CASE WRITE-UP

ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH

MD-MBA Program

Medical Case Writeup: Pelvic Endometriosis

Prepared by:

QUEROL, Zachary Ivan G.

Preceptor: Dr. De Leon

 CASE WRITE-UP

IDENTIFYING INFORMATION

NAME: J.B. DATE OF INTERVIEW: January 11, 2024

DATE OF BIRTH: May 2, 1996 PLACE OF INTERVIEW: EAMC OB-GYNE OPD

AGE: 27 SEX: Female CIVIL STATUS: Single

RELIGION: Roman Catholic INFORMANT: Patient

ADDRESS: Montalban, Rizal RELIABILITY: Good

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

Chief Complaint Hypogastric pain

History of Present The patient is a 27 year old nulligravida coming in for

Illness hypogastric pain.

9 months ago, patient started having hypogastric pain

characterized as persistent, crampy, lasting for 5 mins in
duration, with a pain severity of 6/10, alleviated by applying a hot
compress and aggravated by strenuous physical activity. No
consultations done. No associated fever, headache, nausea,
vomiting, dysuria, diarrhea, weight changes, excessive hair
growth. She self-medicated with paracetamol 500 mg as needed
for pain, which provided temporary relief.

In the interim, hypogastric pain would still occur on-and-off at

least once a month.

2 months prior, she then noted heavy menstrual bleeding with

associated clots, using up to 8-10 pads per day, moderately
soaked, and noted irregular cycle. She describes menstrual
cycles ranging from 35 to 40 days, with occasional episodes of
heavy menstrual bleeding and the presence of clots. She notes
that the pain occurs at various points throughout her menstrual
cycle and is not consistently associated with menstruation.
Persistence of symptoms prompted consult.
 REVIEW OF SYSTEMS

General (-) jaundice (-) fever, (-) fatigue

Musculoskeletal / (-) muscle pain, (-) joint pain, (-) edema, (-) acne
Integumentary

HEENT (-) blurring of vision, (-) tinnitus, (-) ear pain/discharge, (-) sore
throat, (-) epistaxis

Cardiorespiratory (-) cough, (-) colds, (-) hemoptysis, (-) orthopnea, (-) paroxysmal
nocturnal dyspnea, (-) exertional dyspnea

Gastrointestinal (-) vomiting, (-) diarrhea

Endocrine (-) polyuria, (-) polydipsia, (-) polyphagia, (-) tremors, (-) heat/cold
intolerance

Genitourinary (-) external genitourinary masses/lesions, (-) dyspareunia and

post-coital bleeding since no recent sexual contact

Neurological (-) seizures (-) tremors

PAST MEDICAL HISTORY

No Hypertension, Type 2 Diabetes Mellitus, Bronchial Asthma, Thyroid, Liver or Kidney

disease
No previous admissions
No previous surgeries
No allergies to food or medications

OBSTETRIC HISTORY

G0P0

GYNECOLOGIC HISTORY

Menarche: 12 years old

Interval: irregular
Duration: 7 days
Amount: 8-10 moderately soaked pads/day
Symptoms: with dysmenorrhea before menses
 REPRODUCTIVE AND SEXUAL HISTORY

No history pelvic infection and STIs

No previous contraception use
Age of first coitus: 19 years old
Age of first pregnancy: 20 years old
Number of sexual partners: 1
No post coital pain
No bleeding after coitus

NUTRITIONAL HISTORY

No dietary restrictions
Usual daily intake includes vegetables and fish
Each meal typically consists of 1 cup of rice and viand

IMMUNIZATION HISTORY

Childhood vaccines were allegedly complete

COVID vaccinated with 2 doses of primary series, with 1 booster
No flu vaccine
No HPV vaccine yet3

FAMILY HISTORY

(+) Diabetes - Maternal side

(+) Hypertension - Paternal side
(-) Asthma
(-) Liver, thyroid, or renal diseases
(-) Cancer, MI, or stroke

PERSONAL AND SOCIAL HISTORY

Non-cigarette smoker
Occasional alcoholic beverage drinker
Denies illicit drug use
BPO agent
 PHYSICAL EXAMINATION

General Awake, alert, not in cardiorespiratory distress

Vital Signs BP 100/60 | HR 88 bpm | RR 18 | T 36.7˚C | O2 99% at room air

Anthropometrics Weight: 61 kg
Height: 151 cm
BMI: 26.7 (Obese I)

Head, Neck, Ears, Pink palpebral conjunctivae, anicteric sclerae

Nose, Throat (HEENT) Wet, moist oral mucosa
Non-distended neck veins

Thorax and Lungs Symmetric chest expansion, clear breath sounds

Cardiovascular Normal rate, regular rhythm, no murmurs

Abdomen No visible abdominal mass/lesion, non distended abdomen,

normoactive bowel sounds (5 bowel sound/min), non-tender (no
direct/rebound tenderness)

Skin and Extremities Warm extremities, full and equal pulses, CRT <2s, no edema

Pelvic exam Gross inspection: Normal external genitalia. No masses, lesions,

discharge.

Speculum exam: Vaginal canal pale and atrophic, cervix atrophic

with minimal mucus secretions, non-smelling, no excoriations,
no polyps, no foul-smelling discharge.

Bimanual exam: Cervix closed, no cervical motion tenderness.

Uterus is enlarged in size, shape, and position, with noted
tenderness. Presence of nodularity and tenderness along the
uterosacral ligaments and cul-de-sac. No palpable masses in the
adnexal areas. Mild tenderness noted upon palpation of the
ovaries.

SALIENT FEATURES

● The patient is a 27 year old, nulligravida, presenting with 9 month history of

hypogastric pain, associated with heavy menstrual bleeding, irregular menses.
• Menstrual history
Menarche: 12 years old
Interval: irregular
 Duration: 7 days
Amount: 8-10 moderately soaked pads/day
Symptoms: no dysmenorrhea
• Bimanual exam: Cervix closed, no cervical motion tenderness. Uterus is enlarged in
size, shape, and position, with noted tenderness. Presence of nodularity and
tenderness along the uterosacral ligaments and cul-de-sac. No palpable masses in
the adnexal areas. Mild tenderness noted upon palpation of the ovaries.

ASSESSMENT

Differential Diagnoses

• Endometriosis
o Rule-in
§ (+) Hypogastric pain
§ (+) Irregular periods
§ (+) Heavy menstrual bleeding
§ (+) Reproductive age
§ (+) Uterus enlarged and tender on bimanual exam
o Rule-out
§ (-) Changes in urine output
§ (-) Changes in bowel movement
§ (+) Adnexal tenderness
• Polycystic Ovary Syndrome
o Rule-in
§ (+) Hypogastric pain
§ (+) Irregular periods
§ (+) Heavy menstrual bleeding
§ (+) Adnexal tenderness
o Rule-out
§ (-) Excessive body hair growth
§ (-) Weight changes
§ (-) Signs of hirsutism
• Uterine fibroids
o Rule-in
§ (+) Hypogastric pain
§ (+) Irregular periods
§ (+) Heavy menstrual bleeding
§ (+) Reproductive age
§ (+) Uterus enlarged and tender on bimanual exam
o Rule-out
§ (-) Abdominal enlargement
§ (-) Dyspareunia
 • (-) Changes in urine output

Primary Diagnosis and Pathophysiology:

G0, t/c Pelvic Endometriosis

Endometriosis is a chronic condition characterized by the presence of endometrial-like

tissue outside the uterus, typically within the pelvic cavity. Current theory on its
pathophysiology is based on the concept of retrograde menstruation. This process sees
menstrual blood, containing endometrial cells, flowing back into the pelvic cavity via the
fallopian tubes. Subsequently, these misplaced endometrial cells can attach to pelvic
organs and tissues, creating endometriotic lesions. Even though retrograde menstruation is
a common event in numerous women, other factors such as genetic predisposition and
immune system malfunctions contribute to the onset of endometriosis. Genetic elements
influence susceptibility, and females with immediate family members diagnosed with
endometriosis have a higher risk. An impaired immune system permits the existence and
implantation of out-of-place endometrial cells, causing the formation of inflammatory
lesions.

Endometriosis can appear with a wide range of clinical presentations, from no symptoms to
extremely incapacitating ones. Infertility, dyspareunia (pain during sexual activity),
dysmenorrhea (painful menstrual cycles), and persistent pelvic discomfort that may persist
outside of the menstrual cycle are common symptoms. The degree of anatomical
involvement does not always correspond with the severity of symptoms; women with little
lesions may be in excruciating pain, while others with substantial illness may not show any
symptoms at all. Endometriosis-related discomfort is frequently cyclical, gets worse
throughout the menstrual cycle, and sometimes has urinary and gastrointestinal side
effects. Sometimes endometriosis is discovered by coincidence when doing diagnostic tests
for unrelated issues.

The cyclical growth and shedding of endometriotic lesions in response to changes in

hormones, especially estrogen, is a hallmark of the course of endometriosis. To provide a
blood supply for their development, these lesions go through angiogenesis, which adds to
the inflammatory microenvironment. When fibrous adhesions develop and persistent
inflammation ensues, the pelvic organs may undergo structural alterations that impair
fertility and cause discomfort. Women who have endometriosis often worry about infertility,
which can be caused by a variety of factors such as decreased ovarian function, pelvic
architecture distortion, and negative effects on the sperm-egg contact. The necessity for a
thorough approach to diagnosis and treatment that considers the variety of clinical
presentations of the disorder is highlighted by the complex pathophysiology of
endometriosis.
 PLAN

Diagnostics

● Transvaginal Ultrasound
○ 80% vs 36% abdominal ultrasound - good visualization
● MRI
○ MRI for endometriosis has a reported sensitivity and specificity of
approximately 91% to 95%.
● Complete blood count
○ To rule out possible anemia
● Diagnostic laparoscopic
○ Definitive diagnostic test

Therapeutics

● Pain Medications:
○ Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Can help alleviate pain and
reduce inflammation associated with endometriosis.
● Hormonal Therapies:
○ Danazol: An androgen derivative that induces atrophic changes in the
endometrium of the uterus and suppresses ovulation and menstruation.
This reduces the growth of endometrial tissue. Recommended dose: 200 mg
once a day.
○ Birth Control Pills: Oral contraceptives containing estrogen and progestin
can regulate the menstrual cycle, reduce pain, and limit the growth of
endometrial tissue.
○ Gonadotropin-Releasing Hormone (GnRH) Agonists: These medications
induce a temporary menopause-like state, suppressing ovarian function and
reducing symptoms. They are often used for short-term symptom relief.
● Surgical Interventions:
○ Laparoscopic Surgery: Diagnostic laparoscopy can confirm the presence of
endometriosis, and surgical excision or ablation of lesions can be performed
during the same procedure.
○ Laparotomy: In severe cases or when laparoscopic surgery is not feasible, a
larger abdominal incision may be required for more extensive excision of
endometriotic lesions.

Sources:

Rogerio A. Lobo, David M Gershenson. (2021). Comprehensive Gynecology 8th edition. :

Elsevier.