San Juan Medical Center

Department of Obstetrics & Gynecology

N. Domingo St. Balong Bato San Juan City
Tel No. (632)7259948

Case Protocol

Identifying Data

C.P 55year old, Roman Catholic, from San Juan City.

Chief complaint: Palpable abdominal mass

History of present illness:

3year PTC, prior to consult, patient noted a gradual enlarging mass associated with hypogastric
pain,no other comlaints note. No change in bowel movement, no urinary symtproms. Consult TVS
done however pt lost t follow-up.

Patient was lost to follow up until 3months prior to consult, patient sought consult at our
institution, still with enlarging and hypogastric pain. No other associated symptoms, vaginal
bleeding/discharge, no gastrointestinal and urinary symptoms. Transvaginal ultrasound TVS
showed: Assymetrically Enlarged retroverted uterus with multiple myoma:1. posterofundal, IM 3.1 x
3 x 2.3 FIGO 6; 2. Rt posterior isthmic 1 x 1 x .6cm;3. rt posterior midsegment 1.08 x 1.3 x 1.1cm; 4.
Rt posterolateral 1.47 x 1.21 x 0.8, IM, SS FIGO4; 5. left anterior midsegment, IM 6. 2.27 X 2.3 X
1.7CM, FIGO 6; 6. Anterior lower segment,IM 1.25 x 1.2 x 1.7cm FIGO 4; 7. anterior left isthmic, IM
SS 4.6 x 4.6 x 3.9, FIGO6.Thin EM (0.42CM). Normal ovaries for age further diagnostic work ups were
requested but due to GCQ there was a delay on follow up.

1 week prior to consult, patient came in with her diagnostic results. Patient was advised for undergo
contemplated picture.

Past Medical/Surgical History:

(+) Hypothyroidism Levothyroxine 10ug OD

(-) Diabetes Mellitus

(-) Bronchial Asthma

(-) Tuberculosis

(-) Thyroid Disease

(-) Previous operation

Family Medical History:

(+) Hypertension

(-) Diabetes Mellitus

(-) Bronchial Asthma

 San Juan Medical Center
Department of Obstetrics & Gynecology
N. Domingo St. Balong Bato San Juan City
Tel No. (632)7259948

(-) Tuberculosis

(+) Thyroid Disease

(-) Cancer

Personal and Social History: The patient is a housewife, Roman Catholic, college undergraduate and
unemployed. She denies smoking and drinking alcoholic beverages.

Menstrual History: Menarche was at 12 years of age, with 28-30 days intervals, lasting for 4-5 days,
consuming 2-3 pads per day, moderately soaked with no accompanying symptoms.

Sexual History: First coitus was at 39 years old and has had 1 sexual partner since. No dyspareunia, no
postcoital bleeding noted, no contraceptives used.

Gynecologic History: No history of gynecologic pathology

Obstetrical History: nulligravid

Review of Systems: No fever, no weight loss, no rashes nor pruritus. No dizziness and headache. No
dyspnea, no chest pain nor easy fatigability nor palpitations. No cyanosis nor loss of consciousness. No
nausea and vomiting, no diarrhea nor constipation. No lumbar and hypogastric pain. No dysuria nor
urgency. No asymmetry, no joint movement nor limitation of movement. No bipedal edema. No easy
bruisability.

Physical Examination:

• Conscious, coherent, ambulatory, not in cardiorespiratory distress

• BP: 110/80 mmHg CR: 82 bpm RR: 18 cpm Temp: 36.5 C O2sat: 99 %

• Weight: 60kg Height: 150Cm BMI: 24 kg/m2 (normal)

• Pink palpebral conjunctivae, anicteric sclerae

• Symmetric chest expansion, clear breath sounds, no retractions

• Adynamic precordium, normal rate and regular rhythm, no murmur

• Abdomen is flabby, soft, non-tender, with palpable globular mass, firm, movable, non-tender,
measuring about 120x18cm located in the hypogastric area

• Speculum Exam: cervix is smooth, pinkish, no lesions, no bleeding

• Internal Exam: cervix is firm, closed, uterus enlarged to 20 week size, no AMT/CMT

• Rectovaginal Exam: parametria are free and pliable

Admitting Diagnosis:
Nulligravid, Menopause for 5 years; Multiple Myoma Uteri (FIGO 4-6); Euthyroid
 San Juan Medical Center
Department of Obstetrics & Gynecology
N. Domingo St. Balong Bato San Juan City
Tel No. (632)7259948

Ancillaries:

CBC 5/3 Urinalysis 5/3/22

Hemoglobin 125 Color Light

yellow

Hematocrit 0.39 Transparency clear

RBC 4.07 pH 5.0

WBC 7.7 Specific Gravity 1.030

Neutrophils 0.46 Sugar Negative

Lymphocytes 0.42 Protein Negative

Monocytes 0.02 Pus cells 1-2/hpf

Platelet count 339 Red Blood Cells None

Blood type 0+ Bacteria Few

HIV; HBsAg; TPPA NR Epithelial cells Few

PAP test (11/03/20) Negative for intraepithelial lesion/malignancy

Tumor Marker Reference

CA 125 13.6 0 – 46
CXR 5/3/22 ECG 5/3/22
 San Juan Medical Center
Department of Obstetrics & Gynecology
N. Domingo St. Balong Bato San Juan City
Tel No. (632)7259948

Normal chest Normal sinus rhythm

TVS (Global) 9/17/21

TVS9/2021
Histopathology Result:
EM biopsy 11/15/2021: em tissues fundal, IM, SS 2.8 x 3 x3cm, FIGO5.; 3. mid-anterior, SS
Seen with features of a polyp
TVS 3/30/22
Discharge Diagnosis:
Assymetrically Enlarged retroverted uterus with multiple
myoma:1. posterior, IM 3x 3x 3.3 x 2.9cm, FIGO 4; 2.
3x 3cm FIGO6; 4. low posterior, IM1.6 x 0.9cm figo 4. 5.
left lat, SS 5.1 x 3.6cm, FIGO 7.Thickened EM t/c olypoid
lining 1.6CMCystic follicle, left ovary. Normal right ovary
with rare follicle.
TVS (SJMC) 3-30-22
Assymetrically Enlarged retroverted uterus with multiple
myoma:
1. posterofundal, IM 3.1 x 3 x 2.3 FIGO 6; 2. Rt posterior
isthmic 1 x 1 x .6cm;
3. rt posterior midsegment 1.08 x 1.3 x 1.1cm; 4. Rt
posterolateral 1.47 x 1.21 x 0.8, IM, SS FIGO4; 5. left anterior
midsegment, IM 6. 2.27 X 2.3 X 1.7CM, FIGO 6; 6. Anterior
lower segment,IM 1.25 x 1.2 x 1.7cm FIGO 4; 7. anterior left
isthmic, IM SS 4.6 x 4.6 x 3.9, FIGO6.
Thin EM (0.42CM)
Normal ovaries for age

Nulligravid, Menopause for 5 years; Multiple Myoma Uteri; Euthyroid