A 38-year-old woman presented with heavy menstrual bleeding for 8-9 days with clots over the past 5 months and lower abdominal pain during menstruation. On examination, a 20-week uterus-sized mass was palpated in her abdomen that was mobile from side to side. She was provisionally diagnosed with abdominal uterine bleeding likely due to a leiomyoma (fibroid tumor of the uterus).

1. RAJESHWARI M.G
Final Year Student
M.V.J. MC&RH
CASE PRESENTATION

2. Name: Mrs. XYZ
Age: 38 years
Address: Hoskote
Occupation: Home maker
Educational status: 10th std
Husband name: Mr. M Age: 45years OCCUPATION:
Shopkeeper
Socio-economic status: Class IV(according to modified BG
Prasad classification)
LMP: 6th July 2020
Obstetric score: P2L2
Date of admission: 14th July 2020
Date of examination: 16th July 2020

3. CHIEF COMPLAINTS
• C/O heavy bleeding per vagina during
menstruation since 5 months
• C/O Lower abdominal pain during
menstruation since 5 months

4. HISTORY OF PRESENTING ILLNESS
• The patient was apparently normal 5
months back came with complains of
prolonged heavy bleeding during
menstruation which lasts for 8-9 days in
30 day regular cycle . She uses 7-8
pads/day. She also complains of passage
of clots .

5. • She also complains of pain in the lower
abdomen since 5 months. The pain starts 1 day
before menstruation which gradually increases
during the cycle and subsides after
menstruation .the pain is of dull aching type
and non radiating .

6. No h/o intermenstrual bleeding , pain during
intercourse .
No h/o of discharge PV , fever
No h/o of difficulty in micturition, urine retention
No h/o of difficulty in passing stools
No h/o of OCPs use
No h/o of varicose veins, edema
No h/o of dyspepsia
No h/o of loss of appetite or unintentional weight
loss

7. •Menstrual History
Menarche: 13 years
Past cycle : 30 days cycle 4-5 days of flow
2-3 pads/day no h/o of dysmenorrhea
or passage of clots
Present cycle : 30 days cycle 8-9 days of flow
7-8 pads /day h/o of dysmenorrhea
and passage of clots

8. Obstetrics history
Last menstrual period: 6th July 2020
Years of marriage: 17 years
P1 - full term vaginal delivery Male - 15 years
P2 - full term vaginal delivery female -10years
Contraceptive history
No h/o of contraceptive use

9. •Past history:
Not a known case of diabetes mellitus, hypertension,
epilepsy, asthma,TB, Thyroid disorders
No h/o of hospitalisation or surgeries in the past
No h/o of blood transfusion in the past
Family History:
No h/o of similar complaints in any of family members
No h/o of any bleeding disorders

10. Personal history
Diet - mixed , adequate in protein and calories
Appetite – normal
Sleep – undisturbed
Bowel and bladder –normal
No h/o of any ill habits
SUMMARY:
An 38 year old Lady of obstetric score P2L2 with no co
morbidities and no significant past history came with chief
complaints of prolonged heavy menstrual bleeding with
passage of clots since 5 months and pain during menstruation
since 5 months.

11. GENERAL PHYSICAL EXAMINATION
A middle aged female who is moderately built and well
nourished .She is conscious , cooperative and well
oriented to time , place and person.
Weight: 62kg
Height: 152cm
BMI: 26.46kg /m2
Mild pallor present
Clinically euthyroid
Bilateral breast : Normal
Spine: Normal

12. Vitals
Patient is afebrile
Pulse – 82 /min regular rhythm, good volume , normal
character, vessel wall is not palpable and all peripheral
pulses are felt.
BP – 126/84 mm hg right arm, sitting position.
Respiration – 16 cycles/min
No icterus , cyanosis,
clubbing,lymphadenopathy,edema

13. PER ABDOMEN EXAMINATION
INSPECTION:
Shape of abdomen: globular
Umbilicus: central and inverted
Corresponding quadrants move equally with respiration
No scars , sinuses ,dilated veins or visible pulsations
seen over the abdomen
Hernial orifices are intact

14. PALPATION:
No local rise in temperature
Non tender
A firm ,smooth mass , mobile from side to side of 20
weeks of gravid uterus size is felt in the midline.
The upper edge and the two lateral borders are
smooth and the lower border is not palpable.

15. PERCUSSION:
Dull note is heard over the mass
AUSCULTATION:
Normal bowel sounds are heard
No audible bruit
P/V EXAMINATION
Not done

16. SYSTEMIC EXAMINATION:
Cardiovascular Examination:
S1, S2 sounds heard, no murmur
Respiratory Examination:
Normal vesicular breath sounds, B/L equal air entry
Central Nervous System:
No focal neurological deficit.

17. PROVISIONAL DIAGNOSIS:
A 38 year old lady presents with prolonged heavy
menstrual bleeding and dysmenorrhea since 5
months.
On examination a firm,non tendermss of 20 weeks
gravid uterus size in the midline ,mobile from side to
side can be palpated , probably a case of
ABDOMINAL UTERINE BLEEDING –
LEIOMYOMA (AUB-L)