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?