UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA

JONELTA FOUNDATION SCHOOL OF MEDICINE

MARK JOSHUA CERVANTES JANUARY 31, 2022

170002578 BLOCK 4
THE CASE:

General data
Patient is LJ, a 30-year-old G0, single, Roman Catholic, homemaker from Las Pinas
Chief complaint: Pelvic Heaviness
Past Medical History: No known comorbidities, hospitalizations and non-obstetric surgical
Procedures. No intake of medications or supplements. No known food or drug allergies
Family Medical History: (-) HPN, DM, Bronchial asthma, Cancer, kidney diseases, blood dyscrasia
Thyroid disease, mental illness, gynecologic conditions
(-) Pulmonary TB in the household
Personal, Social and Sexual History: high school graduate, currently a homemaker, non-smoker, and
non-alcoholic beverage drinker. Patient was 24 y/o at first coitus and had 1 heterosexual male partner for 6
years. She has no history of sexually transmitted. Infections; only had a Pap smear once in 2017 as part of
Pre employment. No contraceptive use.
Menstrual history: Menarche at 15 years old, occurring at regular intervals, lasting for 3 days, using up 3
pads/day but with note of pad use to 4-6 ppd during the pandemic; with occasional dysmenorrhea.
LMP Jan 16, 2022
PMP Dec 12, 2021

History of Present Illness:

12 mos prior to consult, patient noted a sensation of hypogastric fullness, vague, occurring intermittently
but more pronounced one week before the onset and during menses, that spontaneously resolves. No note
of dysuria, fever, vomiting or change in bowel habits. No consult was done at this point

7 months prior to consult, aside from the hypogastric fullness, the patient also noted an increase in the
number of sanitary pads used per day during menses and with associated crampy pain for which patient
self-medicated with Ponstan. She noted that with intake of the medicine the pain resolves and her menstrual
bleeding will decrease in amount. She reports being constipated and that hypogastric discomfort will ease
with bowel movement. No nausea, vomiting, fever or vaginal discharge noted.

Review of Systems:
General: (-) fever, (-) weakness, (-) weight loss/gain, (-) pallor
HEENT: (-) headache, (-) BOV, (-) tinnitus, (-) otalgia, (-) dysphagia, (-) dysphonia
Pulmonary: (-) dyspnea, (-) cough
Cardiovascular: (-) chest pain, (-) palpitations (-) easy fatigability
Gastrointestinal: (+) constipation, (-) diarrhea, (-) jaundice, (-) hematochezia, (-) melena
Genitourinary: (-) vaginal bleeding, (-) dysuria, (-) dyspareunia, (-) hematuria

___________________________________________________________________________________
5th Floor, Tamayo Tower
Alabang – Zapote Road, Pamplona, Las Piñas City
Tel. No. 874-8515 loc. 652/653; 873-4938 (Direct Line)
 UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
JONELTA FOUNDATION SCHOOL OF MEDICINE

Neurological: (+) numbness of right leg, (-) seizure, (-) paresthesia

Physical Exam:
General: Awake, alert, conversant, not in cardiorespiratory distress, ambulatory
Vital Signs: BP 100/60 mmHg, PR 86bpm, RR 16 cpm, Temp 36.5oC, O2 sat 98%
HEENT: anicteric sclerae, sl.pale palpebral conjunctivae, (-) anterior neck mass, (-)cervical
lymphadenopathy
Chest/lungs: equal chest expansion, clear breath sounds, (-) adventitious breath sounds
Heart: adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, (-) murmurs
Abdomen: soft, flat, (-) direct tenderness (+) firm palpable mass measuring 8x8cm, non-tender, movable,
(-) guarding
Extremities: Full equal pulses, CRT < 2 secs, (-) cyanosis, (-) edema, (-) jaundice

External genitalia: Normal

Speculum exam: smooth, pink, parous vagina, with no lesions, (-) vaginal discharge, cervix is closed,
smooth, (-) lesions
Internal exam: smooth parous vagina, cervix is smooth and closed, (-) cervical motion tenderness, uterus
is asymmetrically enlarged to 12 weeks size, non-tender, movable.
Rectovaginal exam: good sphincter tone, empty rectal vault, no nodularities nor fluid noted at the posterior
cul-de-sac, no intraluminal masses.

Questions:
1. What are the salient features of the case based on the history? Are there additional information that
can be asked to help with the case?
Salient Features:
• 30 years old
• G0P0
• Pelvic Heaviness
• First coitus at 24 years old, with 1 heterosexual partner
• Only pap smear at 2017
• No contraceptive use
• Menarche at 15, regular intervals, 3 days, 3 pads/day, 4-6 pads/day in pandemic, occasional
dysmenorrhea
• LMP: January 16, 2022
• PMP Dec 12, 2021
• (+) vague, intermittent, hypogastric fullness, more pronounced during menses
• (+) Increase in sanitary pads during menses with crampy pain. Self-medicated with Ponstan
• (+) Constipation

___________________________________________________________________________________
5th Floor, Tamayo Tower
Alabang – Zapote Road, Pamplona, Las Piñas City
Tel. No. 874-8515 loc. 652/653; 873-4938 (Direct Line)
 UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
JONELTA FOUNDATION SCHOOL OF MEDICINE

• (+) right leg numbness

Additional Information
• We can ask for the timing of the hypogastric fullness, how often it happens
• How painful is the crampy pain during menses?
• We should also probe for the BMI of the patient. Obesity can be a risk factors for a number of
diseases
• Ask for the diet, high fat diet is a concern.
• Radiation exposure
• With the history of no contraceptive use, we must further ask if the patient have other practices
of contraception like withdrawal. If a woman with a 6-year relationship with no form of
contraception has not yet gotten pregnant, infertility might be an issue

2. What are the pertinent PE findings? How would these findings help in making the primary working
impression or excluding other diagnoses?
Primary Working Impression: G0P0, AUB-L (Leiomyoma Uteri), T/C Chronic Anemia secondary
to Blood Loss
• Pale palpebral conjunctiva
o This suggests anemia that might be from blood loss because of the leiomyoma.
• (+) Firm palpable 8x8cm mass in the abdomen, nontender, movable
o In conjunction to the hypogastric fullness, an enlarging pelvic mass, pain during
menses and prolonged duration and heavier menses are common symptoms of
leiomyoma
• (+) Uterus asymmetrically enlarged to 12 weeks size, nontender, movable
o An enlarged myoma can be unilateral.
o Adenomyosis might also be considered because of the asymmetrical uterus but it
usually doesn’t present to a large size unless with uterine myoma.
o Pregnancy can be ruled out because menses is recent and doesn’t correlate to the size
of the uterus and is usually not asymmetrical

3. What are the differential diagnoses for the case being discussed?

ADENOMYOSIS
RULE IN RULE OUT
• (+) menorrhagia • 30 years old
• (+) increase in dysmenorrhea • G0P0
• (+) enlarged uterus • (-) uterine surgery/trauma
• (+) Asymmetrical uterus • (-) dyspareunia
• (+) Firm palpable 8x8cm mass in the
abdomen, nontender, movable

ENDOMETRIOSIS
RULE IN RULE OUT
• 30 years old • (-) dyspareunia
• G0P0 • (-) retroverted uterus
• (+) Dysmenorrhea
• (+) Pelvic heaviness
___________________________________________________________________________________
5th Floor, Tamayo Tower
Alabang – Zapote Road, Pamplona, Las Piñas City
Tel. No. 874-8515 loc. 652/653; 873-4938 (Direct Line)
 UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
JONELTA FOUNDATION SCHOOL OF MEDICINE

• (+) Menorrhagia
• (+) asymmetric uterus enlargement

PREGNANCY
RULE IN RULE OUT
• 30 years old • LMP: January 16, 2022
• (+) pelvic heaviness • (-) nausea, vomiting
• (+) enlarged uterus
• No contraceptive use with 1
heterosexual partner
• Regular menstrual intervals

4. What laboratory exams should be ordered to confirm the primary working impression or exclude
other possible diagnoses?
• CBC to check for the presence of the suspected anemia
• Ultrasound is diagnostic for leiomyoma. It can differentiate a pregnant uterus from an adnexal
mass. Pelvic sonogram is a cost-effective method that allows rapid diagnosis
• Submucosal myomas may be diagnosed by vaginal ultrasound, sonohysterography,
hysteroscopy or as a filling defect on hysterosalpingography
• CT and MRI are definitely more expensive than ultrasound and most of the time are not
necessary but these can distinguish benign and malignant myomas and MRI can differentiate
adenomyosis or adenomyoma.
5. What are the options in the management of this patient?
• The patient’s age and reproductive goals direct the modality and goals of treatment.
Treatment goals should aim to:
o Relieve signs and symptoms
o Reduce the size of the myoma
o Maintain or improve a woman’s fertility
Medical Therapy
• Medical management is often the initial intervention for symptomatic fibroids and includes
hormonal therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and/or modulation of
the hypothalamic-pituitary axis. The major drawback of medical management is the limited
duration of use. Many of the medical management options are only able to be used for a
short duration, and after the cessation of treatment, symptoms reoccur, and the fibroids
often continue to grow. Hormonal options for treatment include combination oral
contraceptives, single agent progesterone suppression or GnRH agonists.
• Gonadotropin-releasing hormone (GnRH) agonists are preoperative treatment to decrease
size of tumors before surgery. This decreases blood loss, operative time and recovery time
but long-term treatment may come with a higher cost.
• Levonorgestrel-releasing intrauterine system to treat AUB by stabilization of the
endometrium. This is the most effective medical treatment for reducing blood loss. This
preserves fertility.
• Oral contraceptives to treat abnormal uterine bleeding by stabilization of the endometrium.
This reduces blood loss and preserves fertility if discontinued after resolution of symptoms.
• Non-hormonal options include NSAIDs and tranexamic acid. Tranexamic acid is for
antifibrinolytic therapy and stabilizes clot formation. Though there are side effects
associated. NSAIDs have been useful for reducing menstrual blood loss and endometrial
prostaglandins.
___________________________________________________________________________________
5th Floor, Tamayo Tower
Alabang – Zapote Road, Pamplona, Las Piñas City
Tel. No. 874-8515 loc. 652/653; 873-4938 (Direct Line)
 UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
JONELTA FOUNDATION SCHOOL OF MEDICINE

Surgical Therapy
• Hysterectomy – surgical removal of the uterus and is the definitive treatment for women
who do not wish to preserve fertility. Transvaginal or laparoscopic approach is associated
with decreased pain, blood loss and recovery time compared to transabdominal surgery.
• Myomectomy – surgical or endoscopic excision of tumors. Resolution of symptoms with
preservation of fertility but with a recurrence rate of 15-30% at five years, depending on
the extent of the tumors.
• Uterine Artery Embolization – an option for those who wish to preserve the uterus or
avoid surgery because of morbidities or personal preference where occluding agents are
infected to the uterine arteries which limits blood supply to the uterus and the leiomyoma.
This has decreased length of hospitalization and decreased time to normal activities but
there is insufficient evidence of the effect on future fertility.
6. What are the possible sequelae of her condition?
• Many patients with leiomyoma can have excellent prognosis and remain asymptomatic for
many years or indefinitely.
• Many of the medical management are only able to be used for a short duration and after
cessation of treatment, symptoms reoccur and myomas continue to grow
• Possible sequelae may be chronic pelvic pain, heavy menstrual bleeding, constipation,
urinary tract infections, infertility, urinary tract infections and torsion.

REFERENCES:
Lobo, R., et al. 2017. Comprehensive Gynecology. 7th Edition. Elsevier.
Florence AM, Fatehi M. Leiomyoma. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing
De La Cruz, M. et al., 2017. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 95(2):100:107

___________________________________________________________________________________
5th Floor, Tamayo Tower
Alabang – Zapote Road, Pamplona, Las Piñas City
Tel. No. 874-8515 loc. 652/653; 873-4938 (Direct Line)