1. Bison, Francis Romeo P. San Beda College Case Presentation

2. General Data  MD  40y.o  Married  Admitted last April 25 2010

3. Chief Complaint  Hypogastric Pain

4. History of Present Illness  10 monts PTA  Hypogastric Pain described as shearing 9/10 pain  Associated with intermenstrual bleeding  Uses 2 diaper and 1 napkin for the whole day  Hot compress  temporarily relieved her symptoms  No consult was done

5.  8 mos PTA  Persistent intermenstrual bloody discharge and hypogastric pain  Consulted QMMC Gyne  Fractional Curettage was done due to thick endometrial lining  Biopsy showed proliferative endometrium  Advised to come back for a week

6.  1 week PTA  Intermittent hypogastric pain with generalized body weakness  Consulted at Amang Rodriguez  Ultrasound and other labs was done  Diagnosed “myoma uteri”, and was advised for surgery  Patient then opted to transfer to another hospital for second opinion, hence consult at QMMC OB-ER.

7. Review of Systems:  Unremarkable

8. Past Medical History  Unremarkable  Occasional cough and colds  Fractional curettage was done at qmmc(2009)  No known food and drug allergy

9. Personal and Social  Housewife  Nonsmoker  Non-alcoholic  Denies drug abuse

10. Family History  Maternal  Hypertension  Paternal  Pott’s disease

11. Ob-Gyne History G3P3(3003) YearNSD/CSPre/Full term HospitalComplicati on G11999NSDFullKamuning G22001NSDFullKamuningSepsis G32004NSDFullSorsogonPlacental Remission (ICU)

12. Menstrual History  M-14 y.o  I- Regular  D- 5-7 days  A- 3 pads per day  S- Dysmnorrhea (7/10)

13. Sexual History  Coitarche at age 21  Had 2 Sexual partner  Last coitus was last month

14. Physical Examination  General appearance: awake, conscious, coherent, ambulatory, not in cardiorespiratory distress Vital Signs  BP=100/60  HR=81/min  RR=20/min  Temp: 36.5 o C

15. (+)Pallor, Anicteric sclerae, Pale palpebral conjunctiva, No cervical lymphadenopathies Heent

16.  Cardiovascular: Adynamic precordium, NRRR, no murmurs  Lungs: Symmetrical chest expansion, no retractions vesicular breath sounds over both lung fields Thorax

17. Abdomen  Globular  Soft  Doughy mass measuring 16 x 18 cm  Movable  Non-tender

18. Extremities  Pale nail bed  No edema

19. SPECULUM EXAM IE Cervix pink Smooth No erosions No discharge Cervix: short Firm Closed Uterus: Asymmetrically enlarged to 20 weeks size Non-tender on deep palpation Movable Doughy 

20. Admitting Diagnosis G3P3 (3003) Abnormal Uterine Bleeding Probably Secondary to Myoma Uteri, Anemia Secondary

21. Course in the Wards April 25April 26April 28April 29May 02 Hgb 40537489110 Hct 0.17 0.22 0.270.310. 38 WBC5.6 10. 8 *Transfused with 4 units of pRBC properly typed and crossmatched

22. Medications  Tranexamic acid  Ferrous sulfate  Vitamin C tablet

23.  Referred to CardioPulmonary service for clearance prior to the procedure.  On the 10 th hospital day, patient was scheduled for hysterectomy.

24. Definition Uterine leiomyoma are benign monoclonal neoplasm arising from smooth muscle cells in the myometri

25. Classified by location:  Submucosal – lie just beneath the endometrium.  Intramural – lie within the uterine wall.  Subserosal – lie at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.

26. Prevalence Age  20% to50% of reproductive age  Incidence increases with advancing age  Rare before puberty  25-35y/o: 0.31 per 1000  45-50y/o: 6.20 per 1000

27. Risk Factor AGE AFRICAN- AMERICAN RACE EXPOSURE TO ESTROGEN FHX DIET Advancing age African american women develop earlier and more symptomatic Early menarche,Obesity NulliparityOcp’s 1 st degree relatives with 2.5x more likely develop fibroids Red meat, Alcohol,Smoking

28. Etiology-Unknown Estrogen Progesterone  Most common during reproductive years, rare before puberty, decrease size after menopaus  Increases the mitotic activity of fibroids in women

29. Complication Menorrhagia Anemia Infertility

30. Diagnostic Approach  Pregnancy test should be obtained in all women  Suggested by symptoms and physical examination  Usually confirm by transabdominal or transvaginal ultrasound

31. Treatment Approach  Tx of Symptomatic fibroids depends on:  Desire for future pregnancy  General health  Size and location

32. Medical  Goal: relieve or reduce symptoms  No definitive medical treatment exist  GnRh agonist- induces hypogonadism through pituitary desensitization, down regulation of receptors and inhibition of gonadotropins

33. Surgery  Hysterectomy- most common and the only definitive treatment  Myomectomy- preserves fertility, risk for reccurence

34. Current Status of Pt.  At 10:35 pm of May 6, BP: O, RR:O, HR:O. ECG showed asystole. Patient pronounced dead at 10:35 pm by IM ROD. Post-mortem care rendered. CBC  Hgb: 134Hct: 0. 46WBC: 30. 2 PT, PTT:  PT: 21. 1PT % Activity: 32. 8aPTT: 47. 7 Blood Chemistry and Serum Electrolytes  CK- MB: 165(inc)Potassium: 4  Crea: 102. 83Chloride: 105  Sodium: 134 (dec)  Troponin I; positive Cause of death:  Sudden cardiac death secondary to acute myocardial infarction; hypoxic encephalopathy, s/p arrest; s/p subtotal hysterectomy/CLEB+GETA

35. Thank You