case presentation college of medicine, inha univ. dept of obstetrics and gynecology presented by lee...
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CASE PRESENTATION
College of Medicine, Inha Univ. Dept of Obstetrics and Gynecology Presented by Lee Joo-Won (973975)
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PATIENT
• 최 O 순 (F/43)• married• housewife
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CHIEF COMPLAINT
menorrhagia with dysmenorrhea(O: March 15th ,2003)
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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.
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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.
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HISTORY OF PRESENT ILLNESS
One week later she was admittedwith persistent bleeding.Hysteroscopic polypectomy was done on April 14th and discharged.
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HISTORY OF PRESENT ILLNESS
Nonetheless, symptoms persisted and admitted via OPD again for surgical treatment.
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PAST MEDICAL HISTORY
• Hypertension/DM/pulmonary Tb/Hepatitis (-/-/-/-)• OP History (+) hysteroscopic polypectomy 4/14• Medication – for anemia (Fe)
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FAMILY HISTORY
SOCIAL HISTORY
Non-contributable
alcohol (-) smoking (-)
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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
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REVIEW OF SYSTEM
General general weakness(-) fatigue(-) febrile/chilling sensation (-/-) weight loss(-)
HEENT dizziness(-) vertigo(-) hearing disturbance(-) tinnitus(-) eye. ear discharge(-) sore throat(-) rhinorrhea(-)
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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
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REVIEW OF SYSTEMCardiovascularcyanosis(-) palpitation(-)
GenitoUrinarydysuria(-) polyuria(-) oliguria(-) urgency(-) frequency(-)
Back and Extremitieslimitation of movement(-)back pain(-)
Menorrhagia(+) – started from MarchDysmenorrhea(+) – started from March
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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
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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
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PHYSICAL EXAMINATION
Back and Extremities no CVAT no PTPE
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OBGY EXAMINATION
• Uterus : woman’s fist size, nodular• Adnexa : both free• Cervix : ns, ne, mT(-)• V/D : whitish, mucoid
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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.
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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
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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
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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 (-)
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RESULTS OF WORK-UP
• PT 13.5(sec) 92(%) 1.06(INR)• aPTT 33.1(sec)• BT 3 (min) - 4/12
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RESULTS OF WORK-UP
• VDRL(serum) non-reactive • anti-HBs (+)• HBsAg (-)• anti-HIV (-)
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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 (-)
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RESULTS OF WORK-UP myoma I myoma II
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RESULTS OF WORK-UP myoma III myoma IV
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RESULTS OF WORK-UP
uterus
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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
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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.
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ONGOING DIAGNOSIS
• R/O uterine myoma• R/O malignancy
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TREATMENT PLAN
• Total Laparoscopic Hysterectomy
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PROGRESSION NOTE
• June 19th (HD#2)Total Laparoscopic Hysterectomy was done
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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
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PROGRESSION NOTE
Pathology report Uterus, Total laparascopic hysterectomy Cervix : chronic cevicitis with squamous metaplasia
Enometrium : proliferative phase Myometrium : leiomyomas, three, intramural
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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
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THANK YOU
She was diagnosed well and treated appropriately and
scheduled to discharge soon.