block g: calma, capili, coruna, dagang, datukon, dayrit, de castro, de la llana, gayeta, golepang
TRANSCRIPT
GYNECOLOGY CASE PROTOCOL
Block G: Calma, Capili, Coruna, Dagang, Datukon, Dayrit, de Castro, de la Llana, Gayeta, Golepang
General Data
MP 34 years old G3P3 (3003) Married, housewife Roman Catholic Cabuyao, Laguna
Chief Complaint
menorrhagia
Past Medical History
No previous illnesses(-) HPN, DM, PTB, BA, goiter
No previous surgeries No known allergies to food or drugs
Family Medical History
(-) HPN, DM, PTB, BA, goiter No relative with similar symptoms as the
patient
Personal/Social History
High school graduate Currently a housewife Non-smoker, non-alcoholic beverage
drinker, does not use illegal drugs
Sexual History
First coitus at 17 years of age 1 non-promiscuous sexual partner (+) OCP use from 1992-1996 (-) previous IUD use (-) previous STD’s
Menstrual History
Menarche at 13 years old Regular monthly intervals 3-4 days’ duration Consuming 3-4 pads/day (+) occasional mild dysmenorrhea LMP: 1/20/2010 PMP: 12/22/2009 No previous Pap smear
Obstetric History G3P3 (3003)
G1 1986, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive
G2 1991, FT via SVD at home c/o hilot, F, AGA, (-) FMC, alive
G3 1997, FT via SVD at home c/o hilot, M, AGA, (-) FMC, alive\
History of Present Illness
3 months PTCIncrease in amount and duration of menses (3-4
pads per day 5-6 pads per, 3-4 days duration 10 days, with flow decreasing to 1-2 pads later)
(-) intermenstrual bleeding, hypogastric pain, bowel/urinary changes
(-) post-coital bleeding, dyspareunia, vaginal discharge, weight loss, anorexia and pallor
(-) consults done / medications taken
History of Present Illness
1 month PTCPersistence of symptomsDuration increasing to 12 daysFlow decreasing to 1 pad/day later in the periodConsulted an Ob-Gyn in Laguna
○ TV UTZ done – unrecalled findings○ Patient lost to follow up
persistence of symptoms prompted this consult
Review of Systems (-) fever (-) malaise (-) cough (-) DOB (-) hemoptysis (-) chest pain (-) orthopnea (-) PND (-) easy fatigability (-) dizziness (-) nape pain
(-) weakness (-) polydipsia (-) polyuria (-) polyphagia (-) palpitations (-) abdominal pain (-) bowel changes (-) dysuria (-) decreasing urine
output Tea-colored urine
Physical Examination Awake, coherent, ambulatory, NICRD BP 120/80 HR 84 RR 18 Weight: 55kg Height: 152cm BMI: 23 HEENT: pink conjunctivae, anicteric sclerae, (-)
CLAD/TPC/ANM Lungs: equal chest expansion, clear breath
sounds, (-) crackles/wheezes Heart: (-) heaves/thrills, distinct heart sounds,
normal rate, regular rhythm, (-) murmurs
Physical Examination
Abdomen: flabby, soft, normoactive bowel sounds, nontender, (-) masses/organomegaly
Extremities: pink nail beds, full equal pulses, (-) cyanosis/clubbing/edema
Physical Examination
Internal Examination: Normal external genitalia; smooth, parous
vagina; cervix smooth, closed, firm; corpus small; (-) adnexal masses/tenderness
Rectovaginal Examination:Good sphincter tone, intact rectovaginal
septum, smooth and pliable parametria, (-) fullness in the cul de sac, (-) intraluminal masses, (-) blood per examining finger
Assessment
Abnormal uterine bleeding probably secondary to adenomyosis, r/o endometrial pathology
Plan
DiagnosticsCBC, Pap smear, Transvaginal ultrasound
TherapeuticsFeSO4 325 mg/tab OD
OthersIncrease OFI, full body bath + perineal hygiene dailyMenstrual calendarFor endometrial biopsy with endocervical curettage
once with ultrasound results
Results
CBC: WBC 9.7, Hgb 117, Hct 0.379, Plt 359, Neut 0.76, Lym 0.23
Transvaginal UltrasoundThe uterus is anteverted with smooth contour and
homogeneous echopattern, measuring 8.1x5x4.5cm, the cervix measures 3.4x3.2x2.8cm, the left ovary measures 1.9x2x1.6cm. There is no free fluid in the cul de sac
IMPRESSION: thickened endometrium, r/o endometrial pathology, normal ovaries
Results
Endometrial Biopsy and Endocervical Curettage was doneFinal Histopathologic Diagnosis:
○ Endometrial polyp○ Secretory phase endometrium○ Chronic endocervicitis
Guide Questions
What is abnormal uterine bleeding (AUB)? How is this different from dysfunctional uterine bleeding?
Differentiate menorrhagia, metrorrhagia, polymenorrhea, and menometrorrhagia.
How is this diagnosed? What are the possible causes of AUB? What other diagnostics may be ordered for the
patient?
Guide Questions
What are the possible methods of medical management for AUB?
What are the possible methods of surgical management of AUB?
What is an endometrial polyp? What is endocervicitis? How should this patient be managed?