CASE PRESENTATION

OBCC Martin Federic Palco

 Objectives
• Present the patient’s history, physical
examination, course in the wards
• Relate actual symptoms manifested with the
theoretical knowledge regarding myoma uteri
• Do a case discussion of the disease process,
diagnosis and case management
•DBC
•48 yo
•Female
•Married
•Roman Catholic
•Datagan, Calinog, Iloilo City
CHIEF COMPLAINT

•Hypogastric Discomfort
HISTORY OF PRESENT ILLNESS

•3 years prior to admission

-Intermittent sensation of hypogastric
discomfort, tolerable, aggravated by
performing strenuous activity, relieved by
topical application of liniment, not
associated with other symptoms
-No consult done
HISTORY OF PRESENT ILLNESS

•1 year prior to admission

-Gradual increase in the abdominal size
•3 months prior to admission
-Abrupt onset of intermittent hypogastric
pain rated as 8/10 in numeric pain scale,
aggravated by performing strenuous activity
-Profuse menses noted
-No consult done
HISTORY OF PRESENT ILLNESS

•6 weeks prior to admission

-Increase in the intensity of hypogastric
pain associated with profuse menses
-Underwent consult with a gynecologist,
and was adviced to undergo ultrasound
-Ultrasound revealed:
HISTORY OF PRESENT ILLNESS

•Ultrasound result
•4/30/2016 (Kua)
•Normal sized anteverted uterus with intact
endometrium (1.0 cm), multiple myoma uteri:
•Posterofundal with subserosal component 25.7x29.6x16.3
cm
•Left anterior IM with ss component 3.3 x 3.2 x 3.4 cm
•Normal left ovary
•Not visualized right ovary
HISTORY OF PRESENT ILLNESS

•6 weeks prior to admission

-the patient was thus advised to undergo
surgical procedure, consented, and was
scheduled for surgery
• On the day of admission
-patient came in for the proposed
surgery
PAST MEDICAL HISTORY
• (-) Hypertension
• (-) Diabetes Mellitus
• (-) Bronchial Asthma
• (-) Food and drugs allergy
• No previous admission
• No surgical operation
FAMILY HISTORY
• Elder sibling had myoma
OB/GYN HISTORY
• G0
• Menarche at 12 years old
• Regular Interval
• 5 days duration
• 2 moderately soaked pads/ day
• No dysmenorrhea and other associated
symptoms
PE
GENERAL SURVEY
Patient is conscious, oriented to time, place and
person; ambulatory, afebrile and not in
cardiopulmonary distress

Vital signs:
Temperature of 36.2 degrees Celsius
Pulse Rate of 90 beats per minute
Respiratory rate of 20 beats per minute
BP of 90/60 mmHg
PE
Skin:
no active skin lesion, no jaundice, good skin
turgor

EENT:
anicteric sclerae, pinkish conjunctivae, no
tonsilopharyngeal congestion, no neck vein
engorgement, no cervical lymphadenopathy
PE
Chest and Lungs:
Symmetrical chest expansion, Bronchovesicular
breath sounds, no wheeze, no crackles

Heart:
adynamic precordium, normal cardiac rate and
regular rhythm, no murmur
PE
Abdomen:

• Globular; symmetrical; no previous scars,

• Normoactive bowel sounds, No bruits, no
pulsations
• Palpable, non-tender, firm, movable mass
approximately 24x24cm in size, inseparable to
the uterus
SPECULUM EXAM
• Cervix pinkish in color, smooth with no
erosions
• (-) discharges
• Vaginal walls are smooth
IE/ BIMANUAL
• Introitus admits 2 fingers at ease
• Cervix is closed
• Uterus is small
• (+) Abdominopelvic mass – firm, movable,
nontender 24x24 cm
• (-) adnexal mass
• (-) blood on examining finger
IE/ BIMANUAL
• Introitus admits 2 fingers at ease
• Cervix is closed
• Uterus is small
• (+) Abdominopelvic mass – firm, movable,
nontender 24x24 cm
• (-) adnexal mass
• (-) blood on examining finger
ADMITTING IMPRESSION
• G0
• Myoma uteri
• Primary infertility for 14 yrs
COURSE IN THE WARD
On the first day of admission:
• For TAHBSO
• NPO at midnight
• Labs requested : CBC
• 2 unit of PRBC requested
• Clearance done with the Dep’t of Internal
Medicine
• Bowel prep done
• Meds:
• Cefoxitin 1 gram IVTT ANST 1 hour PTOR
COURSE IN THE WARD
On the first day of admission:
• Anesthesia medications given
COURSE IN THE WARD
On the second day of admission
• TAHBSO was performed
– Intraoperative findings:
• Cervix – 5x3x2 cm
• Right ovary – 3x1.5 cm
• Right fallopian tube – 7 cm
• Left ovary – 5x4x2 cm, thin-walled containing blood
• Left fallopian tube – 8 cm
• Endometrium – thin
• (+) Adenomyosis (+) Intramural-subserosal myoma
fundal area – 20x19x18 cm
• (+) Intramural myoma Left anterior wall – 5x4x3 cm
COURSE IN THE WARD
On the second day of admission
• Antibacterial and pain medications were
administered

• Meds: Cefoxitin 1 gram IVTT q8H x 2 doses

then shift to Cefuroxime 500 mg/tab 1 tab BID
• Tramadol 50 mg IVTT q8h x 2 days start 6am
tom
• Celecoxib 100 mg/cap 1 cap OD to start once
ketorolac is consumed
 COURSE IN THE WARD
On the second day of admission
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Fully awake and No swelling, Status quo -Transfer back to
verbalize redness and wards
minimal pain on discharges on -Monitor vital signs
incision site surgical site every 15 minutes for 2
hours then every 4
hours thereafter
-Give analgesics
Able to flex legs Normal and -Discontinue Oxygen
stable Blood and Pulse oxymeter
Pressure,
Cardiac Rate and
Oxygen
Saturation
Adequate, clear
 COURSE IN THE WARD
On the First Postoperative day
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Minimal pain No swelling, Status quo Start Na
on incision site, redness and Ascorbate and
no dizziness, discharges on MTV+Fe
nausea and surgical site Femurate
vomiting Deep breathing
exercises
(+) Flatus
Soft abdomen
Adequate UO
Normal and
stable BP
 COURSE IN THE WARD
On the Second Postoperative day
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Minimal pain No swelling, Status quo May have soft
on incision site, redness and diet
no dizziness, discharges on Retain folley
nausea and surgical site catheter
vomiting
(+) Flatus
Soft abdomen
Adequate UO
Normal and
stable vital
signs
 COURSE IN THE WARD
On the Third Postoperative day
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
Minimal pain No swelling, Status quo For discharge
on incision site, redness and
discharges on
surgical site
Normal and
stable vital
signs
Voided freely
COURSE IN THE WARD
On the Fourth Postoperative day

• Patient was discharged in improved condition

FINAL DIAGNOSIS
• G0
• Myoma Uteri
• Primary Infertility x 14 years
CASE DISCUSSION
• Myoma Uteri (Uterine Fibroids)
• Definition: benign growths that develop from
the muscle tissue of the uterus. Also called
“leiomyomas” or “myomas.”
• Prevalence: most common female
reproductive tract tumors; increases as
women grow older; may occur in more than
30 percent of women 40 to 60 years of age.
• Associated with menorrhagia, pelvic pain,
pelvic or urinary obstructive symptoms,
infertility, and pregnancy loss
CASE DISCUSSION
Factors That Affect the Risk of Uterine Fibroid Tumors
(American Academy of Family Physician)
Decreased risk
• More than five pregnancies – patient is nulligravida
• Postmenopausal status – patient is still menstruating
• Prolonged use of oral contraceptives – no history of contraceptive
use
• Smoking – non smoker

Increased risk
• 40 years or older – patient is 48 years old
• Black race
• Family history of uterine fibroid tumors – elder sibling died due to
untreated myoma
• Nulliparity
• Obesity
CASE DISCUSSION
Clinical Features
• Mostly asymptomatic
• Menorrhagia
• pelvic pain
• obstructive symptoms
• Infertility
• pregnancy loss.
CASE DISCUSSION
Diagnosis
• bimanual examination
• transvaginal ultrasonography,
• sonohysterography,
• hysteroscopy,
• magnetic resonance imaging (MRI),
CASE DISCUSSION
Management
• Dependent on patient’s age and proximity to
anticipated menopause, symptoms, patient
preference, experience and skills of the
clinician
• Nonsurgical management
– Periodic examination
– Use of GnRH agonist
– Use of GnRH agonist with estrogen add-back
therapy
– Target therapy to growth factors or its receptors
CASE DISCUSSION
Management
• Surgical management
– Indications for surgical management:
• AUB resulting to anemia, unresponsive to hormonal or
other conservative management
• Chronic pain, lower abdominal pressure or pain
• Acute pain
• Urinary symptoms – hydronephrosis
• Infertility with leiomyoma as the only abnormal finding
• Recurrent pregnancy loss
• Markedly enlarged uterine size with compression
symptoms or discomfort
CASE DISCUSSION
Management
• Uterine artery embolization
– Provide short-term relief of bulk-related and
bleeding symptoms of leiomyoma
• Thank you!