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CLINICAL CASES (GYNAECOLOGY)

CASE 1 – DYSFUNCTIONAL UTERINE BLEEDING

CASE 2 – FIBROID UTERUS

CASE 3 – UTERINE PROLAPSE

1. CASE OF DYSFUNCTIONAL UTERINE BLEEDING

Name – Sameedha                                                                          Husband’s Name – Javed Sharieff
Age – 33 years                                                                                Age – 35 years
Address – Magadi Road                                                                   Occupation – Factory worker
Occupation –Worker in beedi factory                                                 Income – Rs. 425/month/person
Religion – Muslim                                                                            SE Status – Upper Lower class
Date of admission – 14/06/07                                                            Date of examination – 26/06/07

PRESENTING COMPLAINT – Prolonged & excessive bleeding per vagina during menses since 6 months

HISTORY OF PRESENTING COMPLAINTS:

  • Patient was apparently normal 6 months back when she developed prolonged and excessive bleeding lasting about 15 days.  The bleeding was excessive compared to her previous cycles, previously used to change 1-2 pads/day but this time 4-5pads/day.  Patient noticed passage of clots for the 1st 8 days.
  • No history of pain during bleeding.                                         (anovulatory cycles, endometriosis)
  • No history of missed periods prior to this episode.                       (metropathia hemorrhagia)
  • No history of white discharge PV, pain, fever or pain during coitus.             (PID)
  • Patient does not complain of any mass per abdomen.                               (Fibroid Uterus)
  • No history suggestive of TB.
  • No history of use of IUCD or OCP.
  • No history suggestive of any bleeding disorders.
  • Patient underwent laproscopic tubectomy 8 years back.                   (post ligation syndrome)
  • No history of fatigue, breathlessness or giddiness.                            (anemia)
  • No history of intake of any drugs other than eltoxin.                          (secondary to drugs)

MENSTRUAL HISTORY:

Age of Menarche – 11 years
Past Cycles – Regular 30 days cycles with 5 days flow, no pain or passage of clots.
LMP – 24/05/06

OBSTETRIC HISTORY:

Married Life – 15 years
Obstetric index – P4L4

  • 1st child – 14 years male FTND, booked & immunized
  • 2nd child – 13 years male FTND, booked & immunized
  • 3rd child – 11 years female FTND, booked & immunized
  • 4th child – 10 years male FTND, booked & immunized

Underwent laparoscopic tubectomy 8 years back.
No history of abortions
Last delivery 8 years back.

FAMILY HISTORY:

No history of bleeding disorders among other family members.
No history of exposure to TB.
No history of cervical Ca among mother or sister.

PAST HISTORTY:

No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
Patient underwent thyroidectomy 6 years back for complaint of enlarged thyroid.

No treatment taken for excess bleeding per vagina

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Patient is about 33 years old lady, moderately built and nourished, conscious, alert & cooperative, sitting comfortably on bed.

Pulse                – 90/min, regular, good volume
BP                    – 130/100 mm of Hg
RR                    – 16/min, regular
Temperature       – Afebrile

Pallor                           – Present
Icterus                          – Absent
Cyanosis                       – Absent
Clubbing                       – Absent
Edema                          – Absent
Lymphadenopathy          – Absent

Thyroid              – Scar over thyroid region present, no palpable gland
Breasts             – Normal
Spine                – Normal

SYSTEMIC EXAMINATION:

CVS – S1 S2 heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.

PER ABDOMINAL EXAMINATION

INSPECTION:

  • Shape of abdomen – normal
  • Umbilicus appears normal
  • Corresponding quadrants move equally with respiration.
  • No visible mass, dilated veins, scars or sinuses.
  • Stretch marks present.
  • No visible pulsations or peristalsis.
  • Hernia orifices – normal

PALPATION:

  • No local rise of temperature, no tenderness.
  • No organomegally.
  • No palpable mass P/A.

PERCUSSION:

  • Tympanic note elsewhere.
  • No evidence of free fluid in the abdomen.

AUSCULTATION:

  • Bowel sounds – heard.

[I would like to do per speculum, per vaginal and bimanual examination to confirm my diagnosis)

PROVISIONAL DIAGNOSIS:

33 yrs old P4L4 (in the reproductive age group) with DUB

**********************************************

2. CASE OF FIBROID UTERUS

Name – Mangala                                                                    Husband’s Name – Chandru
Age – 30 years                                                                      Age – 34 years
Address – Dasarahalli                                                            Occupation – Clerk in private factory
Occupation – House wife                                                        Income – Rs. 2000/month/person
Religion – Hindu                                                                     SE Status – Lower middle class
Date of admission – 20/07/07                                                  Date of examination – 23/07/07

PRESENTING COMPLAINS – Excessive bleeding per vagina during menses   – 4 months
Mass per abdomen                                         – 1 month

HISTORY OF PRESENTING COMPLAINTS:

  • Patient was apparently normal 4 months back when she developed increased bleeding during menstruation lasting for 12-15 days during 30 day cycle, she changes 5-6 pads/day as against 1-2 pads/day earlier.  Flow is associated with passage of clots.
  • Patient also complains of associated pain in the lower abdomen, starts with the onset of menstruation and increased on subsequent days.  The pain is dull aching and in nature, present continuously and often associated with cramps.  No radiation, relieved on taking medication.
  • Patient noticed a mass in her lower abdomen in the mid-region, insidious in onset, non-progressive, not associated with pain.  No history of change in size of the mass.
  • No history of white discharge per vagina with fever.
  • No history of fatigue, weakness, breathlessness, palpitation or pedal edema.
  • No history of increased frequency of micturation, incontinence or constipation.
  • No history of dysparenuia.
  • No history of breast discomfort.
  • No history of evening rise of temperature, cough with expectoration or hemoptysis.
  • No history suggestive of thyroid dysfunction or use of anti-thyroid drugs.
  • No history of any bleeding disorders.
  • No history of IUCD implantation.
  • No history of mass protruding out of vagina.

MENSTRUAL HISTORY:

Age of Menarche – 14 years
Past Cycles – Regular 30 days cycles with 4 days flow.
Present Cycles – 12-15 days flow for every 30 days cycle, 5-6pads/day associated with pain and passage of clots.
LMP – 05/07/07

OBSTETRIC HISTORY:

Married Life – 15 years
Obstetriec index – P2L2

  • G1 – Full term home delivery, male baby cried immediately after birth, 3kg at birth, booked & immunized, breast fed for 6 months, now 14 years old.
  • G2 – Full term home delivery, female baby cried soon after birth, 2.8 kg, booked & immunized, breast fed for 8 months, now 12 years old.

No history of use of any contraceptives.

FAMILY HISTORY: Nothing significant.

PAST HISTORTY:

No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Patient is middle aged lady, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 80/min, regular, good volume
BP                    – 110/70 mm of Hg
RR                    – 18/min, regular
Temperature    – Afebrile

Pallor                           – Absent
Icterus                         – Absent
Cyanosis                     – Absent
Clubbing                       – Absent
Edema                         – Absent
Lymphadenopathy         – Absent

Thyroid                          – Normal
Breasts                         – Normal
Spine                            – Normal

Height                          – 155 cm
Weight                         – 55 kg

SYSTEMIC EXAMINATION:

CVS – S1 S2 heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.

PER ABDOMINAL EXAMINATION

INSPECTION:

  • Shape of abdomen – normal
  • Umbilicus appears normal
  • Corresponding quadrants move equally with respiration.
  • No dilated veins, scars or sinuses.
  • Striae albicans – present.
  • No visible pulsations or peristalsis.
  • Hernia orifices – normal

PALPATION:

  • No tenderness over the
  • Single globular mass felt in the hypgastric region, corresponding to 16 wks sized gravid uterus, 4×6 cm extending 4 cm above the pubic symphysis.
  • Lower border not made out, superior and lateral borders are well defined – appears to be arising from the pelvis.
  • Surface is smooth, firm in consistency.
  • Mobile horizontally but vertical mobility is restricted.
  • On asking her to raise the legs, the mass becomes less prominent (intra-abdominal)
  • No organomegally.

PERCUSSION:

  • Dull note over the mass.
  • Tympanic note elsewhere.
  • No evidence of free fluid in the abdomen.

AUSCULTATION:

  • Bowel sounds – heard.

[I would like to do per speculum, bimanual examination to confirm any diagnosis)

DIAGNOSIS:

Fibroid uterus (corresponding to 16 weeks gravid uterus)

DIFFERENTIAL DIAGNOSIS – Ovarian tumour or dermoid.

**********************************************

3. CASE OF UTERINE PROLAPSE

Name – Shivamma                                                                        Husband’s Name – Rajanna
Age – 65 years                                                                             Age – 70 years
Address – Aravahalli                                                                      Occupation – Coolie
Occupation – Coolie                                                                      Income – Rs. 1000/person/mth
Marital status – Married                                                                  SE Status – Upper Lower class

PRESENTING COMPLAINT – Mass per vagina since 6 months.

HISTORY OF PRESENTING COMPLAINT:

  • Patient was apparently normal 6 months back when she initially noticed a mass protruding from the vagina while voiding urine, insidious in onset, initially the size of a lemon which has gradually progressed to attain the present size.  The mass used to come out on straining and coughing and reduces on lying down.
  • Patient gives history of lifting heavy weights.
  • No history of backache.
  • No history of any discharge (white discharge, foul smelling, blood stained) per vagina or bleeding per vagina.
  • No history of increased frequency, retention or difficulty in passing urine.
  • No history of burning micturation or itching over the genital region.
  • No history of ulceration over the mass or bleeding.
  • No history of chronic constipation or cough.
  • No history of abdominal distention or mass per abdomen.

MENSTRUAL HISTORY:

Age of Menarche – 15 years
Past Cycles – Regular, 30 days cycle, flow lasting 4-5 days, normal amount

No history of pain during menses or passing clots or inter-menstrual bleeding.
Attained menopause 14 years back.

OBSTETRIC HISTORY:

Married Life – 35 years
Obstetric index – P2L2

  • 1st child – Male, FTD, booked and immunized, home delivery, conducted by an untrained dai.
  • 2nd child – Female, FTND, booked and immunized, hospital delivery.
  • Patient conceived 5 years after marriage and the 2nd child was 2 years after the 1st pregnancy.
  • No history of prolonged delivery, difficulty in removing placenta or big baby.
  • Underwent tubectomy (BAT) after the 2nd child, no history of contraceptive usage prior to it.
  • Last delivery 28 years back.

PAST HISTORTY:

No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.

FAMILY HISTORY:

No history of similar complaints among mother or sister.       (especially in cases of nulliparous prolapsed)

PERSONAL HISTORY:

Diet – Mixed
Appetite – Good
Sleep – Sound
Bowel & Bladder – Regular
Habits – Nil

GENERAL PHYSICAL EXAMINATION:

Patient is an elderly lady, moderately built and nourished, conscious, alert & cooperative.

Pulse                – 72/min, regular, good volume
BP                    – 110/70 mm of Hg
RR                    – 18/min, regular
Temperature       – Afebrile

Pallor                           – Present
Icterus                          – Absent
Cyanosis                      – Absent
Clubbing                       – Absent
Edema                         – Absent
Lymphadenopathy         – Absent

Thyroid                         – Normal
Breasts                        – Normal
Spine                           – Normal
Gait                             – Normal

Height              – 155 cm
Weight             – 55 kg
BMI                  – 23

SYSTEMIC EXAMINATION:

CVS – S1 S2 heard, No murmurs.
RS – NVBS heard, no basal crepts.
CNS – NAD.
PER ABDOMEN EXAMINATION
INSPECTION

  • Shape of abdomen – normal.
  • Umbilicus – normal.
  • Corresponding quadrants move equally with respiration.
  • No scars or sinuses.
  • Hernia orifices – normal.

PALPATION

  • No mass felt per abdomen, no organomegally.

PERCUSSION

  • No signs of free fluid in the abdomen.

AUSCULTATION

  • Bowel sounds heard.

[I would like to do a PS/bimanual examination to complete the examination]

DIFFERENTIAL DIAGNOSIS:

  1. Genital prolapse.                                                                     (in this case the only diagnosis)
  2. Cervical polyp/Fibroid polyp.                                                                            (ruled out)
  3. Bartholin’s cyst or any other cyst.                                                                    (ruled out)
  4. Inversion of uterus.                                                                                          (ruled out)
  5. Congenital elongation of cervix.                                                                        (ruled out)
 

3 responses to “CLINICAL CASES (GYNAECOLOGY)

  1. abiel

    April 30, 2012 at 10:53 pm

    good

     
  2. geoffrey mokora

    November 21, 2012 at 11:23 pm

    am grateful for ur guideline

     
  3. ramya

    January 10, 2013 at 12:23 am

    thanks a lot sir…..

     

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