A 45 year old lady, a housewife Came with continuous bleeding since 20 days and Irregular cycles with heavy flow since 1yr.

1. By
Siwani Teki
GIMSR

2. A 45 year old lady named N. Durga Bhavani ,
a housewife from a lower middle class social
status, living in Natayapalem, Gajuwaka ,
Vizag
Admitted in GITAM hospital on 7th June 2018.
Chief complaints:
Came with continuous bleeding since 20 days
from the last menstrual cycle.
Irregular cycles with heavy flow since 1yr

3. History of present illness:
The present complaint started as
menorrhagia with irregular periods for the
last 1 year
she used get periods once in 3 -4 months
lasting for about 8-10 days with heavy
flow and clots and pain for first 3 days and
changing about 20-25 diapers per cycle.
Not associated with fever, pain abdomen

4. Gynaec history:
Age of menarche – 13years
Irregular cycles
Severe blood flow
8-10
80-90
Painful for first 3 days
No white discharge
LMP: 15-5-18
L LMP : 7-2-18
Marital life: 28 years

5. Obstetric history:
• Two children
• male and female child
• Both were Institutional Normal vaginal delivery
• No ante partum, partum or post partum complication
• Last child birth : 26 years
• Underwent tubectomy 15days after 2nd child birth
{Puerperal tubectomy}

6. Past history:
• Known diabetic since 2 years and on medication
• Known hypertensive since 2 years and on medication
• Known hypothyroid patient since 2 years and on
medication
• Known patient of coronary artery disease and
underwent angiography 2 years back
• No history of bronchial asthma , tuberculosis or
epilepsy or bleeding disorders.

7. Treatment history:
• Thyroxine sodium tablets 50microgram since 2
years
• Metformin + glimepride since 2 years
• Rosavastatin and Atenolol
• Aspirin 75micrograms since 2 years
• Underwent Angiography 2 years back in a
private hospital
Family history:
• No similar complaints in the other members of
the family
• Mother is a known diabetic and hypertensive
• Sister is a known diabetic

8. Personnel history:
• Mixed diet
• Normal appetite
• Normal sleep pattern
• Bowl and bladder habits are regular
• Not habituated to smoking
• Not addicted to alcohol
• Not addicted to any other high risk
behaviours

9. General examination:
• Height- 145cm
• Weight – 63kgs
• Moderately built and moderately
nourished
• Mild pallor
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• No pedal edema

10. Vitals:
• Pulse rate: 86 beats/min regular rhythm and
character
• Blood pressure: 120/90 mm of Hg in left upper
arm in sitting position
• Respiratory rate: 16 breaths / min
• CVS- S1 and S2 heard. No murmurs heard.
• Respiratory system- breath sounds are normal no
added sounds heard

11. Thyroid examination:
• No gross enlargement is observed
• No lymphadenopathy
Breast examination:
• shape size areola and nipple – normal on both
sides
• no engorged veins
• no breast tenderness
• no palpable lumps
• No axillary lymphadenopathy

12. Abdominal examination
Inspection
• Lower abdominal fullness seen
• Umbilicus is normal( shape and position)
• Striae gravidarum seen
• No definite visible mass seen
• no visible pulsations seen
• Hernial sites are normal
• Suprapubic transverse scar is seen (tubectomy
scar)

13. Palpation
• 14 week size firm mass occupying the
hypogastric region felt .
• Clear cut borders felt except lower border.
Mass is mobile from side to side
• No tenderness .
• Liver and spleen- not palpable
• no inguinal lymphadenopathy
Percussion:
lower abdomen Dull on percussion,
Auscultation:
No bruit heard
no other sounds heard

14. Bimanual examination:
Per vaginal examination:
Labia majora and minora appears to be
healthy
Per speculum examination:
Cervix and vagina healthy
Uterus bulky, Anteverted and mobile
Fornix free

15. Provisional diagnosis
• Abnormal uterine bleeding with
uterine fibroids
Or
• Adenomyosis

16. Investigations
• Routine blood examination
• Complete Blood Cell Count, Total Leucocyte Count,
Differential Leucocyte Count, Bleeding Time , Clotting
Time.
• Fasting Blood Sugar, Post Prandial Blood Sugar
• Screening for HIV, Hepatitis B &C , other systemic
infections
• MRI

17. • Urine routine
• Thyroid function test
• Kidney function tests
• Liver function tests
• PAP smear
• Ultrasound ( pelvis/ complete abdomen)
• Hysteroscopy ( a high risk case)
• Endometrial biopsy

18. THANK YOU….!!!