Myoma Uterine

Patients Profile: Case# 2982252

Name: Patient X Age: 44 yrs old Sex: Female
Address: Meycauayan, Bulacan Civil Status: Married Nationality : Filipino
Admission:
Date: August 26, 2014 Time: 5:00 PM
Admitting Physician: Michelle F. Espedido M.D

General Data:
Patient X 44 years old, Married, Filipino, Catholic, unemployed, presently residing at 351
Togatog Mecauayan, Bulacan. Admitted for the first time at VMC.
Chief Complain: Abdominal Mass
History of Present Illness:
3 years prior to admission: Abdominal Mass
3 years prior to admission: consult at OPD. TVS Done Myoma Uterine. Patient advice for
surgery.
Past Medical History:
No Goiter No Diabetes Mellitus No Hypertension No Asthma
Family History:
With Hypertension ( Sister & Brother) No Diabetes Mellitus
Personal and Social History:
Non Smoker Non Alcoholic


Obstetrical History:
Nulli Gravida
Mestrualys History:
Menarche: 10 years old
Interval: Regular
Days: 3-7 days, 3 pads per day

Physical Exam:
Vital Signs: BP: 120/70 mmHg CR: 88/min RR: 19/ min Temp: 36.5 C
Skin: No Rashes , No Dermatosis
HEENT: Pink Palpebral Conjuctiva
Chest: Symmetrical Chest Expansion, Clear Breath Sounds
Heart: No murmur
Lungs: Symmetrical Chest Expansion
Abdomen: Flabby soft, mass measuring 6x5 cm
Genitalia: Uterus enlarged to 16 weeks size
Rectum: No Adnexia mass , no tenderness, no vaginal bleeding
Extremities: Grossly Normal Extremities
Neurological: CN are intact
Admitting Diagnosis: Nulligravida, Myoma Uterine, Primary infertility for 17 years






Hematology
Test Name Result Reference Range/ Unit
WBC 4.2 LOW 5.0 10.0 x10^9L
Neutrophils 49.9 40 60 %
Lymphocytes 39.3 20 40 %
Monocytes 9.2 2 10 %
Eosinophils 1.5 1 6 %
Basophils 0.1 0.1 %
Red Blood Cells 4.01 LOW 4.5 5.5 x10^12/L
Hemoglobin 99 LOW 125 160 g/L
Hematocrit 0.298 LOW 0.380 -0.500 L/L
Platelet Count 340 150 450 x10^9L

Blood Type: AB Rh +

Glucose Test
Test Name Result Reference Range/ Unit
GLUCOSE 6.19 3.85 6.40 mmol/L

Test Name Result Reference Range/Unit
BLOOD UTERIE NITROGEN 2.43 LOW 2.50 - 6.5Ommol/L
CREATININE 67.6 61.9 - 121.1 mmol/L
ALT 21.9 0.0 34.0
AST/SGOT 34.3 0.0 - 40.0
SODIUM 139.60 135 - 148mmol/L
POTASSIUM 3.19 LOW 3.50 - 5.30mmol/L
CHLORIDE 103.80 98 - 107
LDH 188.9 O.O - 243






HEMATOLOGY
COAGULATION TEST REPORT
TEST RESULT NORMAL RANGE
PT (Prothrombin Time) 12.0 (11 - 4sec)
%Activiity 112.6
INR O.95
APTT (Activated Partial
Thromboplastin Time)
24.4
Ratio 0.81
(24 - 35sec)

RADIOGRAPIC REPORT
EXAMINATION:
CHEST X-RAY PA/ALV
BOTH LUNGS FIELDS ARE CLEAR
HEART IS NOT ENLARGED
DIAPHRAGM AND SINUSES ARE INTACT
IMPRESSION:
NORMAL CHEST

ULTRASOUND REPORT
I. Uterus 13.99 x 11.00 x 9.49 cm
Abnormalities noted: The uterus is enlarged, irregular in size and nodular due to
multiple myomas as follows:
1. Fundal Measuring 6.70 x 6.42 x 6.17 cm
2. IM anterior low segment measuring 6.51 x 5.19 x 5.01 cm)
3. IM anterior mid segment measures 6.95 x 6.6 x 5.03 cm
4. Posterior IM measures 6.12 x 5.96 x 7.4 cm
II. Endometrium: Thickened 0.76 cm Hyperechonic
III. Adnexae:
Right ovary: 2.91 x 2.47 x 1.2 cm Lateral
Left ovary; 2.11 x 1.88 x 1.36 Lateral
IV: Cervix: 2.44 x 2.35 x 1.84 cm Nabothian Cyst: None
V: Others: No Free fluid in the cul de sac
DIAGNOSIS:
ENLARGED AND NODULAR UTERUS DUE TO MYOMA
THICKENED ENDOMETRIUM
NORMAL BOTH OVARIES

















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