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CASE PRESENTATION

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.

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CASE PRESENTATION

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

  2. PATIENT • 최O순 (F/43) • married • housewife

  3. CHIEF COMPLAINT menorrhagia with dysmenorrhea (O: March 15th ,2003)

  4. HISTORY OF PRESENT ILLNESS The patient was in her usual state of good health until 3 months ago when she noted abnormally extended period and too much of menstruation followed by dysmenorrhea.

  5. HISTORY OF PRESENT ILLNESS She visited EMC of our hospital on April 6th complaining of above symptoms and received D/C/B yeilding the diagnosis of chronic endometritis and endometrial polyp.

  6. HISTORY OF PRESENT ILLNESS One week later she was admitted with persistent bleeding. Hysteroscopic polypectomy was done on April 14th and discharged.

  7. HISTORY OF PRESENT ILLNESS Nonetheless, symptoms persisted and admitted via OPD again for surgical treatment.

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

  9. FAMILY HISTORY Non-contributable SOCIAL HISTORY alcohol (-) smoking (-)

  10. 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

  11. REVIEW OF SYSTEM General general weakness(-) fatigue(-) febrile/chilling sensation (-/-) weight loss(-) HEENT dizziness(-) vertigo(-) hearing disturbance(-) tinnitus(-) eye. ear discharge(-) sore throat(-) rhinorrhea(-)

  12. 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

  13. REVIEW OF SYSTEM Cardiovascular cyanosis(-) palpitation(-) GenitoUrinary dysuria(-) polyuria(-) oliguria(-) urgency(-) frequency(-) Back and Extremities limitation of movement(-) back pain(-) Menorrhagia(+)– started from March Dysmenorrhea(+) – started from March

  14. PHYSICAL EXAMINATION Vitals BP 150/70mmHg-Pulse92beats/min-Resp 20/min-BT 36.2oC General Appearance not so ill looking appearance Mental Status alert consciousness HEENT anicteric sclera slightly anemic conjunctiva

  15. 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

  16. PHYSICAL EXAMINATION Back and Extremities no CVAT no PTPE

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

  18. ASSESSMENT 1. R/O anovulation 2. R/O uterine myoma 3. R/O uterine polyp 4. R/O malignancy 5. R/O thyroid dysfunction 6. R/O coagulation abnormalities Listed according to the incidence of the disease in perimenopausal women and fatality when missed.

  19. 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

  20. 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

  21. RESULTS OF WORK-UP • admission panel Ca 9.4 P 3.3 glucose 133 (high) BUN/Cr 13.3/0.61 uricacid 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 (-)

  22. RESULTS OF WORK-UP • PT 13.5(sec) 92(%) 1.06(INR) • aPTT 33.1(sec) • BT 3 (min) - 4/12

  23. RESULTS OF WORK-UP • VDRL(serum) non-reactive • anti-HBs (+) • HBsAg (-) • anti-HIV (-)

  24. RESULTS OF WORK-UP • TVS uterus : 6.7*11.2cm ET(T) =5.3mm myoma • 2.3*2.7cm post.wall, intramural • 1.7*1.7cm ant. cx. Portion, intramural • 1.3*1.1cm ant. wall, intramural • 3.3*2.6cm post. Fundus, intramural adnexa : both N/S CDS fluid (-)

  25. RESULTS OF WORK-UP myoma I myoma II

  26. RESULTS OF WORK-UP myoma III myoma IV

  27. RESULTS OF WORK-UP uterus

  28. DIFFERENTIAL DIAGNOSIS • anovulation ruled out. There should be no other organic diseases to make diagnosis of anovulation. 2. R/O uterine myoma most likely 3. R/O uterine polyp ruled out. We found no evidence of uterine polyp

  29. 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.

  30. ONGOING DIAGNOSIS • R/O uterine myoma • R/O malignancy

  31. TREATMENT PLAN • Total Laparoscopic Hysterectomy

  32. PROGRESSION NOTE • June 19th (HD#2) Total Laparoscopic Hysterectomy was done

  33. 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 – 142-3.4-1.1 A) post operative state P) 1. BR 2. Pain control

  34. PROGRESSION NOTE Pathology report Uterus, Total laparascopic hysterectomy Cervix : chronic cevicitis with squamous metaplasia Enometrium : proliferative phase Myometrium : leiomyomas, three, intramural

  35. 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 serosanguinous A) post operative state day 2 P) 1. foley catheter removal 2. pain control 3. soft diet 4. ward ambulation

  36. THANK YOU She was diagnosed well and treated appropriately and scheduled to discharge soon.

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