INTRODUCTION

Mrs. Winnie Poe, 42 years old woman from Sta. Cruz, Ilocos Sur was rushed to
the ER of St. Paul University Hospital by her brother-in-law, with chief complains of
abdominal pain and cramping, nausea and vomiting, and passing of blood clots for
2 weeks. She thought that these are just normal for menopausal women. The
attending physician’s admitting diagnosis is Dysfunctional Uterine Bleeding which
made her a candidate for Dilatation and Curettage.

DUB is an abnormal uterine bleeding interms of amount, duration, and timing

during menstrual cycle with no discernible organic cause. The normal menstrual
cycle is dependent on the influence of four hormones; estrogen, which
predominates during proliferating phase; progesterone, which predominates during
secretory phase and follicle stimulation hormones and luteinizing hormones both of
which stimulates the ovarian follicle to mature. Disrupting the balance of these four
hormones usually resukts in an ovulation and DUB. Complications of DUB in
ovulation include anemia, infection from prolonged used of tampons, and, in rare
situations, hemorrhagic shock.

PATIENT’S PROFILE

PATIENT’S NAME: Winnie Poe

AGE: 42 years old
GENDER: Female
HEIGHT: 5’ 2”
WEIGHT: 110 lbs
PERMANENT ADDRESS: #123 Casabaan St., Sta. Cruz, Ilocos
Sur
BIRTHDATE: April 10, 1968
BIRTHPLACE: Rizal St. Santa Catalina, Ilocos Sur
CIVIL STATUS: Married
CITIZENSHIP: Filipino
RELIGION: Roman Catholic

ADMISSION DATE: September 9, 2010

ADMISSION DIAGNOSIS: Dysfunctional Uterine Bleeding
ATTENDING PHYSICIAN: Dra. Dora Bells
Dra. Maria Flurty

PHYSICAL ASSESSMENT
I. Head- to- Toe Examination

1.1General Survey
 Patient has a weak appearance but is still able to comprehend
with instructions.

1.2Vital Signs
Blood Pressure: 90/70 mmHg
Respiratory Rate: 23 cpm
Pulse Rate: 69 bpm
Temperature: 36.9˚C

1.3Head and Face

a. Cranium
 The cranium has no deformities and tenderness.
 No mass, no scalp lesions and no lice.

b. Temporal Arteries
 The temporal arteries are not protruding.
c. Face
 Facial features are symmetrical.
 The shape of the face is round.
d. Nose
 Symmetric and straight , no nasal discharges noted, no flaring
noted
 Each nostrils is patent.

1.4Eyes and Vision

External Eye Structure

 Eyelid appears symmetrical. Patient can raise both eyelids. Sclera

is white with some small superficial vessels. The cornea is shiny.
The pupils are black and round. The lenses are transparent in
color.

Visual Acuity
 Patient has no difficulty identifying the letters showed to her
whether near or far.
 Patient has no problem identifying colors shown to her.

Extra ocular muscle function (Cranial nerve III, IV, and VI)
 The client was able to follow the finger with her eyes from
different directions.

1.5Ears and hearing

External ear
 Symmetrically aligned to the face, firm and not tender with no
discharged noted.

Hearing
 The patient has a good hearing.

1.6Neck

a. Musculoskeletal structures
  The patient is able to move her head through full range of
motion without complains of discomfort.

b. Lymph Nodes

 Non-palpable

c. Thyroid gland

 Non-palpable

d. Musculoskeletal function and Cranial Nerve XI

 The patient can rotate her head. The client demonstrates the
ability to shrug her shoulders against resistance.

e. Carotid Arteries

 The carotid arteries can be palpated.

 The pulse is weak.

1.7Upper Extremities

a. Musculoskeletal structures, skin, nails

• The client has no structural defect. In standing position the

head is in upright position.
• Skin: Brown complexion, warm to touch, dry, pallor
• Nails: Cyanotic. No presence of edema.

b. Musculoskeletal functions

 The client can perform active ROM without pain and

discomfort.

1.8Anterior Chest

Breast and axillae

 N/A

Thorax
 Symmetric chest expansion, quiet, rhythmic and effortless
respiration

1.9Back

a. Musculoskeletal structure
 No structural defect

b. Posterior Thorax
 Posterior thorax is straight without lateral deviation.
 No lumps, no masses, no rashes, skin-intact and skin color is
lighter than the neck.

1.10 Neck Veins

 Neck veins are not visible to the eye

1.11 Abdomen
  Audible bowel sound of 10 per minute. Dark pigments around
the umbilicus. There is muscle rigidity felt during palpation.

1.12 Lower Extremities

 Skin texture is dry, warm. No masses.

 Foot is aligned with lower leg. Skin is brown in color. Her nails
are clean and well trimmed.
 No edema, no deformities and can move freely
 Capillary refill: 2 seconds
 Ankles and feet and can perform ROM
 Arteries are not protruding and visible.
 Posterior tibial and pedal arteries in both feet are palpable with
mild pulsation.

1.13 Genitals

• Not performed for privacy reason

1.14 Rectum

• Not performed for privacy reason

PATHOPHYSIOLOGY
Endocrine Factors Myometrial Factors Psychosocial Factors

Increase Uterine Muscle Stressful life events

prostaglandin Spasms application of pain.
synthesis

Decrease estrogen/ Decreased

progesterone levels Uterine Blood
occurring with Flow
menses

Uterine
Ischemia

Pain of Primary
Dysmenorrheal