Fercae SmParasseg incident of heavy period lst week vf visting 2 (ierd, Mary, ed 44, consults her famy doctor complaining thet har Pst concerned Sx weeks Ago to race two exsodes of Hoenn betes penod. CUES e5ninz * Ldentity and list the major signs and symptoms = #-yearol female = Hashad an erterassng indent beeing ~ Yer hoy periods, with bad pete pan det > ndicais benny vag = Large cats passed on severe eee ( “Fees ncanotane come Fad od ochy = Two recent eisodes of ntementua leetng . pls quant “~ HYPOTHESIS GENERATION ~30nins rece stb Pav pln She fees 'uncomtortadle Gurng hes Mere ee oe passed large clots on several occasions, She was * Abnormalities of body structure and function that may. ‘explain the main symptoms and signs listed in the cues ‘menstrual pattern? What is normal? What factors may contibute to ‘abnormal pattern? Js this an abnormal, + Outline of normal eycte + Factors thet may generate abnormal pattern “Aas fe se and source ofthe ntermenstraa bleeding? Lyon Sees the ntermensial bleeding occur? (2, post cota) — Hh is this patents normal menstrual evel, and over whet ceric of tne 125 the pattern changed? Is this menorrhagia? ~ Clear definition a 1 Whats the sinicance ofthe histary of pissing large cists? penal are the possible causes of her changed menstus petern? ~ What are the possible sites of vaginal bleeding? (ag, vaginal, cervical, uterine) “nae cei pathologies are associated wth mancrrhaeia? ay, oka endometrial plyps, adenomyosis, conc «Coe citer possible causes of menorthagia? (ap, antonio as disorders, dysfunctional uterine bleeding) + Gould ths bleeding be cervical in orig? 1D ante clotrng ageud? {ists pattern of menstnal change Bssockted vith pensmenopevse? Age le What hormonal interaction is likely to be occuring? Outine Of main hormones involved. "Rae Mata hormones associated with menstrit cycle? Which ones ‘may be associated with this bleeding? = What, 1S may be involved? Why might there be pelvic pala? Discussion > Quttine anatomy of the pelvis. + Possible pain pathways, eet, 74 there pain associated with the episodes of bleeding? smock _ [at does the patient mean by feeling uncomfortabie? aa ~ Could feeling ‘uncomfortable’ be associated with anaemia?) Siew nasa What structures could generate this discomfort? “ w pdated 27.01.2016 ere (ened) Modified by: Dr. Si Lay Khaing, Dated: 03° March 2015 sity of Malaye Mecical Programme’ 2015* List the conditions that could plausibly explain the symptoms and signs of case (ie, the differential diagnosis) “Ths is abnormal forthe patient Henonthaaia, due to = vaginal utenne pathclogy pper-menopause Features of a haemostatic csorder dysfunctional uterine bleeling ther mecical disorders (29, hypathyroiism) ‘excessive blood loss Patient may be anaemic due ENQUIRY PLAN ~20mins * Decide what you need to know in order to reach a firm diagnosis. List issues that you should explore in patient's HISTORY, identify signs that you will need to elicit in PHYSICAL EXAMINATION, and then list INVESTIGATIONS that you will request. Ensure that you understand how each piece of information will help you in the diagnosis and/or assessment of the problem and possibly also contribute to the management HISTORY $ * Consider relevant questions for initial rapid assessment { = What is Mary’s normal menstrual pattern? (regularity, amount of bleeding, etc.) ox \ = What has been the recent change? = What is the estimated blood lass with each period (this needs to be assessed in terms of tamon/oad use, 2.9,, size, frequency changing, flooding, etc.)? «Is this blood loss consistent with a definition of menorrhagia (i.e., > 60-80 ml perperiod)? ~ What has been her past and what is her current contraceptive use (hormonal and non-hormonal, in particular TUCD use)? - Is there post-coital bleeding? 5 Is the bleeding associated with pain? =»-sPEp? i ~ Past gynaecological and obstetric history (\infection, miscarriages, tefmination of pregnancy, etc.)? ~ What is her Pap smear history (e.g., how frequent, any abnormalities, most recent)? = What is her family history? ~ How is the bleeding affecting her life (work, relationship, family, etc.)? ~ Are there symptoms of anaemia (e.g., lethargy, shortness of breath, pallor)? ~ Are there symptoms of peri- menopause (¢.g,, hot flushes, moodiness, sleep disturbance, etc.)? ~ Are there any symptoms of hypothyroidism (e,g., dry skin and hair, constipation, etc.)? = Are there any features of bleeding disorder (e.g., easy bruising, prolonged bleeding)? PHYSICAL EXAMINATION . ° pot ited cont Hexely * Consider the physical signs that you need to elicit ane + Appearance (2.g,, pallor, feature of hypothyroidism) evmelly Renae *5P = Pulse rate = Weight BMt = Abdomen — masses = PV ~ abnormalities, pain + Speculum = vaginal wall, vault, cervix + Ultrasound examination of pelvis and abdomen INVESTIGATIONS # Consider the investigations that you will require in the light of the history and physical examination findings ~ FBC ~ Pap smear + Ultrasound examination of pelvis and abdomen Updated 27.01.2016 Reviewed/Modiiod by: Or. Si Lay Knaing, Dated: 03 March 2015 University of Malaya Medical Programme © 2013,+ Obtain information from the patient data below, in accordance with the enquiry plan that you have developed HISTORY History of Presenting Cofdition “Menstrual problems started 5 years previously and have increased steadily in severity since that time - increase in volume of menstrual blood loss. ‘She has been using increasinoly larger saritary pads, non requiring two at a time, changing them every 1-2 hours on heavier cays. Periods come approximately every 28 days and lat for 10, Recent presence of large dots in her menstrual ass. ix weeks previously, Mary had two episodes of intermenstrual bleeding. The bleeding was, painless and lasted for ony a day with equivalent loss to @ normal period. These bleeds were not related to intercourse; no post-cota bleeding, “Inereasinaly bad aching and dragaing pelvic dscomfort, worsening atthe ime of menstruation, No acute pain and ro pain or teeing with intercourse Nausea and tiredness during periods. Increasing tiredness between periods; no shortness of breath “Menarche at the age of 13. First year after menarche her mensrual Cycles were irregular but sotled down to 2 regular cycle of 28 days with ‘menstrual periods lasting 4 days, Mild spasmodic dysmenortnoea but no other menstrual cycle symptoms. Hig acne from the age of 15, which resolved by the age of 20. Has had a series of accidental heavy bleeds which mears that she now wears dark clothing and curtals her social life curing her menses. | Contraceptive history = Sexually active atthe age of 19. Started taking a combined oral contraceptive from the age of 20. Stopped the contraceptive to have a femly at the age of 33 and canceived quickly. The pregnancy proceeded normally witha vaginal delivery of a male infant at term weighing 3.65 ka, Breast- fed the infant for 3 months. Had an intrauterine contraceptive device inserted, Periods then became slightly heavier. At age 36 the IUCD was removed and she again concelved quickly. The pregnancy progressed uneventfully and she spontaneously delivered a 4.12 kg female infant, following a wide episiotomy. She breastfed the infant. For contraception she began to use the progestogen-only pil. This caused frequent intermienStUal spotting and at 38, she consulted her general practitioner for advice. She chase to have a tubal ligation. The operation vias performed laparoscopicaly Using Fishie dips to block the fallopian {ubes. The laparoscopic exarnination showed a tiny Sub-serosal myoma atthe fundus ofthe uterus. The ovaries were rormal in appearance. General medical bistory ; An appendectomy was performed at age 9. Personat history \ “vapelly maried With bo chien aged 11 and 8, Works parttime asa receptionist She is genial hapoy at work and at home and her personel Ife is satisfactory. She describes her sex-ife as fulling. Not ware of any extemal stresses or difficulties that may have bearing on her symptoms. Her menstrual problems however, sometimes make work dificult and she has often had to stay off work. “Non-smoker and non-drnker. No other symptoms suggestive of menopause, le, ht fushes. Regular, negative Pap smears; last one 6 months 200. Family history = Father dled ofa heart attack at age 57. Mother is well ~ had a hysterectary aged 4 (reason unknown). + She has 2 sisters, aged 4? and 48. Both stil menstruating but the older sister was said to have irregular periods. | Her grandmother had ded from ovarian cancer at the age of 76. | Discussion Deas she have menarrhagia? - What is the significance ofa past history of TUCD use? | + Hihat is the signiteance of paint and painless Bleecing? ~ What i the siniicance of past-coftal bleeding? + What isthe significance ofintermenstrual bleeding? - What are the features of dysfunctional uterine bleeding? = What family history isimpartane to obtain? - What i the association between hypothyroidism and menstrual dlsturbance? =At what level of haemogiobin is pallor evident? PHYSICAL EXAMINATION allo - not noticeable, Weight 92 kg. BMI - 34. CVS - normal, Blood pressure - 130/80 mmHg, Lungs - clear. Breast exam normal. Abdomen findings = No abdominal tendetness. No palpable organomegaly. Uterus enlarged about 18 week's size. Vaginal examination. | Normal vulva, Speculum examination: Healy vaginal mucosa, small cystocoele, no rectacnel, no uterine descent. | ~Cervix: Healthy, Normal cervical epithelium. No cericls. No cervical pops. Doctor elected not to take a Pap smear, | _Bmanual examination. Uterus enlarged, motile smooth and reqular in shape, No adnexal masses or tenderness were evident INVESTIGATIONS pak Posen can AD Her family doctor arranged for a_pelvic ultrasound to be perfored. However in view ofthe intemenstral bleeding, she simultaneously arranged referral toa gynaecologist and asked My to tke her ulrasound scan and report tothe gyneecocaist. The gyraecslogst confirmed the above ‘examination findings and arranged for Mary to come infor 3 hysceroscony and endometrial samling. tthe tie ofthe hysteroscopy some were obtained and sent for histology. Discussion ‘What are the stons/symptoms of hypothyroidism? » What physical ndings may be suggestive ofa bleeding clsarder? What isthe slgiicance of pain mit cervical excitation? - Wht should Be looked for an specuhum examination? + What should be looked far on pelvic examination? - Are there other bleeding studies indicated and why/why nat? What features on blood film woukd suggest ron deficiency ansemia? - Should apap smear be dane? = Should hormone levels be measured? DIAGNOSIS ~smins # On the basis of this clinical information, students should make a diagnosis (for presentation to tutor in session 2). Students should have a grasp as to what has happened to the patient and the factors that have generated their signs and symptoms Updated 27.01.2026 Rewexed/Modifiod by: Or. Si Lay Khaing, Oated: 03 March 2015 University of Malaya Medical Programme © 2013,SESULTS - HAEMATOLOGY - FULL BLOOD COUNT Ld Deliver to Ward/Location Patient No: Name: SewAge: Location: PATHOLOGY Dept Accession Number: MB-98-400807 [ HAEMATOLOGY - Fall Blood Count Test Range Units 12 Aug Full blood count normal HAEMOGLOBIN 125 - 164 gL 105* WHITE LS 4.0- 11.0 10°, 10.2 PLATELETS 150 - 400 10% 215 Films: the red cells demonstrate hypochromia, microcytosis and anisocytosis Legend “= ABNORMAL ANSIWLYYdad ADO. RefNo. MB-98-400801 Simulated Report Form psated 27.01.2015, Reviewed/Mocified by Or. SiLay khsing, Osted: C3" marc University of talaya Medical Programme © 2034SULTS) HISTOLOGY REPORT - 1 Deliver to Ward/Location Patient No: Name: SexAge: Location: _ PATHOLOGY Dept Accession Number: MB-98-400807 HISTOLOGY History: Severe menorrhagia; LMP - 6/8/98 UTERINE CURETTINGS 13 Aug. ‘The endometrium is proliferative in phase and within normal limits. There is no evidence of hyperplasia, infection, neoplasia or other disorder architecture. steele eects sie END OF REPORT : See: oe Printed 13 Aug Ref No. MB-98-400801 ANSWLAYd3d ADOIOLSIH Simulated Report Form Updated 27.01.2016 Raviewec/Modied by: Or S Lay Khaing, Oated: 03° March 2018 Unversity of Malaya Medical Programme © 2014RESULTS) ste the large surface blood vesecl, updated 27.01 2015 Feviewed/Mocifiod by: Dr. Si Lay Khang. Dated: O3" March 2015 [Unversity of Malaya Medial Programme © 2024 tbe submuccus myoma protruding (Ve ASraat Updated 27.01 2016 ‘Accession Muli: 113.98.400807 wo-opherectomy Operative findings: ‘The werus was slighty enlerged wih several “seeding” myomata on the uterine surface, The ovaries appeared normal and contained several smal foltcies. The falepion tubes were normal and fishie clps were presect on the isthmic portion ofeach mabe Surgical procedure: ‘The abdomen was opened through a Plannenstel incision, and a strighrforward estrafascial total abdominal hysterectomy and bilateral salpingo-oopherectomy cactied cut, The round Lgaments were doubly heated and diaded The ureters acedutenne vessels were idenhfied and the bladder pushed well down out of the operative field. The utenne vasetiar padeles, the uterosacral ligaments and the ‘parametnal issues were clamped divided and hosted. The vaggna was pened snd the uterus removed. The vaginal vant was closed in 2 layers, The abdomen ‘was closed in layers. Peritoneal layerc were not suture, Goad haemoctacis was achieved and measured bleed Ines was 400 ml ‘Sherwoen -sopsare obeicniteneiacH a eSoo ee apiacaraichiacteteacbanke Puzted 15 Aug RefNo MB-98-409801 Simulated Report Form Reviewed/Modfied by: Or. Si Lay Khang, Dated: 03" March 2015, Unvwerty of Malaya Medical Programme © 2024‘AMSULTS RADIOLOGY, TRANSVAGIVAL PELVIC ULTRASOUND nett Teena = Seecetee te See re : jeted 27.01.2036 ewed/Medied by: Dr. ta ersity of Molaya Medical Y Khang, Dated 03” March 2015, oaramme @ 2018RESULTS) RESULTS - PATHOLOGY REPORT — HYSTERECTOMY Patient Wo Name Suge Locwion PATHOLOGY Dest Recession Number: MB.P8-00507 PATHOLOGY REPORT Haters Menorrhagia with anaemua Submaucout reyoma, and small inkrarural myomas MACROSCOFIC APPEARANCE 1B Aug ‘The uterus measures 75mm in length andthe myometrum is up to 25 mmiz thickness There is a angie subimmecus rmyomatcus polyp protruding into the uterine cavty measuring 30 nia mi Garaeter Several small ntrarnural myomata are also prevent ‘MICROSCOPIC APPEARANCE “The mycenata axkikit tical benian appearances with ao cytological gpa ot pleiomorphism, and the mitotic count is less than 2 per 10 high power Seida, The codsmetrinm is of acemal proliferative appearence otc tet ontntanciceinettenieisceecbeaceissectiaaererg 'ENDOF RSPORT Prot 15 aug ‘RefNo, MS-98-400801 Simulated Report Form i Updated 27 01.2016 Reviewed/Modiied by r. i Lay Khaing, Dated 03 March 2015 University oF Malaya Medical Programme © 2014 ANAWLYVdad ADOIOHLYd