GYNAECOLOGY CASE

PRESENTATION
- SUDHAMSHU KASHYAP
• Name - Mrs. ABC
• Age - 45 years
• Occupation - Farmer
• Address - Sakleshpur, Hassan
• Education - Class 9
• Socioeconomic status - Class 4 ( according to modified B.G.Prasad
classification)
• Husband's name - Mr. BCD
• Husband's age - 55 years
• Husband's education - Class 4
• Date of examination - 22/01/2020
CHIEF COMPLAINTS
1. Abdominal distension since 4 months
2. Heavy menstrual bleeding since 4 months
3. Painful menstruation since 4 months
4. Pain abdomen since 1 month
HISTORY OF PRESENTING ILLNESS
• Patient was apparently normal 4 months back after which she noticed
distension of abdomen which was insidious in onset and gradual in
progression.

• She complains of heavy menstrual bleeding since 4 months, regular

28 day cycle with 9-10 days of flow, changing 5-6 pads per day,
associated with pain during menstruation and passage of clots.
Previously, she used to have 3-4 days of flow and used to change 2-3
pads per day.
• She also complains of pain in lower abdomen, insidious in onset,
gradually progressive, dragging type, present throughout the day,
radiating to back. No aggravating and relieving factors.
• There is history of loss of appetite since 4 months,
• Disturbed sleep (due to pain) since 1 month.
• 2 weeks back she had consulted a local doctor for heavy menstrual
bleeding and was told to have low hemoglobin. 4 bottles of blood was
given.
• There is no history of –
• Intermenstrual bleeding
• Mass coming out of vagina
• Discharge per vagina
• Increased frequency of micturition
• Burning micturition
• Difficulty in passing stools
• Weight loss
• Fever
MENSTRUAL HISTORY
• Menarche at the age of 11 years
• LMP – 08/01/2020
• Since 4 months, she is having 28-30 days cycle with 9-10 days of flow,
changes 5-6 pads per day. It is associated with pain during days of
menstruation and she passes clots.
• Previously, she had regular 28-30 days cycle with 3-4 days of flow,
used to change 2-3 pads per day. It was not associated with pain and
passage of clots.
OBSTETRIC HISTORY
• First child – 24 years back, a female child was born at term by normal
vaginal delivery at hospital. Birth weight being 2.8 kg.
No antenatal, perinatal and postnatal complications
Breast fed for 1 year.
• Second child – 20 years back, a female child was born at term by
normal vaginal delivery at hospital. Birth weight being 3 kg.
No antenatal, perinatal and postnatal complications
Breast fed for 1 year.
• Post partum sterilisation done after second delivery.
PAST HISTORY
• Not a K/C/O diabetes mellitus, hypertension, tuberculosis, bronchial
asthma, epilepsy, cardiac diseases.
• No surgeries done other than post partum sterilisation.
• No known allergies.
FAMILY HISTORY
• Mother is K/C/O hypertension
• She has undergone hysterectomy for mass in the uterus
• No history of diabetes mellitus, tuberculosis in the family.
PERSONAL HISTORY
• Predominantly non vegetarian diet
• Reduced appetite since 4 months
• Disturbed sleep since 1month
• Regular bowel and bladder habits
• Occasionally consumes arecanut and beetle leaves.
GENERAL PHYSICAL EXAMINATION
• Patient is cooperative and well oriented to time, place and person
• She is moderately built and nourished.
• Vitals –
• Pulse rate = 72 beats/min
• BP = 124/82 mm Hg
• Temperature = 98.4 degrees F
• Respiratory rate = 16 cycles/min
• Weight = 50 kg
• Height = 168 cm
• BMI = 17.7 kg/m2 (underweight)
• There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and
edema.
• Thyroid, breast and spine appear normal.
• Teeth are slightly stained.
PER ABDOMEN EXAMINATION
• Inspection –
• Abdomen is slightly distended
• Umbilicus is pushed up and inverted
• All quadrants move equally with respiration
• Tubectomy scar is seen and looks healthy
• No sinus and dilated veins
• Hernial orifices are intact.
• Palpation –
• No local rise in temperature
• No tenderness
• A firm to hard mass is palpable at just above the level of umbilicus
corresponding to around 24 weeks of gestation
• It is 11x22 cm in size, extending to right and left iliac fossa and
umbilical region
• Its surface is smooth
• It is only transversely mobile
• All borders except the lower one are felt
• No organomegaly.
• Percussion –
• Dull note is heard over the mass
• Resonant note is heard over other areas
• No shifting dullness.

• Auscultation –
• Normal bowel sounds heard.
SYSTEMIC EXAMINATION
• Cardiovascular system –
• First and second heart sounds heard normally. No murmurs

• Respiratory system –
• Bilateral normal vesicular breath sounds heard. No added sounds.

• Central nervous system –

• No focal neurological deficit.
PROVISIONAL DIAGNOSIS
Forty five year old female farmer with complaints of abdominal
distension, heavy menstrual bleeding and painful menstruation since 4
months and pain abdomen since 1 month, on examination is found to
have a 11x22 cm transversely mobile firm to hard mass with smooth
surface corresponding to 24 weeks of gestation extending to right and
left iliac fossa and umbilical region with all borders except the lower
one felt and which is dull on percussion is suggestive of fibroid uterus.