New Case Pres...

Uterine Myoma

Presented by: Abu, Camile Granada, Glyde Pebbles Landicho, Katrina Linatoc, Jeanne Lyn Luza, Ailen Maralit, Ma. Krishna Sim, Khay Ulan, Darlene Umali, Marianne Lyn Avena, Gaudencio Dimaculangan, Argenald Joseph Hernandez, Michael Franklin

INTRODUCTION Uterine myoma is the most common tumors of the female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been a common therapy in patients who have completed reproduction. Total hysterectomy plus unilateral salphingo oophorectomy TAHBSO- this procedure removes the utereus, cervix, one ovary and one fallopian tube, while one ovary and one fallopian tube are left in places.

Fibroids can be present and be apparent. However they are clinically apparent in up to 25 % of the women. Although, myoma is generally considered to be slowly growing tumor in 20-40% of women at the age of 35 and more have uterine fibroids of significant sizes with severe clinical symptoms. Moreover, myoma can be relapse in 7-28% of patient after surgical treatment and in certain case it may even turn to malignant tumor, this could causes significant morbidity including prolonged or heavy menstrual bleeding, pelvic pleasure and pain and in rare cases reproductive dysfunction. Myoma affects one of every four women ¾ of woman with this condition,however, experience no symptoms.

Uterine myoma is developing on the background of hyper estrogen, progesterone, deficits in hyper gonodotrophine. The majority of the researches say that the growth of myoma depends on concentration of cystosolic receptors to the sex hormones and their interactions, with the endrogen or extrogen hormones. In accordance to clinical observations, it can be admitted that both growth and regressions of myoma are estrogen-dependent, is the tumor size gets increased during pregnancy and is regressed after menopause. The only that needs to clear is to find out whether it is decreased in receptors numbers of estrogen, progesterone and androgen- hormones quantities which lead to regression in myoma size ( regarding androgen there is an hypothesis that myoma is sensitive to androgen ) for growth that formed tumors, the need to be further supported by negative factors.

Abortions, long term used of inadequate contraceptive pills, chronic sub-acute and acute inflammation of uterus or its appendices, stress, ultraviolet radiation, cystic formation of ovary etc. for example, the woman who had ten abortions by the age of thirty have double to developed uterine myoma at fourty years old. In fact, uterine myoma = account for 20% of 650,000 hysterectomies performed annually in the U.S interest in the uterine preservation and organ preserving surgery through techniques minimally invasive surgery has increased the first reports of laparoscopic myomectomy.

PATIENT’S PROFILE PATIENT’S NAME: Lady L. AGE: 48 years old GENDER: Female PERMANENT ADDRESS: Inosluban, Lipa City BIRTHDATE: August 26, 1960 BIRTHPLACE: Lipa City, Batangas CIVIL STATUS: Married CITIZENSHIP: Filipino RELIGION: Roman Catholic ADMISSION DATE: August 22, 2008 ADMISSION DIAGNOSIS: Uterine Myoma ATTENDING PHYSICIAN: Dra. Lovely Cacho Dra. Alice Lojo

HISTORY OF PRESENT ILLNESSS Present condition started about 6 years prior to admission. When patient noted heavy vaginal bleeding and body weakness every menstrual period that last almost a week. Due to that instance, she went to the hospital for check-up and she found out that she has a myoma. Her attending physician said that she need to undergo surgery but they didn’t have enough money that time, they would need to save for the hospitalization and operation that will undergo. Until August 22, 2008, when her relative noted her to be pale, having dizziness and body weakness bought her to the hospital. After a series of examination, she was scheduled and prepared her to surgery.

PAST MEDICAL HISTORY She has never been hospitalized except when she had two breech presentations with her two sons. Other than that, she usually experiences cough, cold, fever and buys over the counter drugs to treat the said illnesses. Prior to that, sometimes she consults the said quack doctors or faith healers if she thinks that it’s just that a simple illness.

SOCIO – CULTURAL She is a friendly person. She is closed with her four sons and loves them so much. She admitted that few years ago, she used to smoke when she is defecating and after eating. She said that she loves to eat vegetables and she exercises regularly. She cooks in a canteen in Lipa bus stop which sustains their basic needs.

PHYSICAL ASSESSMENT ACTUAL NORMAL VITAL SIGNS VALUES

INTERPRETA TION

RR- 24

12-20 beats/min.

Normal

PR- 80

60-100 beats/min.

Normal

BP- 120/70

90/60- 130/90 mmHg

Normal

Height = 5’1 cm

Weight = 57 Kg.

Body Parts Technique Normal used findings

Actual findings

Significance

Head

Inspection Palpation

NormocephaNormocephaNormal lic lic Normal No No abdominal abdominal mass mass

Hair and scalp

Inspection

Evenly distributed, Thick hair, no infection and infestation

Even Normal distribution of hair , no infection and infestation

Eyes

Inspection

Symmetric Sunken to the face, eyeball both eyes coordinated with parallel alignment.

Not Normal. Due to dehydration

External eye Structure Eyebrows

Inspection

Hair evenly Evenly distributed, distributed Skin intact with skin intact

Normal

Eyelashes

Inspection

Equally distributed, Curled slightly outward

Equally Normal distributed, Curled slightly outward

Eyelids

Inspection

Skin intact, Skin intact, Normal No no discharge, discharge, No no discolorationdiscoloration , , lids are Lids close symmetrical. symmetricall y

Lacrimal gland

Inspection No edema No edema Normal or tearing. and tearing

Pupils Inspection Black in (color , color, equal shape and in size symmetry normally 3of size) 7 mm in diameter, round smooth border , iris flat and round.

Black in Normal color, equal in size 4mm in diameter

Ears

Inspection Symmetrica Positioned Normal lly aligned symmetrically to the face, to the face, firm and No notable ear not tender discharge, with no clean and dry,. discharged noted.

Nose

Inspection Symmetric and straight, no discharges or flaring

Symmetric Normal and straight , no nasal discharges noted, no flaring noted

Mouth Lips

Inspection Uniform Uniform dark pink in color dry color, soft and moist and smooth

Tongue

Inspection Tongue at midline without lesion

Not Normal due to chemical content of cigarette such as nicotine.

Dry and free ofNormal lesion

Teeth

Inspection

Complete, Incomplete, Not normal. white, shiny missing teeth, ill Aging is a tooth enamel, fitting dentures factor free of debris affecting loss of teeth and also insufficient calcium and fluoride.

Neck

Inspection Palpation

Coordinated , Coordinated Normal smooth movement with Normal movement no discomfort with no No masses, discomfort tenderness No masses, tenderness

Upper Inspection Extremities Skin

Palpation

Pinkish in color

Pallor

Not normal. It is a manifestatio n of in adequate circulating blood or hemoglobin.

Slightly moist

Poor skin turgor Not normal due to dehydration

Palpation

Arms

Normother Not warm, not Normal mia cold to touch, T=36

Inspection Normally Normally firm, Normal Palpation firm, no no contracture, Normal contracture, no swelling, no swelling, equal size on equal size both sides of on both body sides of Pulse rate: 80 body Pulse Rate: 60-100

Nails

Inspection Palpation

Smooth, highly Pink, smooth Normal vascular and texture, convex Normal intact curvature epidermis Capillary refill: 2 Capillary Refill seconds of 1-2 seconds

Chest and Lungs

Inspection

Symmetric Symmetric chest Normal chest expansion, quiet, expansion, rhythmic and quiet, rhythmic effortless and effortless respiration respiration

Palpation

No No retraction, Normal retraction, no tenderness, no no masses tenderness, no masses

Auscultatio Quiet, n rhythmic

Heart

BronchovesiculNormal ar and vesicular breath sounds

Auscultatio Normal Cardiac rate of Normal n heart rate 80 60-100bpm

Abdominal

Inspection

Unblemishe Lesions noted Not normal d skin, on the surgical because of uniform in site post color procedure done

Auscultation Average Audible bowel Normal normal sound of 8 per bowel minute sounds 5-25 per minute

Lower Inspection No lesion, extremities Palpation can move Skin freely Capillary refill: 1-2 seconds

No edema, no Normal deformities Normal and can move freely Capillary refill: 2 seconds

IV. ANATOMY AND PHYSIOLOGY ANATOMY OF FEMALE REPRODUCTIVE ORGAN

STRUCTURE

Cervix

LOCATION & DESCRIPTION

FUNCTION

The lower narrower portion During childbirth, of the uterus. contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external is dilates

Fallopian tubesExtending upper Egg transportation from part of the uterus ovary to uterus (fertilization on either side. usually takes place here).

Ovaries (female gonads)

Pelvic region on Provides an environment for either side of the maturation of oocyte. uterus. Synthesizes and secretes sex hormones (estrogen and progesterone).

Vagina

Canal about 10-8 cm long going from the cervix to the outside of the body.

Receives penis during mating. Pathway through a woman’s body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as an IUD, diaphragm, neva ring, or female condom

Uterus Endometrium Myometrium Perimetrium

Located in the center of House and nourishes the fetus. the pelvic cavity Contains glands that secrete fluids The innermost layer of that bathe the uterine lining. uterine wall. Contract to help expel the baby. Smooth muscle in the Covers the uterus uterine wall. Outer layer of the uterus

Uterus Endometrium Myometrium Perimetrium

Located in the House and nourishes the center of the pelvic fetus. cavity Contains glands that The innermost layer secrete fluids that bathe of uterine wall. the uterine lining. Smooth muscle in Contract to help expel the uterine wall. the baby. Outer layer of the Covers the uterus uterus

ESTROGEN

It is the most important hormone during puberty in female and is responsible for secondary sexual characteristics (e.g. breast enlargement, menstruation, pelvic enlargement, long bones). Generally secreted by the ovary specifically secreted by the Grafian follicle.

Estrogen production Hypothalamus ↓ GnRH ↓ Anterior Pituitary Gland ↓ FSH ↓ Graafian Follicle ↓ Estrogen

V.

PATHOPHYSIOLOGY Early Menarche (11 years old)

Pregnancy

Increase Estrogen production

Increase the lifetime exposure to estrogen

Stimulates the growth of fibroid

Grows in the anterior wall of the uterus

Pelvic pain

Deform uterine cavity Menorrhagia

Myoma

Day 1 A 48 years old female was admitted at exactly 2:16:07 p.m last August 22, 2008, accompanied by her son, with a chief complaint of body weakness. She was admitted under the service of Dra. Lovely Cacho and Dra. Alice Lojo and following orders are given. Diet as tolerated, temperature, pulse rate and respiratory rate must be recorded every shift, for chest x-ray posterioranterior, for electrocardiogram x 12 leads, for complete blood count blood typing and for chem. 7. It was done at the same day. The physician ordered a 5% Dextrose in Lactated Ringers 1 liter plus 1 ampule of EC to be regulated at 20 gtts/min. The physician ordered four units of whole blood that are properly typed and cross matched to be run for 4-6 hours. The physician also ordered “Lady L” that may have full diet at 4:40 p.m. The first unit of whole blood with a serial number B-08-4660 started at 10:00 p.m.. Diphenhydramine 1 ampule intravenous 30 min. prior to blood transfusion.

Day 2 The above unit of blood finished at August 23, 2008, 2:20 a.m. There is no reaction during and after the blood transfusion. At the same time, the second unit of whole blood with a serial number B-08-4681 was hooked and consumed at 7:20 a.m. The third unit of blood with a serial number B-08-4666 was started at same time. The blood transfusion site was transferred from left to right at 11:20 a.m. At 12:30 p.m., the third unit of whole blood with a serial number B-084668 was consumed and followed up of fourth unit of whole blood and consumed at 4:30 p.m. Intravenous fluid number one consumed and followed the number two 5% Dextrose in Lactated Ringers 1 liter plus one ampule of EC regulated at the same rate. By 11:10 p.m. “Lady L” is under nothing per orem. “Lady L” informed about Total Hysterectomy Bilateral Salphingo Oophorectomy with signed consent of her husband and her son at the same day. Anesthesiologist on deck was informed. Cefuroxime 750 mg, intravenous started every 8 hours after negative skin testing. At 11:40 p.m. Valium tablet 5 mg one tablet was given as pre-operative drugs.

Day 3 August 24, 2008, at exactly 7:00 a.m. “Lady L” was brought to the operating room. At 4:50 p.m. post-op orders were given. Monitor vital signs every 15 minutes until fully stable. Nothing per orem temporarily. The patient was instructed to lie flat on bed and low back rest for pneumonia precaution. Oxygen inhalation administered at 3 liters per minute. Suction secretion when necessary. Intake and output were recorded hourly. 5% Dextrose Lactated Ringers 1 liter post-op to run at 15gtts/min then to follow 5% Dextrose Lactated Ringers 1 liter at same rate. Last dose of Cefuroxime to consumed, Metronidazole 500 mg slow intravenous push every 6 hours. Tramadol 500 mg after negative skin testing every 6 hour. Intravenous fluid regulated at 30 gtts/min when blood transfusion finished. Repeat hemoglobin and hematocrit.

At 5:20 p.m. the operation ended and at 6:40 p.m. patient was bought to the intensive care unit and hooked to ventilator and Furosemide 40 mg IV was given. At around 8:45 p.m Omeprazole 40 mg IV was given. Serum, sodium, potassium, chloride, prothrombin time, partial prothrombin time done and result in “Lady L” was nebulized if Combivent 1 neb and maintained every 8 hours potassium 30 millequivalent incorporate to her intravenous fluid and decrease it to 8 hours. Another one unit of packed red blood cell, Calcium gluconate one ampule was given thru slow intravenous push.

Day 4 August 25, 2008, 5a.m. patient was brought to room 206 and then nebulization started and extubated at the time and secretion suctioned. Oxygen maintained at 4 liters per minutes via nasal canula. Diphenhydramine one ampule was given at 3:30 p.m, 30 minutes prior to blood transfusion. Blood type “B” with a serial # of BO8-445 run at 4-6 hours. At 6:05 p.m “Lady L” was confirmed that she is positive in flatulence and may sips of water and hot soup. Measuring drained output was recorded shiftly.

Day 5 1 a.m. of August 26, 2008, to follow intravenous fluid 5% Dextrose Lactated Ringers 1 liter regulated at same rate and encouraged patient to turn side to side. Serum, creatinine, and complete blood count done. At 9:37 a.m. the physician advised to continue medications. At 10:00 p.m. patients temperature is 38.2˚C and paracetamol 200 mg one ampule was given thru intravenous. At 11:03 a.m. nebulization was stopped. The physician suggests changing Cefuroxime to Tazocin 4.5 grams intravenous every 8 hours. Above intravenous fluid consumed and followed up of 5% Dextrose in Lactated Ringers 1 liter regulated at same rate. At 3:15 p.m. incentive spirometer every 8 hours and two minutes oxygen inhalation was discontinued. Patient was encouraged to ambulate. At 8:30 p.m. intravenous to follow of 5% Dextrose Lactated Ringers 1 liter regulated at same rate. Foley catheter was removed at 9:15 p.m. At 10:45 p.m “Lady L” was gargled a one tablespoon of Orahex solution plus 30 cc water every 6 hours.

Day 6 Nursing care done. Vital signs are monitored and recorded. Intravenous fluid regulated at 15 gtts/min “Lady L” has no further complaint. The patient is ambulatory. Tazocin 4.5 grams intravenous every 8 hours was given. Attending Physician did not visit’s the patient and no new orders were made that day.

Day 7 August 28, 2008, patient may have clear liquid then soft diet at 4 p.m., above intravenous fluid consumed and followed up of 5% Dextrose Lactated Ringers 1 liter regulated at the same rate. For possible discharge on the next day.

Day 8 August 29, 2008, removal of jackson-pratt drain was done and intravenous fluid was terminated. There is no o objection for discharge. Home medications instructed and patient may go home and start oral medication. At 8 p.m. patient was discharged accompanied by her son via the wheelchair.

VII.

LABORATORY AUGUST 26, 2008 HEMATOLOGY

Diagnostic/Lab oratory Test Hemoglobin

Normal Value

Result

M 13.0-18.0 11.4 g/dL g/dL F 12.0-16.0 g/dL

Significance/Inter pretation Anemia, recent hemorrhage

Hematocrit

M 40-54% 35.10 % F 37-47%

Anemia

WBC

5,00010,000

15,200

infection.

196,000 cu/mm

Normal

Platelet Count 150,000450,000 cu/mm Segmenters

0.51-0.57 0.90

Infection

Lymphocytes 0.21-0.35 0.08

Infection

Monocytes

Normal

0.02-0.35 0.02

AUGUST 25, 2008 HEMATOLOGY Diagnostic/Labo ratory Test

Normal Value

Result

Significance/Interp retation

Hemoglobin

M 13.0-18.0 10.5 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

Anemia

32.70 %

WBC

5,00010,000

16,600

Infection

Platelet Count 150,000450,000 cu/mm

206,000 cu/mm

Normal

Segmenters

0.51-0.57

0.96

Infection

Lymphocytes 0.21-0.35

0.02

Infection

Monocytes

0.02-0.35

0.01

Infection

Eosinophill

0.01-0.04

0.01

Normal

AUGUST 24, 2008 HEMATOLOGY Diagnostic/Laborator y Test

Normal Value

Result

Significance/Interpretati on

Hemoglobin

M 13.0-18.0 g/dL 12.5 g/dL F 12.0-16.0 g/dL

Normal

Hematocrit

M 40-54% F 37-47%

37.5 %

Normal

WBC

5,000-10,000

20,600

Infection

Platelet Count

150,000-450,000 cu/mm

225,000 cu/mm

Normal

Segmenters

0.51-0.57

0.93

Infection

Lymphocytes

0.21-0.35

0.03

Infection

Monocytes

0.02-0.35

0.04

Infection

Eosinophill

0.01-0.04

Infection

AUGUST 23, 2008 HEMATOLOGY Diagnostic/Laborat Normal Value ory Test

Result

Significance/Interpret ation

Hemoglobin

M 13.0-18.0 10.8 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

36.70 %

Anemia

WBC

5,000-10,000

6,500

Normal

Platelet Count

150,000-450,000 247,000 cu/mm Normal cu/mm

Segmenters

0.51-0.57

0.83

Infection

Lymphocytes

0.21-0.35

0.11

Infection

Monocytes

0.02-0.35

0.06

Normal

AUGUST 22, 2008 HEMATOLOGY Diagnostic/Laborat Normal Value Result ory Test

Significance/Interpret ation

Hemoglobin

M 13.0-18.0 6.93 g/dL g/dL F 12.0-16.0 g/dL

Anemia, recent hemorrhage

Hematocrit

M 40-54% F 37-47%

21 %

Anemia

WBC

5,000-10,000

5,000

Normal

Platelet Count

150,000-450,000 337,000 cu/mm Normal cu/mm

Segmenters

0.51-0.57

0.70

Lymphocytes

0.21-0.35

0.20

Monocytes

0.02-0.35

0.10

Normal

AUGUST 22, 2008 CLINICAL CHEMISTRY Laboratory Test

Normal Value

Result

Significance/Inter pretation

FBS

3.89-5.84 mmol/L 4.24 mmol/L

Normal

BUN

2.5-8.33 mmol/L 2.80 mmol/L

Normal

Creatinine

45-235 u/L

Normal

Bld. Uric Acid

143-345 mmol/L 179.0 mmol/L

Normal

Triglyceride

0.11-2.37 mmol/L 0.58 mmol/L

Normal

HDL

0.25-2.65 mmol/L 1.50 mmol/L

Normal

LDL

1.10-3.81 mmol/L 2.52 mmol/L

Normal

89.0 u/L

AUGUST 24, 2008 CLINICAL CHEMISTRY

Laboratory Normal Value Test Sodium Potassium

135-145 mmol/L

Result

Significance/I nterpretation

142.3 mmol/L Normal

4-4.5 mmol/L 3.133 mmol/L Hypokalemia

Chloride

99.9-110 mmol/L

106.7 mmol/L Normal

Pro- time

12-15 seconds 13 seconds

Normal

AUGUST 26, 2008 CLINICAL CHEMISTRY

Laboratory Test

Normal Value

Result

Significance/Interp retation

Potassium 4-4.5 mmol/L

3.56 mmol/L Hypokalemia

Creatinine 45-235 u/L

102.0 u/L

Normal

AUGUST 22, 2008 ULTRASOUND Transvaginal Ultrasound Transabdominal pelureus shows an enlarged uterus measure about 12.6x7.5x9.1 cm (LxWxAP). There is a large hypo echoic mass in the posterior lower segment of the uterus, measuring approximately 10.0x10.0x9.0 cm. There is a cystic structure with internal echoes and septations in the night adnexae, measuring about 60x4.5x4.3 cm. There is no fluid in the posterior culde-sac. Impression: Enlarged uterus with large sub serous myoma wit intramural component, posterior lower segment consider ovarian cyst at the right. Normal left ovary.

AUGUST 24, 2008 CHEST X-RAY AP > There are no active parenchemal infiltrates. > The heart is not enlarged. > Aorta is tortous. > The rest of the findings are unremarkable. > ET at level of T4. Impression: > Tortous Aorta ` AUGUST 24, 2008 ABDOMEN AP > Hx: S/P TAHBSO > Free air is noted at the pelvic cavity. > There are feces filled undilated bowel loops obscuring the renal and psoas shadows. > The flank stripes are intact > No abnormal calcification noted. Impression: >Pneumoperitoneum, likely post surgical.

I.DRUG STUDY