Prepared by: Syed, Mujif

Tamayo, Ma. Chesca DEPARTMENT OF OBGYN

Tangpuz, Jofen Ann Preceptor: Dr. Lajara
Medical Clerks

Date and time of Interview: November 17, 2020, 9 AM

HISTORY
Source of information: Patient
Source of referral: None
Reliability: 90%

o IDENTIFYING DATA

Patient K.C., G2P2, 50 years old, Filipino, born on August 11, 1970, married, housewife, Roman
Catholic, residing in Brgy. Cogon Palo, Leyte, was admitted for the second time in EVRMC on
November 17, 2020 at around 8 in the morning.

o CHIEF COMPLAINT

Abdominal enlargement

o HISTORY OF PRESENT ILLNESS

10 months PTA, patient experienced dull, intermittent lumpiness in the right lower abdomen with
no radiation nor aggravating factors. No other associated symptoms such as hypogastric pain nor vaginal
bleeding was noted. No medical consultations done.
At the interim, symptoms of abdominal lumpiness persisted until 1-month PTA, when patient
palpated a firm, rubbery, movable mass approximately the size of a tennis ball on the right suprapubic
region. This was associated with dull intermittent lower abdominal discomfort, increased urinary
frequency and increasing abdominal girth. Patient sought local “hilot” and afforded only temporary relief.
2 weeks PTA, patient experienced heavy bleeding of approximately >80 ml lasting 12 days, with
increasing pelvic pressure from the abdominal mass, prompting the patient to seek medical consultation at
EVRMC, Cabalawan. Imaging results showed rounded heterogeneously hypoechoic solid lesion,
12*11.6*10.5 cm in size, occupying the entire uterine wall. Hence, admission for scheduled surgical
removal of the lesion on November 16, 2020, 8:00 a.m.

o PAST MEDICAL HISTORY

Childhood Illnesses: Contracted chickenpox and measles as a child. No history of MUMPS.

Immunization: Unrecalled.
Allergies: No known allergies to food and medication.
Adult illness: Medical history: Admitted at 25 years old, for spontaneous abortion.
Surgical: Dilation and curettage (1995 at EVRMC)
Blood Transfusions/hemolytic reactions: No previous blood transfusions
Allergies: No known allergies to food or drugs
Psychiatric: No history of psychiatric illness

o FAMILY HISTORY
 Father Died at the age of 73 y.o due to Congestive Heart Failure
Mother Died at the age of 49 y.o. due to myoma
1st sibling Known to be hypertensive and claimed to be taking maintenance medications
(Female) regularly.
2nd sibling (Male) Apparently well.
Patient has only 1 daughter, and is alive and healthy.
There was no history of Asthma, Diabetes, Tuberculosis and other heredo-familial diseases
noted.

o MENSTRUAL HISTORY

Patient had her menarche at the age of 10 years old. Her menstrual cycle is regular every month
and usually lasts for 3 days, soaking 3-4 sanitary pads/day with normal flow and no accompanying
symptoms such as dysmenorrhea.
Patient’s last menstrual period (LMP) was on October 30, 2020.

o OBSTETRICAL HISTORY

Patient is G2P2 (1-0-1-1).

G1 – July 27,1995, spontaneous abortion at 15 weeks AOG.

G2- August 10, 1998, Term, male, delivered via NSVD in cephalic presentation, hospital delivery
assisted done by her OB. Child was breastfed and is alive and well.
Last Menstrual Period (LMP) – October 30, 2020. Lasted for 3 days, regular, with normal flow
consuming about 3-4 pads a day. No dysmenorrhea noted. Fundal height not measured.

o SEXUAL HISTORY

Patient’s first intercourse was when she was 24 years old. Patient is a housewife and has a
monogamous relationship with her husband who fathers her child. No dyspareunia and sexual
dysfunction nor STIs noted. Patient does not use contraceptives pills.

o PERSONAL AND SOCIAL HISTORY

Patient is a housewife living in a well ventilated, concrete house with 3 rooms together with her
husband and their only child. They have their own water-sealed toilet facility located inside the house.

PHYSICAL EXAMINATION

Their garbage is segregated and is regularly picked up by the city government truck. She usually wakes
up at around 6am to cook for breakfast and eat at around 6:30am. Diet consist mainly of rice, pork and
processed food. They eat 3-5 times a day. She usually consumes 8 glasses of water per day and does not
drink coffee. She is a non-smoker and an occasional drinker. Financial resources are mainly from her
husband who works as a contractor.

o GENERAL SURVEY
Patient is examined lying down, conscious, coherent, and oriented as to place, time, and
person. She has good eye contact. She has an endomorph physique. Interview and physical exam
done on the day of admission.

o VITAL SIGNS

Vital Signs Actual Normal Value Interpretation

Temperature 36C 36.5-37.5 °C Afebrile
Heart Rate 90 60-100 bpm Normal
Respiratory Rate 20 18-20 cpm Normal
Blood pressure 110/80 Systolic- 90-120 Normotensive
Diastolic- 60- 80

Integument
Skin: Pale brown skinned complexion warm to touch with good skin turgor; no lesions, no
rashes, no petechiae, no ecchymosis, no hypo/hyperpigmentation nor jaundice.
Nails: poor capillary refill of > 2secs, no cyanosis, no ridges nor, no clubbing.
Head
Skull: atraumatic, symmetric, no masses
Hair: black in color, short, straight, fine, equal distribution evenly on scalp.
Eyes
Eyebrows: symmetrical, no scars nor active lesions
Eyelashes: fine, black and oriented outwards
Eyelids: No edema, no tenderness nor lid lag.
Conjunctiva: Pale palpebral conjunctiva, no hemorrhage, nodules nor swelling
Sclera: anicteric, no hemorrhage nor ulceration
Cornea and lens: clear and no ulcerations
Pupils: equally round and reactive to direct and consensual light stimulation; diameter approx.
2mm
EOM: intact
Ears: symmetrical, firm pinnae, no lesions nor discharges
Nose and Sinuses: septum midline, no lesions, no congestion nor discharges  
Mouth and Throat:
Lips: no lumps nor ulcers
Oral Mucosa: pale and slightly dry, no bleeding, no ulcers nor nodules
Gums: pinkish, no swelling nor ulcerations on gums margins, no bleeding
 Teeth: complete set of teeth without dental caries
Tongue: symmetric protrusion, pinkish, no ulcerations nor sores
Throat: Uvula at the midline, tonsils not enlarged
Neck: trachea at midline, jugular vein not engorged, thyroid gland not enlarged and moves with
deglutition. Lymph nodes not swollen noted. Carotid upstrokes are brisk and no bruit noted. No
lesions nor scars noted.
Breast:
Symmetrical, non-tender. Areola is dark brown with everted nipples, no lumps, no palpable
lymph nodes, no mastitis nor discharges.

Chest and Lungs

Chest is symmetrical with no lesions, no masses, no lagging nor abnormal retraction on the
lower intercostal spaces. With symmetrical chest expansion, unimpaired tactile fremitus in all lung
fields, no tenderness upon palpation. Resonant in all lung fields of both anterior and posterior chests
upon percussion and with bronchovesicular breath sound auscultated with no adventitious sounds
noted.

Heart/Cardiovascular
Adynamic and no precordial bulging. With no thrills, heaves, nor tenderness upon palpation
and with the PMI at the 4 th intercostal space left MCL. S2>S1 at base and S1>S2 at apex. Normal Heart
rate at 90 bpm and is synchronous with pulse rate, no murmur upon auscultation.

Extremities:
Both upper and lower extremities are symmetrical, non-tender, non-edematous and warm to
touch. No evidence of deformity. No limitation of range of motion for both upper and lower
extremities. Peripheral pulses are palpable and regular in rhythm.

Abdomen
Soft, Globular, no surgical scars. Active bowel sounds, with Palpable midline pelvic mass size
2/3> PS, globular in shape, irregular, rubbery, not tender, movable. No hepatosplenomegaly. Normal
bowel movement, once every other day.

PELVIC EXAMINATION

PELVIC EXAM

External genitalia: Coarse black hair distributed evenly, Midline episiotomy scar present. Labia and
clitoris not enlarged. No lesions, discharge or signs of infection noted. Anus not protracted. No
hemorrhoids noted. No bleeding nor lacerations.
Bimanual Examination:
Uterus: 16th week size with globular mass at fundus , asymmetrically enlarged, mobile
Cervix: Closed, non-tender, no visible abnormality, mass and polyps.
No vaginal discharges and lesion
 Adnexa: No mass and tenderness

NEUROLOGICAL EXAMINATION/MENTAL STATUS EXAM

Mental Status: Patient is examined while lying on bed. Patient was conscious, attentive and cooperative.
Active and oriented to person, time and place. Well- groomed, Speech is clear and can easily recall
recent activities and coherently answers questions appropriately. Has good judgment and no changes in
mood.

Cranial Nerves:

 CN I- no anosmia
 CN II- 2 mm in diameter symmetrical, equally round and briskly reactive to direct and consensual
light stimulation. Has good visual acuity.
 CN III, IV and VI- Full EOM without nystagmus, good convergence
 CN V- Intact facial sensation as to light touch and pain. Strong muscles of mastication.
 CN VII- Intact and adequate strong muscles of facial expression. Taste sensation: not done
 CN VIII- Intact hearing acuity in both ears, Weber midline and Rinne’s AC>BC
 CN IX and X- Positive gag reflex. Swallows and speaks without difficulty.
 CN XI- Shoulder shrug with strong resistance.
 CN XII- Midline tongue protrusion with adequate tongue movements.

Sensory: (+) stereognosis, (+) position sense, (+) 2-point discrimination, (+) graphestesia

Motor: not done

Cerebellum:

Rapid alternating movements and fine finger movements are slow but is able to perform. There
are no abnormal or extraneous movements.

HISTORY RISK FACTORS PE

-Abdominal enlargement SALIENT&FEATURES
-Perimenopause Early -Palpable firm, rubbery, non-
-Heavy bleeding for 12 days menarche tender movable mass (tennis ball
-History of spontaneous size)
abortion -Pelvic exam: Asymmetrically
-Obesity enlarged uterus 16th week size
with globular mass at fundus

INITIAL IMPRESSION: ABNORMAL UTERINE BLEEDING

 AUB is any significant deviation from normal frequency, regularity, volume and duration of
menstrual bleeding. Include shortened or prolonged (but regular) menses, heavy or scanty periods,
irregular cycles, intermenstrual bleeding, premenarcheal or postmenopausal bleeding with or without
any recognizable pathology.

o CURRENT DEFINITION OF TERMS:

Heavy menstural bleeding Menses lasting >7 days, or with blood flow of
>80ml/cycle (formerly menorrhagia)
Intermenstural bleeding Bleeding between clearly defined cyclic and
predictable menstrual cycles (replced
metorrhagia)
Acute AUB Significant amount causing hypotension,
tachycardia, or shock, thus warranting immediate
intervention
Chronic AUB Abn. Is volume, regularity, and duration in the
last 6 mos. Doesn’t require immediate
intervention
 Diagnosis Rule-in Rule-out Lab Diagnosis
Adenomyosis - 50 y.o No dysmenorrhea
- Female Uterus asymmetrically
- Prolonged and enlarged
heavy bleeding >12
days
- Palpable firm,
rubbery, non-tender
movable mass
(tennis ball size)
- 16th week size with
globular mass at
fundus
Pregnancy -Most common cause of -Although, Serum & urine B-Hcg
AUB Perimenopausal,
- 16th week size with pregnancy should
globular mass at fundus always be r/o
-Heavy bleeding
(abortion?)
Intramural Leiomyoma - 50 y.o Cannot completely be CBC- anemia
- Early menarche r/o UTZ
- Obese & high-fat Hysterescopy
diet
- Prolonged & heavy
bleeding
- Hx of abortion
- Enlarged uterus
with globular, firm,
movable mass

DIAGNOSTIC WORK UPS

DIFFERENTIAL DIAGNOSIS

1. Ultrasound-differentiate fibroids from pregnant uterus or adnexal mass.

2. Hysteroscopy
3. CT
4. MRI-imaging modality of choice for diagnosis of fibroid. It does precise fibroid mapping and
characterization in which it detects all fibroids accurately, differ from adenomyosis and
adnexal pathology, ovaries are easily seen and detects small myomas.
5. HSG-not done for diagnosis, done for infertility evaluation.
6. Laparoscopy
7. Operative Diagnosis
8. Biopsy

HISTOPATHOLOGICAL RESULT
 FINAL DIAGNOSIS

Intramural Myoma

ANATOMY AND PATHOHYSIOLOGY

o PELIVC ANATOMY:
o PATHOPHYSIOLOGY

MANAGEMENT

I. ABNORMAL UTERINE BLEEDING

A. Medical B. Surgical
o Acute AUB: 1. Dilation & curettage
High-dose conjugated equine -quicket wasy to stop bleeding
estrogen, Combined OCPs, for pxs with markedlet excessive
Oral progestogens, bleeding
Tranexamic acid -for acute AUB unresponsive to
o Chronic AUB: tx
LNG-IUS 2. Endometrial Ablation
Tranexamic acid 3. Uterine artery embolization
NSAIDs
Combined OCPs
Cyclic progestogens
Danazol
II. INTRAMURAL LEIOMYOMA
A. Medical
1. When the tumor is first discovered, it is appropriate to perform a pelvic examination
at 6 month intervals to determine the rate of growth. The majority of women will
not need surgery, especially those women in the perimenopausal period, where the
condition usually improves with diminishing level of circulating estrogens.
2. Pharmacological: GnRH agonists, COC, Depo-provera, Danazol, Aromatase inhibitors
and antiprogesterone RU 486
B. Surgical
1. Laparoscopic myomectomy
2. Hysterectomy
3. Uterine Artery Embolization