CASE PRESENTATION College of Medicine, Inha Univ.

Dept of Obstetrics and Gynecology Presented by Lee Joo-Won (973975)

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

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

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.

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

HISTORY OF PRESENT ILLNESS One week later she was admitted with persistent bleeding.

Hysteroscopic polypectomy was done on April 14 th 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 Non-contributable SOCIAL HISTORY alcohol (-) smoking (-)

OB AND GY HISTORY • Parity : 2 - 0 - 0 – 2 • Menses : regular cycle - 30days duration - 7days • LMP : June 4 th 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 SYSTEM Cardiovascular cyanosis(-) palpitation(-) GenitoUrinary dysuria(-) polyuria(-) oliguria(-) urgency(-) frequency(-) Menorrhagia(+) Dysmenorrhea(+) – started from March – started from March Back and Extremities limitation of movement(-) back pain(-)

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

o C General Appearance not so ill looking appearance Mental Status alert consciousness HEENT slightly anemic conjunctiva anicteric sclera

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 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.

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 BUN/Cr 13.3/0.61 uric acid T.protein

7.2 albumin ALP 3.0 cholesterol 4.2 T.bilirubin

45 AST/ALT 20/22 globulin 133 (high) 154 0.2

3.0

• urinalysis color pH ketone bilirubin straw turbidity 5.0 protein (-) blood (-) nitrite clear S.G

1.025 (-) glucose (-) (+++) urobilinogen normal (-) 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 • TVS uterus : 6.7*11.2cm ET(T) =5.3mm

myoma a) b) 2.3*2.7cm post.wall, intramural 1.7*1.7cm ant. cx. Portion, intramural c) d) 1.3*1.1cm ant. wall, intramural 3.3*2.6cm post. Fundus, intramural adnexa : both N/S CDS 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 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

DIFFERENTIAL DIAGNOSIS 4. R/O malignancy P atient 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 19 th (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 – 36.8

o C 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

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 – 37.5

o C 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

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

THANK YOU