History TakingIdentification DataName – Registered no – Age – 52 years oldRace – MalaySex – Female Address – Pulau Chondong, MachangParity – 3 + 2Last Menstrual Period – 2nd of April 2013Date of Admission – 4th of April 2013Date of Clerking – 6th of April 2013Informer – Patient herself (reliable)

Chief complaintHeavy and painful menses associated with worsening shortness of breath and lethargy for 10 days prior to admission

History of Present IllnessMy patient was previously diagnosed to have uterine fibroids for more than 10 years at Hospital

Universiti Sains Malaysia when she first presented with complaint of sudden onset of localize suprapubic pain which was cramping in nature and associated with menses. During that time, she gave a pain score of 6/10 and she was unable to tolerate the pain, making her to seek treatment at the hospital. Ultrasound scan was done and she was told to be having multiple uterine fibroids. She was then discharge with analgesia (NSAIDs – Ponstan) and was given follow up 3 monthly at gynaecology clinic. She never missed her follow up but as there was no specific intervention done to the fibroids and she was told that the disease did not show any signs of progress, she defaulted the follow up about 2 years ago. She claimed that she experience severe suprapubic pain associated with menses almost every month but initially was relieved by analgesia, which she bought from the pharmacy. The menstrual pain lasted throughout the menses

For 10 days prior to admission, she developed heavy menses. Previously, she stated that her menstrual cycle lasted for 28 – 30 days with bleeding at day 1 to day 7. She usually experience peak flow on day 1 to day 3 and she had to use 5-6 pads per day. About 10 days prior to admission, she experience heavy menstrual bleed, from day 1 to day 6 of her menses. She had to use 10 – 12 pads per day and she claimed that it was fully soaked. The bleeding was fresh blood associated with blood clots. The bleeding was associated with localized suprapubic pain, which she claimed to be similar with previous episodes, which occurs throughout the menses but does not relieved by analgesia. Patient gave a pain score of 9 over 10 and she was unable to sleep due to pain

Subsequently, the patient experience gradual onset of shortness of breath. The shortness of breath was progressively worsening. Initially patient developed shortness of breath during doing her

daily chores but subsequently the shortness of breath occurs at rest. It was associated with lethargy, palpitation and light-headedness. Her daughter notice that the patient became pale and lethargy and brought her to Klinik Kesihatan Pulau Chondong before she was referred to HUSM.

She gave no history of mucousal bleed, unexplained bruising, per rectal bleed, malaena, haematuria, joint selling, fever, arthralgia and myalgia. There were no history of taking the anticoagulant or family history of bleeding disorder.

Past Gynaecololgy and Menstrual HistoryShe attained menarche at the age of 12 years old. Her menstrual cycle was 28 to 30 days with

bleeding at day 1 to day 7. The peak flow was on day 1 to day 3. The cycle was regular until this current admission where she experience heavy flow. She experienced dysmenorrhoea almost every month after being diagnosed to have uterine fibroids and had to take analgesic to relieve her symptoms.

There were no history of intermenstrual bleeding, post-coital bleed and dyspareunia

Past Obstetrics historyShe is married 35 years ago and was blessed with 3 children. All of her children was born at full

term vuia spontaneous vaginal delivery at HUSM with birthweight ranging from 2.8 – 3.0 kg. She claimed that her antepartum, intrapartum and postpartum was uncomplicated. She breastfed all of her children for 2 years

Patient had history of miscarriage 2 times. First miscarriage was 11 years ago at 17 weeks of period of amenorrhoea. She had another miscarriage at 9 weeks of period of amenorrhoea 6 years ago. Dilatation and curettage was done for both miscarriages.

Past Medical and Surgical HistoryPatient had underlying;

Gastritisa. Diagnosed at HUSM when she came for follow up for her uterine fibroids about 5 years

ago when she complaint of burning epigastric pain associated with vomitingb. She was told by the doctor that she developed gastritis due to the use of analgesic,

which was Ponstanc. She was prescribed with antacids and she claimed the symptoms was improved upon

taking the medicationsd. No history of haematemesis, passing out malaenic stools

There were no other chronic illness such as diabetes mellitus, hypertension, bronchial asthma or heart disease and she never underwent any surgical intervention before

Family History

Patient is the second child out of 5 siblings. Her father with underlying hypertension was passed away at the age of 75 years old due to heart disease while her mother had passed away at the age of 78 years old due to stroke. All of her siblings were alive. Her husband was diagnosed to have hypertension 2 years ago and currently on medications while her brother had been diagnosed to have diabetes mellitus and she claimed that the other siblings were well. There were no history of chronic disease running in the family and no family history of congenital abnormalities

Social history

Patient is a housewife. He lives with his youngest daughter and her husband, who is a businessman at grocery stores. Her eldest daughter and second daughter currently working and support her financially. She does not consume alcohol and not smoking

Drug history

Currently patient was on antacids and non-steroidal anti inflammatory drugs. She gave history of allergic to penicillin antibiotics, which she developed erythematous and itchy skin rashes upon ingesting the drugs

Diet history

Patient was on normal adult diet. There were no history of allergic to any foods

Systemic review General system

No loss of weight No loss o appetite

Respiratory system

No runny nose No sore throat No cough

Cardiovascular system

1. No chest pain2. No leg swelling

Genitourinary system

No dysuria No frothy urine No frequency

Central nervous system

No headache No altered consciousness No syncope

SummaryMy patient, a 52 years old Malay female with underlying uterine fibroids for more than 10 years currently was admitted with complained of dysmenorhoea and menorrhagia associated with symptomatic anaemia

PHYSICAL EXAMINATIONGeneral inspection

Patient was lying comfortably in supine position supported by 1 pillow. She was alert, conscious and well oriented to time place and person. She was not in pain but in respiratory distress evidence by using accessory muscle to breath and respiratory rate of 26 breaths per minute. She looks pallor. Her hydrational and nutritional status looks clinically adequate. There was no obvious deformity or abnormal movement noted. There was intravenous cannula attached to the dorsum of her left hand connected to intravenous normal saline.

Vital sign

Pulse rate : 110 beats per minute (normal volume, regular rhythm)Blood pressure : 110/70 mmHgTemperature : 36.9 °C

Gross parametersHeight – 158 cmWeight – 72 kgBody Mass Index – 28 kg/m2

General examination

Hands Palms were cold, dry and pale No wasting of thenar and hypothenar muscle No koilonychias No peripheral cyanosis Capillary refilling was good (< 2 sec)

Arms No bruising No scratch mark

Face Conjunctivae were pale No yellowish discoloration of the sclera Oral hygiene was good The tongue was moist and not coated No presence of central cyanosis

Neck Jugular venous pressure was not elevated. Cervical lymph nodes were not palpable

Leg No pitting edema Palpable dorsalis pedis and posterior tibialis on both side

Specific abdominal examination

Inspection Abdomen was flat and moves symmetrically with each respiration Umbilical was centrally located and inverted Overlying skin was normal No dilated vein No visible peristalsis

Palpation Abdomen was soft and non tender Uterus size was 16 weeks , asymmetry (more on right iliac fossa), firm, smooth surface, regular

margin, mobile in horizontal direction, globular in shape and non tender No hepatoslenomegaly Both kidneys were not ballotable

Percussion Resonance Traube’s space No shifting dullness

Auscultation Bowel sound present No renal bruit

Uterus size 16 weeks, mobile, smooth surface, regular margin and non tender

Specific examination of the respiratory system

Inspection Chest wall moved symmetrically during each respiration. There was no chest wall deformity, skin discolouration, surgical scar, dilated veins and visible

pulsation seen in this patient.

Palpation Trachea was centrally located and no tracheal tug present. Chest expansion was equal on both sides. Vocal fremitus was equal and of normal intensity on both sides

Percussion All zones were resonance on both sides

Auscultation Vesicular breath sound with normal intensity was heard over both lungs Vocal resonance was equal and of normal intensity on both sides

Specific examination of cardiovascular system

Inspection There was no chest wall deformity, precordial bulge, skin discolouration, surgical scar, dilated

veins or visible pulsation noted in this patient

Palpation Apex beat was palpable at left 5th intercostal space, 1 cm medial to mid-clavicular line There was no parasternal heave and no thrill palpable over mitral, tricuspid, pulmonary and

aortic area

Auscultation 1st and 2nd heart sounds present and there was no murmur heard over mitral, tricuspid,

pulmonary and aortic area

Problem List and Diagnosis

Problem Lists in this patient

Symptoms Age – 52 years old Underlying uterine fibroids – not progressively enlarge Secondary dysmenorrhoea – the pain lasted throughout the menses Menorrhagia Symptomatic anaemia 2 previous miscarriages

Signs Obesity – BMI 28 kg/m2

Signs of anaemia Uterus size of 16 weeks , asymmetry (more on right iliac fossa), firm, smooth surface, regular

margin, mobile in horizontal direction, globular in shape and non tender

Provisional Diagnosis

Provisional diagnosis Positive findings Negative findingsUterine fibroids with symptomatic anaemia

Symptoms Risk factor – age more than

30 years old Secondary dysmenorrhoea Menorrhagia Symptomatic anaemia Underlying uterine fibroids

which was not progressively enlarged

Signs Risk factor - Obesity – BMI 28

kg/m2

Signs of anaemia Uterus size of 16 weeks ,

firm, smooth surface, regular margin, mobile in horizontal direction, globular in shape and non tender

No compressive symptoms such as urinary frequency (not all uterine fibroids have this symptoms)

No other risk factors in this patient – nulliparous or positive family history

No problems with spontaneous conception (subfertility was associated with subfertility)

Differential Diagnosis

Provisional diagnosis Positive findings Negative findingsLeiomyosarcoma with symptomatic anaemia

Symptoms Secondary dysmenorrhoea Menorrhagia Symptomatic anaemia

Signs Signs of anaemia Uterus size of 16 weeks , firm,

smooth surface, regular margin, globular in shape and non tender

The uterus was mobile in horizontal direction

Underlying uterine fibroids which was not progressively enlarged for the past 10 years

No signs of malignancy such as loss of weight and loss of appetite

No metastatic signs and symptoms such as jaundice, enlarge lymph nodes

Endometriosis with symptomatic anaemia

Symptoms Risk factor – uterine

abnormality (uterine fibroids) and long duration of menstrual flow previously (> 7 days)

Secondary dysmenorrhoea Menorrhagia Symptomatic anaemia

Signs Signs of anaemia Mass per abdomen

No history of infertility or subfertility

No other risk factors such as family history, early menarche, short menstrual cycle

Endometrial carcinoma Symptoms Risk factor – age more than 35

years old Secondary dysmenorrhoea Menorrhagia Symptomatic anaemia

Signs Risk factor - Obesity – BMI 28

kg/m2

Signs of anaemia Mass per abdomen

No intermenstrual bleeding No signs of malignancy such

as loss of weight and loss of appetite

No metastatic signs and symptoms such as jaundice, enlarge lymph nodes

Adenomyosis Symptoms Risk factor – age more than 30

years old and previous history of dilatation and curretage

Secondary Dysmenorrhoea Menorhhagia

Signs Mass per abdomen

No intermenstrual bleeding No dyspareunia Non-tender uterus on

palpation Uterus size is 16 weeks (rarely

the adenomyosis will be presented with uterus size of more than 14 weeks)

Investigations

Aims of investigations

Several goals of performing investigations in this patient which includes;To establish the final diagnosisTo rule out the differential diagnosisTo detect any life-threatening complications which may occurs in this patientTo treat the underlying cause

Blood Investigations

1. Full blood count – to detect the haemoglobin levels as it serves as an indications for blood transfusion and the blood volume that is needed to be transfused. This investigations also would help in terms of categorizing the patient into the types of anaemia, which narrow down the diagnosis

Results Normal Range InterpretationHaemoglobin

6.0 g/dL11.5 – 15.5 g/dL Presence of anaemia which was talley with

the clinical findingsMean Cell Volume

58.7 fl80 – 100 fl Low MCV indicates microcytic red blood

cellMean corpuscular haemoglobin

17 pg27 – 31 pg Low MCH indicates hypochromic red

blood cellsMean Corpuscular Haemoglobin

Concentration27 g/dL

32 – 36 g/dL Low MCHC

White Cell Count8.4 x 109 /L

4 – 11 x 109 /L Normal white cell count

Platelet 237 x 109 /L

150 – 400 x 109 /L Platelet is normal. There is no platelet dysfunction

This patient has hypochromic microcytic anaemia with normal white cell count and platelet, talley with the clinical findings

2. Group Screen Holed and Group Cross Match – to anticipate the need of blood transfusion in this patient

3. Full blood picture – to detect any abnormalities by means of visualization of the red blood cells which may have abnormal morphology

Results

i. Presence of pencil shaped/ cigar-shaped poikilocytesii. Widening of central pallor of the red blood cell of more than 2 3rd of its size

iii. Presence of numerous microcytes Impression – Iron deficiency anaemia

4. Blood Urea Serum Electrolytes (BUSE) / creatinine – to detect any complications which may arise from the anaemia as well as preoperative assessment

Results Normal Range InterpretationSodium

140 mmol/L135 – 145 mmol/L As a baseline investigation to assess

electrolyte and renal function of the patient. These parameters are normal in this patient

Potassium 4.5 mmol/L

3.5 – 5 mmol/L

Urea 5.8 mmol/L

2.5 – 6.7 mmol/L

Chloride 105

98 – 106 mmol/L

Creatinine 93 µmol/L

70 – 150 µmol/L

5. Liver function test – total protein and albumin serves as preoperative investigations as study shows that the patient with adequate nutritional status (normal albumin and protein) had significant risk of surgical morbidity. The albumin also serves as a predictors of wound healing after surgery

Results Normal Range Total protein

68 g/L64 – 82 g/L

Albumin 41 g/L

35 – 50 g/L

Bilirubin12 µmol/L

5 – 17 µmol/L

Alkaline Phosphatase (ALP)80 IU/L

38 – 126 IU/L

Aspartate transaminase (AST)37 IU/L

10 – 35 IU/L

Alanine Aminotransferase (ALT)30 U/L

9 – 40 IU/L Normal ALT

6. Transabdominal Ultrasound

Presence of multiple fibroids; o 2 anterior wall fibroids (3 x 3 cm) and (3.4 x 4.2 cm)o Subserosal fibroids (6.7 x 5.2 cm) and (4.9 x 5.1 cm)o Posterior wall fibroids (7.7 x 6.4 cm)

Uterus size – 11.4 x 7.6 cm Endometrial thickness (4.6 mm) No adnexal mass

Final Diagnosis

Uterine fibroids with symptomatic anaemia

Problem ListsAcute problem – symptomatic anaemia Uterine fibroids with symptomsSurgical menopause following the treatment

TreatmentThe treatment goals in this patient are to stabilize the life-threatening complications as well as to remove the underlying pathology that cause significant effects in patient activity of daily living. Thus, the treatment approach in this patient is based upon the problem lists (as listed above)

Symptomatic anaemia Based on the full blood count taken in this patient which was 6.0 g/dL, it is unquestionable that

the patient is indicated for blood transfusion Among the indications of blood transfusion includes;

o Haemoglobin levels of less than 8.0 g/dLo Symptomatic anaemia regardless of the haemoglobin level

1 pint of packed red blood cell may increase the haemoglobin of 1.0 – 1.5 g/dL The target haemoglobin in this patient, as the patient subsequently planned for operation of her

fibroids should be more than 10 g/dL Thus, 3 to 4 pint of packed red blood cells needed to be given in this patient in order to achieve

the haemoglobin level of >10 g/dL The blood group is based upon the investigations ordered previously (Group screen hold and

group cross match) Precautions

o In order to prevent fluid overload due to massive blood transfusion, intravenous diuretics for example Frusemide can be given in between the transfusion to lower the plasma volume, making the blood more concentrated with haemoglobin

The blood is transfused at a rate of 60 minutes to 90 minutes for each pint. Too fast transfusion may increase the risk for the patient to developed heart failure secondary to fluid overload while too slow transfusion will leads to tube clots

Complications of blood transfusion needed to be assessed as this patient had history of allergic to penicillin and she never underwent any blood transfusion before

Full blood count needs to be repeated after the transfusion to see the haemoglobin levels Screening for blood transfusion-related infections are necessary in this patient

Uterine fibroids This patient is suitable for operation as she had several indications for operation

o Uterus size is 16 weekso Multiple fibroids

o Symptomatic – menorrhagia, dysmenorrhoea that cause significant effects in patient activity of daily living

This patient has completed her family and the recurrence rate of uterine fibroids after myomectomy is around 20 – 30 % (www.ncbi.nlm.nih.gov/pubmed/20098994)

Thus, to prevent the risk of recurrence, as well as the findings in ultrasound (large, multiple fibroids) I would suggest the patient to underwent total abdominal hysterectomy

This patient also reaching the menopausal age and peak incidence of ovarian ca is 50 to 70 years old. Thus, in order to prevent risk of reoperation due to ovarian ca, additionally, I would suggest the patient to underwent bilateral salphingo-oopherectomy

Thus, the patient will be surgical menopause Several preoperative measures needed to be taken;

o Written consent as with husband permissiono Pre-operative investigations (as stated before)o Informed regarding the risk, method of operation, alternatives of surgery as well as the

complications which may arise from the operationo Keep the patient nil by mouth – to prevent risk of aspiration as the operation is done

under general anaesthesiao Start the patient on fluid maintenance (40mls/ kg)

Patient bodyweight – 72 kg Fluid requirement daily in this patient – 72 x 40 = 2880 mls/ day (around 6 pint) Sodium requirement = 2 – 4 mmol/kg/ day

In this patient – 144 to 288 mmol of sodium per day 1 pint of normal saline contains 77 mmol Thus 2 – 4 pints of normal saline needed in this patient To complete the 6 pints, I would add 2 pint of dextrose 5%

The complications of TAHBSO needed to be informed to this patient, such as;o Haemorrhageo Infectiono Complications of general anaesthesia

Surgical Menopause Following the TAHBSO, the patient would be surgical menopause Symptoms of menopause such as hot flushes, vasomotor symptoms as well as complications

arising from estrogen depletion needed to be assess during follow up as it serves as a guide for us whether to start the patient on hormonal replacement therapy or not