CASE PRESENTATION

College of Medicine, Inha Univ. Dept of Obstetrics and Gynecology Presented by Lee Joo-Won (973975)

PATIENT

• 최 O 순 (F/43)• married• housewife

CHIEF COMPLAINT

menorrhagia with dysmenorrhea(O: March 15th ,2003)

HISTORY OF PRESENT ILLNESS

The patient was in her usualstate of good health until3 months ago when she notedabnormally extended period and too much of menstruation followed bydysmenorrhea.

HISTORY OF PRESENT ILLNESS

She visited EMC of our hospital on April 6th complaining of above symptomsand received D/C/B yeilding the diagnosis of chronic endometritis and endometrialpolyp.

HISTORY OF PRESENT ILLNESS

One week later she was admittedwith persistent bleeding.Hysteroscopic polypectomy was done on April 14th and discharged.

HISTORY OF PRESENT ILLNESS

Nonetheless, symptoms persisted and admitted via OPD again for surgical treatment.

PAST MEDICAL HISTORY

• Hypertension/DM/pulmonary Tb/Hepatitis (-/-/-/-)• OP History (+) hysteroscopic polypectomy 4/14• Medication – for anemia (Fe)

FAMILY HISTORY

SOCIAL HISTORY

Non-contributable

alcohol (-) smoking (-)

OB AND GY HISTORY

• Parity : 2 - 0 - 0 – 2• Menses : regular cycle - 30days duration - 7days• LMP : June 4th 2003• PMP : May ? 2003 regular• LD : normal spontaneous delivery• Contraception : IUD (+)• Menarche : 17 YO

REVIEW OF SYSTEM

General general weakness(-) fatigue(-) febrile/chilling sensation (-/-) weight loss(-)

HEENT dizziness(-) vertigo(-) hearing disturbance(-) tinnitus(-) eye. ear discharge(-) sore throat(-) rhinorrhea(-)

REVIEW OF SYTEM

Respiratory dyspnea(-) cough(-) sputum(-) chest discomfort(-) chest pain/palpitation(-/-)

GastroIntestinal A/N/V/D/C(-/-/-/-/-) melena(-) hematochezia(-) abdominal pain(+) – Ass. W/ vaginal bleeding

REVIEW OF SYSTEMCardiovascularcyanosis(-) palpitation(-)

GenitoUrinarydysuria(-) polyuria(-) oliguria(-) urgency(-) frequency(-)

Back and Extremitieslimitation of movement(-)back pain(-)

Menorrhagia(+) – started from MarchDysmenorrhea(+) – started from March

PHYSICAL EXAMINATION

Vitals BP 150/70mmHg-Pulse 92beats/min-Resp 20/min-BT 36.2oC

General Appearance not so ill looking appearance

Mental Status alert consciousness

HEENT

anicteric sclera slightly anemic conjunctiva

PHYSICAL EXAMINATION

Chest symmetric expantion without retraction regular heart beats without murmur clear breathing sound without rale

Abdomen soft & slightly obese normoactive bowel sound no organomegaly no palpable mass no tenderness no rebound tenderness

PHYSICAL EXAMINATION

Back and Extremities no CVAT no PTPE

OBGY EXAMINATION

• Uterus : woman’s fist size, nodular• Adnexa : both free• Cervix : ns, ne, mT(-)• V/D : whitish, mucoid

ASSESSMENT

1. R/O anovulation 2. R/O uterine myoma3. R/O uterine polyp4. R/O malignancy5. R/O thyroid dysfunction6. R/O coagulation abnormalities

Listed according to the incidence of the disease inperimenopausal women and fatality when missed.

DIAGNOSTIC PLAN

• Laboratory works 1. routine lab - CBC, admission panel, electrolytes, urinalysis, ECG 2. pregnancy test, Pap smear, CBC, stool exam, CA-125 3. check PT, aPTT, BT 4. VDRL, HPV DNA Chip 5. Thyroid function test

• Radiologic Works 1. simple abdominal X-ray 2. ultrasonography

RESULTS OF WORK-UP

• CBC WBC 5.3 RBC 3.82 (low) Hb 11.9 (low) Hct 35.2 (low) PLT 205

• Electrolytes Na 144 K 3.9 Cl 109 TCO2 23.9

RESULTS OF WORK-UP• admission panel Ca 9.4 P 3.3 glucose 133 (high) BUN/Cr 13.3/0.61 uric acid 3.0 cholesterol 154 T.protein 7.2 albumin 4.2 T.bilirubin 0.2 ALP 45 AST/ALT 20/22 globulin 3.0

• urinalysis color straw turbidity clear S.G 1.025 pH 5.0 protein (-) glucose (-) ketone (-) blood (+++) urobilinogen normal bilirubin (-) nitrite (-) WBC (-)

RESULTS OF WORK-UP

• PT 13.5(sec) 92(%) 1.06(INR)• aPTT 33.1(sec)• BT 3 (min) - 4/12

RESULTS OF WORK-UP

• VDRL(serum) non-reactive • anti-HBs (+)• HBsAg (-)• anti-HIV (-)

RESULTS OF WORK-UP

• TVSuterus : 6.7*11.2cm ET(T) =5.3mmmyoma a) 2.3*2.7cm post.wall, intramuralb) 1.7*1.7cm ant. cx. Portion, intramuralc) 1.3*1.1cm ant. wall, intramurald) 3.3*2.6cm post. Fundus, intramural

adnexa : both N/SCDS fluid (-)

RESULTS OF WORK-UP myoma I myoma II

RESULTS OF WORK-UP myoma III myoma IV

RESULTS OF WORK-UP

uterus

DIFFERENTIAL DIAGNOSIS

1. anovulation ruled out. There should be no other organic di

seases to make diagnosis of anovulation.2. R/O uterine myoma most likely3. R/O uterine polyp ruled out. We found no evidence of uterine pol

yp

DIFFERENTIAL DIAGNOSIS

4. R/O malignancy Patient has no risk factor for malingnancy, but should be ruled out on pathology and must be included in ongiong diagnosis

5. R/O thyroid dysfunction TFT was not performed but unlikely because uterine mass was found on sonography

6. R/O coagulation abnormalities Ruled out.

ONGOING DIAGNOSIS

• R/O uterine myoma• R/O malignancy

TREATMENT PLAN

• Total Laparoscopic Hysterectomy

PROGRESSION NOTE

• June 19th (HD#2)Total Laparoscopic Hysterectomy was done

PROGRESSION NOTE

• June 20th (HD#3, POD#1)S) febrile/chilling sense(-/-) dyspnea(-) wound pain (+)O) vitals 90/50 –64- 20 –36.8oC I/O 2920/1600 J/P 200cc serosanguinous CBC 7.9-7700-116K electrolytes – 142-3.4-1.1A) post operative stateP) 1. BR 2. Pain control

PROGRESSION NOTE

Pathology report Uterus, Total laparascopic hysterectomy Cervix : chronic cevicitis with squamous metaplasia

Enometrium : proliferative phase Myometrium : leiomyomas, three, intramural

PROGRESSION NOTE

• June 21st (HD#3, POD#2)S) febrile/chilling sense(+/-) wound pain (+) gas out(+)O) vitals 90/60 –83- 20 –37.5oC I/O 2400/3430 J/P 110cc serosanguinousA) post operative state day 2P) 1. foley catheter removal 2. pain control 3. soft diet 4. ward ambulation

THANK YOU

She was diagnosed well and treated appropriately and

scheduled to discharge soon.