progressively enlarged
for the past 10 years
No signs of malignancy
such as loss of weight
and loss of appetite
No metastatic signs and
symptoms such as
jaundice, enlarge lymph
nodes
No history of infertility
or subfertility
No other risk factors
such as family history,
early menarche, short
menstrual cycle

No intermenstrual
bleeding
No signs of malignancy
such as loss of weight
and loss of appetite
No metastatic signs and
symptoms such as
jaundice, enlarge lymph
nodes

No intermenstrual
bleeding
No dyspareunia
Non-tender uterus on
palpation

Secondary
Dysmenorrhoea
Menorhhagia

Signs
Mass per abdomen

Uterus size is 16 weeks

(rarely the adenomyosis
will be presented with
uterus size of more
than 14 weeks)

Investigations
Aims of investigations
Several goals of performing investigations in this patient which includes;
To establish the final diagnosis
To rule out the differential diagnosis
To detect any life-threatening complications which may occurs in this patient
To treat the underlying cause

Blood Investigations
1. Full blood count to detect the haemoglobin levels as it serves as an
indications for blood transfusion and the blood volume that is needed to be
transfused. This investigations also would help in terms of categorizing the
patient into the types of anaemia, which narrow down the diagnosis
Results
Haemoglobin
6.0 g/dL
Mean Cell Volume
58.7 f
Mean corpuscular
haemoglobin
17 pg
Mean Corpuscular
Haemoglobin
Concentration
27 g/dL
White Cell Count
8.4 x 109 /L
Platelet
237 x 109 /L

Normal Range
11.5 15.5 g/dL
80 100 fl
27 31 pg
32 36 g/dL

4 11 x 109 /L
150 400 x
109 /L

Interpretation
Presence of anaemia which was
talley with the clinical findings
Low MCV indicates microcytic red
blood cell
Low MCH indicates hypochromic
red blood cells
Low MCHC

Normal white cell count

Platelet is normal. There is no
platelet dysfunction

This patient has hypochromic microcytic anaemia with normal white cell count and
platelet, talley with the clinical findings
2. Group Screen Holed and Group Cross Match to anticipate the need of blood
transfusion in this patient

3. Full blood picture to detect any abnormalities by means of visualization of

the red blood cells which may have abnormal morphology
Results
i. Presence of pencil shaped/ cigar-shaped poikilocytes
ii. Widening of central pallor of the red blood cell of more than 2 3 rd
of its size
iii. Presence of numerous microcytes
Impression Iron deficiency anaemia

4. Blood Urea Serum Electrolytes (BUSE) / creatinine to detect any

complications which may arise from the anaemia as well as preoperative
assessment
Results
Sodium
140 mmol/L
Potassium
4.5 mmol/L
Urea
5.8 mmol/L
Chloride
105
Creatinine
93 mol/L

Normal Range
135 145 mmol/L
3.5 5 mmol/L
2.5 6.7 mmol/L

Interpretation
As a baseline investigation to
assess electrolyte and renal
function of the patient. These
parameters are normal in this
patient

98 106 mmol/L
70 150 mol/L

5. Liver function test total protein and albumin serves as preoperative

investigations as study shows that the patient with adequate nutritional
status (normal albumin and protein) had significant risk of surgical morbidity.
The albumin also serves as a predictors of wound healing after surgery
Results
Total protein
68 g/L
Albumin
41 g/L
Bilirubin
12 mol/L

Normal Range
64 82 g/L
35 50 g/L
5 17 mol/L

Alkaline Phosphatase (ALP)

80 IU/L
Aspartate transaminase
(AST)
37 IU/L
Alanine Aminotransferase
(ALT)
30 U/L
6. Transabdominal Ultrasound

38 126 IU/L
10 35 IU/L
9 40 IU/L

Normal ALT

Presence of multiple fibroids;

o 2 anterior wall fibroids (3 x 3 cm) and (3.4 x 4.2 cm)
o Subserosal fibroids (6.7 x 5.2 cm) and (4.9 x 5.1 cm)
o Posterior wall fibroids (7.7 x 6.4 cm)
Uterus size 11.4 x 7.6 cm
Endometrial thickness (4.6 mm)
No adnexal mass

Final Diagnosis
Uterine fibroids with symptomatic anaemia
Problem Lists
Acute problem symptomatic anaemia
Uterine fibroids with symptoms
Surgical menopause following the treatment

Treatment
The treatment goals in this patient are to stabilize the life-threatening complications
as well as to remove the underlying pathology that cause significant effects in
patient activity of daily living. Thus, the treatment approach in this patient is based
upon correcting the anemia, removal of the fibroid, relieving the pain caused by
fibroid.

Symptomatic anaemia

Based on the full blood count taken in this patient which was 6.0 g/dL, she is
ndicated for blood transfusion
Among the indications of blood transfusion includes;
o Haemoglobin levels of less than 8.0 g/dL
o Symptomatic anaemia regardless of the haemoglobin level
1 pint of packed red blood cell may increase the haemoglobin of 1.0 1.5
g/dL
The target haemoglobin in this patient, as the patient subsequently planned
for operation of her fibroids should be more than 10 g/dL
Thus, 3 to 4 pint of packed red blood cells needed to be given in this patient
in order to achieve the haemoglobin level of >10 g/dL
The blood group is based upon the investigations ordered previously (Group
screen hold and group cross match)
Precautions
o In order to prevent fluid overload due to massive blood transfusion,
intravenous diuretics for example Frusemide can be given in between

the transfusion to lower the plasma volume, making the blood more
concentrated with haemoglobin
The blood is transfused at a rate of 60 minutes to 90 minutes for each pint.
Too fast transfusion may increase the risk for the patient to developed heart
failure secondary to fluid overload while too slow transfusion will leads to
tube clots
Complications of blood transfusion needed to be assessed as this patient had
history of allergic to penicillin and she never underwent any blood transfusion
before
Full blood count needs to be repeated after the transfusion to see the
haemoglobin levels
Screening for blood transfusion-related infections are necessary in this
patient

Uterine fibroids

This patient is suitable for operation as she had several indications for
operation
o Uterus size is 16 weeks
o Multiple fibroids
o Symptomatic menorrhagia, dysmenorrhoea that cause significant
effects in patient activity of daily living
This patient has completed her family and the recurrence rate of uterine
fibroids after myomectomy is around 20 30 %
Thus, to prevent the risk of recurrence, as well as the findings in ultrasound
(large, multiple fibroids) the patient is best suited to underwent total
abdominal hysterectomy
This patient is also reaching the menopausal age and peak incidence of
ovarian carcinoma is 50 to 70 years old. Thus, in order to prevent risk of
reoperation due to ovarian carcinoma, additionally, she should also
underwent bilateral salphingo-oopherectomy
Thus, the patient will be surgical menopause
Several preoperative measures needed to be taken;
o Written consent as with husband permission
o Pre-operative investigations
o Informed regarding the risk, method of operation, alternatives of
surgery as well as the complications which may arise from the
operation
o Keep the patient nil by mouth to prevent risk of aspiration as the
operation is done under general anaesthesia
o Start the patient on fluid maintenance (40mls/ kg)
Patient bodyweight 72 kg

Fluid requirement daily in this patient 72 x 40 = 2880 mls/ day

(around 6 pint)
Sodium requirement = 2 4 mmol/kg/ day
In this patient 144 to 288 mmol of sodium per day
1 pint of normal saline contains 77 mmol
Thus 2 4 pints of normal saline needed in this patient
To complete the 6 pints, I would add 2 pint of dextrose 5%
The complications of TAHBSO needed to be informed to this patient, such as;
o Haemorrhage
o Infection
o Complications of general anaesthesia

Surgical Menopause
Following the TAHBSO, the patient would be surgical menopause
Symptoms of menopause such as hot flushes, vasomotor symptoms as well
as complications arising from estrogen depletion needed to be assess during
follow up as it serves as a guide for us whether to start the patient on
hormonal replacement therapy or not