1. CASE PRESENTATION
6

2. CASE
Case 48

 10
2555
 30

90%

3. CHIEF COMPLAINT
 5
PTA

4. PRESSENT ILLNESS
5 PTA
3 5
8 6-7
2 PTA
DMPA

5. PRESSENT ILLNESS




6. PAST HISTORY
U/D Thyroid
6 PTA
P3003 last 20


LMP 4-8 55 (5 days/28-30 days/
3pads per day)
PMP

7. FAMILY HISTORY





8. PERSONAL HISTORY




9. PHYSICAL EXAMINATION
Vital signs
 BP 110/50 mmHg PR 72 /min
 RR 18 /min BT 37 c
GA
 Good consciousness, mild pale, no jaundice, no
cyanosis, no edema
HEENT
 Mile pale conjunctivae, no icteric sclerae
Cardiovascular
 Pulse full and regular, normal S1S2, no murmur

10. PHYSICAL EXAMINATION
Lung
 Equal chest expansion, clear, no adventitous sound
Abdomen
 No distention, Normoactive bowel sound, soft,,
palpable midline pelvic mass size 2/3> PS, globular
shape, irregular surface, rubbery, not tender, movable
no rebound tenderness
Neurological
 Grossly intact
Extremities
 No edema, no fracture

11. PHYSICAL EXAMINATION
Per vagina examination :
 MIUB - Normal
 Vg - No discharge, no lesion
 Cx - No mass and polyps, closed
 Ut - 16 wk. size with globular mass at fundus
 Adn - No palpable mass, no tenderness
 CDS - No bulging

12. PERTINENT FINDING
An middle aged Thai woman 48 years
Perimenopausal period
Abnormal uterine bleeding
Abdominal mass
Anemic symptoms
Underlying Thyroid disease (Clinical Euthyroid)
s/p Surgery 6 years PTA

13. PROBLEM LIST
 Abdominal mass with Abnormal uterine
bleeding and anemic symptoms
 Underlying Thyroid disease Clinical
euthyroid s/p Surgery 6 years PTA

14. APPROACH AUB

15. APPROACH AUB

16. Causes of menorrhagia

17. DIFFERENTIAL DIAGNOSIS
Uterus mass (leiomyoma vs leiomyosarcoma)
Adenomyosis
Ovarian tumor
Endometrium disease
Cervical cancer
Systemic conditions
 Hypothyroid
 Coagulopathies

18. INVESTIGATION
CBC
 Hb 10.0 g/dl WBC 6,500 /ul
 HCT 29.0 % PMN 58.0 %
 MCV 55.0 fl Lymp 39.0 %
 MCH 19. pg Mono 1.0 %
 MCHC 35.1 g/dl Eo 2.0 %
 Plt 208,000 /ul Baso 0 %

19. INVESTIGATION
PBS
 RBC Morphology Abnormal RBC
 Microcytic 1+
 Hypochromic 1+
 Target cell, schitocyte Few
Thyroid function test
 FT3 2.245 (1.21-4.18) mmol/l
 FT4 14.25 (7.2-17.2) mmol/l

20. INVESTIGATION
 UA
 Color/Appearance Y/C
 pH 7
 Ketone Neg
 Protein Neg
 Nitrite Neg
 Glucose Norm
 WBC 0-1
 RBC 0-1
 Sq.epithelium 10-20
 Bacteria -

21. INVESTIGATION
 Coagulogram normal
 BS 86 mg/dl
 BUN 10 mg/dl
 Creatinine 0.7 mg/dl
 Anti-HIV negative
 CXR normal
 EKG normal sinus rhythm, rate 70/min

22. INVESTIGATION
PAP smear
 Negative for intraepithelial lesion or malignancy but
reactive cellular change associate with inflammation
Endometrium Biopsy
 Inactive endometrium

23. INVESTIGATION
Ultrasound
-

24. TREATMENT (11/12/2555)
 Total abdominal hysterectomy with bilateral
salpingooophorectomy
 Uterus 16 wk size with large intramural myoma at fundus 8x8 cm.
and intramural myoma 4x4 cm. at anterior of body of uterus
 Both normal
 Normal liver and spleen
 Normal omentum
 No immediate comlication
 Estimate blood loss 800 ml.

25. TREATMENT (11/12/2555)

26. PROGRESS NOTE (12/12/2555)
 S:
Hct 35 vol%
 O: V/S BP 100/40 mmHg RR 18 /min
PR 90/min BT 36.5 c
Abd soft, normoactive bowel sound, no
tenderness, no active bleeding
 A+P :
 Multiple myoma with hypermenorrhea S/P TAH c BSO day 1 :
clinical stable
 Step diet
 Off IV+Foley
 Pain control

27. PROGRESS NOTE (13/12/2555)
 S:
 O: v/s BP 100/50 mmHg RR 18 /min
PR 72/min BT 36.8 c
Abd soft, normoactive bowel sound, no
tenderness, no active bleeding
 A+P :
 Multiple myoma with hypermenorrhea S/P TAH c BSO
day 2 : clinical stable
 Observe bleeding
 Pain control
 Plan discharge