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Gynecology Case Presentation
Gynecology Case Presentation
PRESENTATION:
“Abnormal Uterine Bleeding”
MANDAWE, MARJORIE
RAMESH, DEEPA
INFORMANT: Patient
RELIABILITY: 97%
Date of Admission: October 9, 2022
GENERAL DATA
L.L, 44 years old, female, married, born on January 1, 1978, Filipino, Roman Catholic,
residing at Basak Kagudoy, Lapu-lapu City.
CHIEF COMPLAINT
3 years prior to admission, the patient noted that her menstrual cycle was
prolonged. Normally, she would have 3 to 4 days duration with no blood clots
associated however she experienced a duration of 7 days associated with blood clots.
She was able to use 3 adult diapers, fully soaked associated with undocumented fever,
paleness, dizziness and headache having a pain score of 4/10. Patient took a one
paracetamol (Saridol) 500 mg tablet as needed and offered relief to her symptoms. No
consult was done and symptoms are tolerated, assuming she was on her menopausal
stage.
Interim, patient still has experienced the same symptoms, yet no consult was
done and symptoms are tolerated.
Interim, symptoms were tolerated. Due to financial constraints, the patient was
unable to comply right away with the surgery as directed and continued taking the
multivitamins she had been prescribed since her previous admission.
4 days prior to admission, the patient was able to secure blood and was admitted
in our institution
Adult Illness:
Surgical: removal of cyst at the index finger of the right hand (1996, Cortes
Hospital)
MENSTRUAL HISTORY
The patient had her menarche at the age of 15 years old with a 30-day regular
menstrual cycle with no history of dysmenorrhea, she claims a non-heavy flow for 3-4
days and can consume two moderately soaked pads per day.
GYNECOLOGICAL HISTORY
The patient is not using any kinds of contraceptive. She had her last menstrual
period on September 20, 2022. No pelvic surgeries.
SEXUAL HISTORY
The patient had her coitarche at the age of 19 years old with the total of one
sexual partner. The patient claims that she is not sexually active, no sexually
transmitted disease and not at risk of the said disease. The patient claims that she had
no post-coital bleeding and no sexual abuse
OBSTETRICS HISTORY
The patient is married with an OB score of G1P1 (1001). She had one child only
born on October 23, 2008 term live baby boy via normal spontaneous vaginal delivery at
Birthing Home in Lapu-Lapu with a birthweight of 2600 grams, APGAR and Ballard
score were unrecalled. Today the child is a 13 years old male currently a Grade 9
student at Bangkal National High School.
FAMILY HISTORY
The patient belongs to a large family with 5 siblings. Her father died because of
cerebrovascular disease and was diagnosed with hypertension while her mother is
diagnosed with hypertension and diabetes. The patient claims that her younger sister
had the same presentation of abnormal vaginal bleeding however it was resolved and
no surgeries were done.
The patient is a housewife married to a carpenter, they only had one child. She
reported that she is a highschool graduate. She claims that she does not use illicit
drugs, is not a smoker and does not drink any alcoholic drinks.
Review of Systems
HEENT: The patient had no redness or pain in the eyes, no cataract, no itching and
tearing, no spots in the visual field, saw no flashing lights, no transient vision loss, no blind
spots; no hearing problems, no earaches, no tinnitus; no nasal discharges; no sinus problems,
no mouth dryness, no sore throat, no voice hoarseness, no neck stiffness, no cervical
lymphadenopathy
CHEST AND LUNGS: The patient has no cough, no shortness of breath, no wheezing,
no chest tightness and no asthma
PHYSICAL EXAMINATION
General Survey: Patient is conscious, cooperative, ambulatory and not in respiratory distress
Vital Signs:
● Temperature: 36.3 C
● Blood Pressure: 120/80 mmHg
● Heart Rate: 72 bpm
● Respiratory Rate: 18 cpm
● O2 Sat: 99% at room air
Anthropometrics:
● Height: 165 cm
● Weight: 58 kg
SKIN: Warm to touch, good skin turgor and mobility, no pallor, no jaundice no masses, no
lesions, no lumps
HEENT: Hair has normal texture. Scalp has no lesions and tenderness. Eyes have pink
palpebral conjunctiva with anicteric sclerae. Ears have no lesions, masses and tenderness. No
nasal discharges. No neck masses, trachea is in the midline
GENITOURINARY
I - Parous
U - 18 weeks size
D - No discharges
SALIENT FEATURES
(+) Jaundice
(+) Paleness
(+) Restlessness
ADMITTING DIAGNOSISnn
BASIS OF DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
DIAGNOSTIC
DIFFERENTIAL COUNT
In the September his CBC revealed a low WBC Count, low RBC Count, low
hemoglobin, low hematocrit, low MCHC and high RDW-CV. Differential count low
neutrophil and hight Lymphocyte, high Eosinophil, hight Basophil levels indicating
ongoing severe infection or inflammation.
In the October CBC revealed a high WBC count (15.44) low RBC count (4.22) high
RDW-CU (17.10). Differential count shows high neutrophil (89.50), low lymphocyte
(5.70), and low eosinophil (0.00), and normal basophil levels.
Urinalysis shows light yellow, clear, with a specific gravity of 1.005 and a pH of 5.5.
Glucose (-) and ketones (-) are absent with 0-1/ hpf RBC and 0-1/ hpf WBC, rare
squamous epithelial cells, rare bacteria and few mucus threads.
Ultrasound findings-
The uterus is anteverted with irregular contour and inhomogeneous myometrium. There
is a well-circumscribed heterogeneous mass measuring 11.4×10.4×8.0cm noted at the
right posterior lower half of the uterus and extending up to the cervix suggestive of an
intramural myima with submucosal and subserosal components.
MANAGEMENT
CASE DISCUSSION
Abnormal uterine bleeding can present in many ways from infrequent episodes, to
excessive flow or prolonged duration of menses and intermenstrual bleeding.
Alterations in the pattern or volume of blood flow of menses are among the most
common health concerns of women. The mean interval between menses is 28 days (67
days). Thus if bleeding occurs at intervals of 21 days or less or 35 days or more, it is
abnormal. The mean duration of menstrual flow is 4 days. Few women with normal
menses bleed more than 7 days, so bleeding for longer than 7 days is considered to be
abnormally prolonged. It is useful to document the duration and frequency of menstrual
flow with the use of menstrual diary cards; however, it is difficult to determine the
amount of menstrual blood loss (MBL) by subjective means. Although mortality and
serious complications of AUB are uncommon, their effect on health-related quality of life
is significant.
INCIDENCE
ETIOLOGY
PATHOPHYSIOLOGY
MANAGEMENT