August 22, 2015

MD-120075
HISTORY
Identifying Information
EBC a 43 year-old female, born on May 26, 1972, married, Filipino, Roman Catholic,
from Concepcion, Marikina City was admitted at our institution on August 16, 2015 with 90%
reliability.
Chief Complaint
Seizures
History of the Present Illness
The patient, previously non-hypertensive is a 49 year-old G3P2 (2012) s/p repeat low
transverse caesarian section and hysterectomy last August 8, 2015 who came in due to
seizures.
3 days prior to admission, the patient experienced severe headache (10/10 pain
scale) accompanied by nape pain, blurring and doubling of vision, with no nausea and
vomiting noted. Symptoms were slightly relieved by intake of naproxen sodium. No consult
was done.
Several hours prior to admission, still with persistence of Headache and nape pain,
patient was noted by the husband to having generalized tonic-clonic seizures with upward
rolling of the eyeballs lasting for 3 minutes and slurring of speech lasting for 10 minutes. No
facial asymmetry, weakness or numbness. Patient was brought to the Marikina Valley
Hospital where Complete Blood Count and CT scan was done. Results for both tests were
normal while results of serum electrolytes revealed hyponatremia and serum creatinine was
high. Vital signs during the consult were as follows: (BP: 180/100, HR: 150, RR: 24, T: 36.8,
O2 sat: 99%). She was given Nicardipine IV. Consideration then was postpartum
preeclampsia. She was advised admission but opted to transfer to our institution and
subsequently admitted.
Review of Medications and Labs
CBC: normal
CT scan: Normal
Serum electrolytes: hypoinatremia
Serum Creatinin: high

Temporal Profile

Review of Systems
fever weight gain weight loss weakness fatigue others
General
MSK/Integumenta rashes lumps sores itching muscle pains joint pains changes
ry
in color joint swelling changes in hair/nails others
HEENT
headache dizziness blurring of vision tinnitus deafness
epistaxis frequent colds hoarseness dry mouth gum bleeding
enlarged lymph node others
dyspnea hemoptysis cough wheezing others
Respiratory
palpitations chest pains syncope orthopnea others
Cardiovascular
Gastrointestinal
nausea vomiting dysphagia heartburn constipation diarrhea
rectal bleeding jaundice others
Endocrine
Genitourinary
Neurological

excessive sweating heat intolerance polyuria excessive thirst cold

intolerance others
dysuria sexual dysfunction discharge others
seizures tremors others

The review of systems is unremarkable.

Past Medical History
The patient is a known asthmatic, last attack was on January 2014. She is currently
not on controller medications but takes salbutamol as needed for acute exacerbations. She
is allergic to Omeprazole but has no known allergies to food. Prior hospitalizations include
admission for headache and dizziness probably secondary to anemia in June 2015 and prior
surgeries include Dilatation and curettage done on July 2015.
Family History
The patient has a family history of asthma, diabetes and heart disease within her
family. There are no hematologic illnesses or other heredo-familial diseases
Family Genogram

Obstetric and Gynecological History

The patient is a nulligravid, with LMP on July 29, 2015 and PMP on June 2015.
Menarche was since 11 years old at regular 28-30-day intervals, lasting 5-7 days, consuming
about 3-4 pads/ day, with occasional signs of dysmenorrhea. Her age at first coitus was at 20
years old.
Immunization History
The patient recently had vaccines for Flu, Hep A and Hep B and HPV.
Personal, Social and Environmental History
The patient is a Human Resources Management Graduate, currently working for
TransCom as an HR staff. She denies tobacco, alcohol, caffeine and illicit drug use.
Stakeholders Analysis
Name/Role
Stake

Stand on
the Issue
Ally

Intensity of
Stand
High

Degree of
Influence
High

Patient

Own well-being

Cecil
Trinidad
Sandoval

Concern for the

well-being
of
daughter
(Mother)

Ally

High

Medium

Aurelio
Sandoval

Concern for the

well-being
of
daughter
(Father)

Ally

High

Medium

Katherine
Pinky
Sandoval

Concern for the

well-being
of
her
sister
(sister)

Ally

High

Medium

Insight/Action
Patient is financially
independent
and
has Philhealth.
Can provide moral
and
financial
support
for
the
treatment of her
daughters
condition
Can provide moral
and
financial
support
for
the
treatment of his
daughterss
condition
Can provide moral
and
financial
support
for
the
treatment of her
sisters condition

PHYSICAL EXAMINATION
General Survey: Awake, alert, and not in cardiorespiratory distress. Patient is
currently not in pain.
Anthropometrics:
Weight: 74kg
Height: 155 cm
BMI: 30.8
Vitals Signs: BP: 120/80 HR: 82 bpm RR: 20 bpm T: 37.1 C
Head and Neck: Normocephalic, No CLADS, No neck vein engorgement. No lesions
in scalp
Eyes: Anicteric sclerae, Pink palpebral conjunctivae, Eyes are briskly reactive to light,
(+) Red orange reflex.
Ears: Ears are symmetric. Ear canal is non-hyperemic and tympanic membrane is
intact and not bulging. Visible cone of light bilaterally
Nose: Nasal bridge is flat, nasal septum is midline, turbinates are pink with no
watery nasal discharge.
Oral Cavity: Dry lips, moist oral mucosa, non-hyperemic buccal mucosa and
pharyngeal walls. No gingival and mucosal lesions.
Cardiovascular: Adynamic precordium, No heaves no thrills, Regular cardiac rate
and rhythm, Distinct heart sounds s1>s2 at the base, Apex beat at the 5 th ICS
Left midclavicular line, No murmurs appreciated.
Chest and Lungs: Symmetric chest expansion, No retractions, No lesions or masses.
Clear breath sounds
Back and Spine: No lesions and obvious spinal deformities.
Abdomen: Flabby abdomen, no abdominal distention, no scars, normoactive bowel
sounds and tympanitic on all quadrants, no masses and organomegaly on
palpation.
Pelvis and GU tract: Normal external genitalia, nulliparous introitus, vagina fits 2
fingers snuggly
Speculum exam
Minimal whitish non-foul-smelling discharge, no erosions no polyps.
Internal Exam
Cervix: the cervix is long, firm, closed and there is no cervical motion
tenderness
Uterus: Uterus is not enlarged and non-tender
Adnexae: No masses no tenderness bilaterally.
Rectal: Digital rectal exam was not performed.
Upper and Lower Extremities: no obvious deformities, no lesions, no clubbing,
and no cyanosis. Full range motion of upper and lower extremities on active
and passive motion
Skin and Nails: No rashes, no lesions, no jaundice, no cyanosis, good skin turgor,
Capillary Refill Time <2secs
Neurologic: Glasgow Coma Scale: 15, Cranial Nerves intact.
ASSESSMENT
Initial Impression: Nulligravid; Abnormal Uterine Bleeding; Endometrial hyperplasia (AUBE)
Problem List
1. Heavy Menstrual Bleeding and Severe Dysmenorrhea/ hypogastric pain
2. History of Asthma

3. Allergy to Omeprazole

Salient Features
The salient features in the history include the patients previous history of normal
menses which increased in the amount and duration over the last 3 months; the presence of
an episode intermenstrual bleeding of 5 days also of increased amount and dysmenorrhea
which also increased in pain intensity in the last bleeding episode. The symptoms of
dizziness and headache experienced during the later course of the illness are also pertinent
because this might be suggestive of anemia due to blood loss. The patients age and
nulligravid status are pertinent because different causes of AUB usually present in specific
age groups and gravidity status and can help rule in or rule out my initial impression and
differential diagnoses. The past medical history and family history are also salient in this
case because the patients chief complaint can be secondary to the patients previously
diagnosed or undiagnosed diseases or there may be inherited hematological diseases that
can contribute or cause the patients chief complaint. In the Physical exam, the salient
features would be the essentially normal abdominal and pelvic/genitourinary tract
examination for the gynecologic causes of her AUB. The patients normal general survey and
integumentary examination are also salient which can show signs of anemia such as pallor,
which might be secondary to AUB. The specific findings in the history and PE will be
correlated in the following discussion of the differential diagnosis.
Differential Diagnoses
Abnormal Uterine Bleeding, according to FIGO, can be caused by either visually
objective structural causes (PALM) or structurally unrelated etiologies (COEI). Based on the
P.E., endocervical polyps can be ruled in because of they cause almost 39% of AUB in
premenopausal women, but because there were no findings indicative of its presence
visualized in the cervix during the speculum exam, a polyp is highly unlikely but cannot be
entirely ruled out because its diagnosis is based on the use of TVS or hysteroscopy.
Adenomyosis can be ruled in because the patient exhibited the classical symptoms of
dysmenorrhea and heavy bleeding. Although palpation of the uterus in the internal exam did
not reveal any enlargement which makes a diagnosis of adenomyosis unlikely, it cannot be
entirely ruled out because definitive diagnosis would require the use of TVS or MRI.
Leiomyomas are also ruled out because there were no findings in the history that would
suggest it such as report of increasing abdominal girth, pelvic heaviness, or uterine
enlargement or other uterine findings in the internal and bimanual exam. Moreover, taking
into consideration the patients age group, leiomyomas would be unlikely because 60%
usually arise in women aged 45 and above. Ovarian endocrinopathy can be ruled out
because there was no history of irregular menses since the patient started menstruating and
there was no past medical history and family history of polycystic ovarian syndrome or
hypothyroidism. The absence of family history and past medical history of bleeding disorders
can, but not entirely, rule out coagulopathies as the cause of the bleeding. Bleeding
disorders can only be diagnosed by laboratory blood tests. Also there were no history of
easy bruisability and easy bleeding from wounds. Iatrogenic causes can also be ruled out
because there was no history of the common causes of iatrogenic bleeding such as IUD use,
gonadal steroids or anticoagulation therapy. The most likely causes of AUB in the patient can
now be narrowed down into two: Endometrial hyperplasia and/or Malignancy. The absence
abnormal findings in the abdomen and pelvic exam makes both impressions likely. Both
conditions can exist in a spectrum owing to the premalignant nature of endometrial
hyperplasia, but malignancy can be differentiated by the constitutional symptoms of
malignancy such as weight loss. Im leaning more towards a diagnosis of endometrial
hyperplasia before considering malignancy because endometrial neoplasia often presents
more frequently in perimenopausal age.

Diagnostics
1. Complete Blood Count- I would first order CBC to see whether the patient has
anemia related to the bleeding and to see if there is infection or underlying blood
dyscrasia which might explain the abnormal bleeding. True enough, the CBC
ordered for the patient revealed thrombocytosis and anemia. The anemia can be
explained by the heavy blood losses incurred by the patient during menstruation
and the thrombocytosis could be explained as a reactive thrombocytosis due to
an underlying inflammatory condition.
2. Transvaginal Ultrasound a transvaginal ultrasound would definitively rule out
most of the conditions in the PALM-COIEN classification. Moreover it could be used
to rule out malignancy if because of its 99% negative predictive value in
eliminating the possibility of neoplasia in thicknesses <5mm. In this case, a TVS
ordered 3 months prior revealed normal results but a more recent TVS ordered 10
days prior to consult revealed thickened endometrium (1.33cm) which supports
my diagnosis of endometrial hyperplasia and supports the possible diagnosis of
endometrial neoplasia.
3. Coagulation Profile can be ordered to find bleeding disorders. The patients
results showed normal coagulation which further rules out coagulopathies as the
cause of the AUB.
4. Endocrine Panel- tests for thyroid hormones can be ordered to detect
endocrinopathies especially polycystic ovarian disease and hypothyroidism which
may indicate whether the bleeding has an endocrine etiology.
5. Dilatation and Curettage with histolopathologic examination to check the
possibility of neoplastic change in the endometrium
The patient was diagnosed to have endometrial adenocarcinoma FIGO Grade 1 upon
histopathologic examination of the endometrial curettings which nullifies my initial
diagnosis based on history and PE.
Final Diagnosis: Nulligravid; Endometrial adenocarcinoma FIGO Stage 1 grade 1.
Therapeutics
Since the patient has no other significant comorbidities other than asthma, surgery is
the primary treatment modality to be considered. Laparoscopic vaginal hysterectomy or a
total laparoscopic hysterectomy with laparoscopic lymphadenectomy can be considered
because it offers a shorter recovery period and less possibility of forming adhesions
compared to Total Abdominal Hysterectomy. Inclusion of the ovaries and fallopian tubes and
ovaries can also be considered because of the possibility of the ovaries to become a
malignant focus in the future. Thorough Lymph node dissection and peritoneal washing
cytology should also be performed in order to stage the neoplasm based on the FIGO
classification. In this case, the patients endometrial adenocarcinoma is FIGO stage 1 grade
1 which prompts a TAHBSO with bilateral lymph node dissection and peritoneal fluid cytology
operation.
The possible complications and adverse outcomes of the surgery should be explained
to the patient. Complications such as bleeding after surgery, post-operative atelectasis,
pneumonia, inability to void, gastrointestinal problems, urinary fistula, wound complications
such as infection, dehiscence and evisceration, cellulitis and excessive granulation tissue
should be explained to the patient. It should also be explained to the patient that post
operatively, she will experience symptoms of early menopause because of the removal of
the ovaries which produce estrogen and symptoms of estrogen deprivation such as hot
flushes, vasomotor symptoms, urogenital tissue atrophy (atrophic vaginitis, dyspareunia,
and urethral syndrome), and osteoporosis and that these could be addresses by hormonal

replacement therapy. An oral tablet of 0.625 mg of conjugated estrogens daily is sufficient to

protect from bone demineralization and osteoporosis but higher dose may be required to
alleviate hot flushes. A 0.050.1 estradiol patch to premenopausal women without risk
factors to use estrogen, starting 2 days after surgery can also be an option because of the
smaller risk of developing coagulopathies compared to oral estrogen.
Pathophysiology and Clinical Course
Endometrial adenocarcinoma usually starts off as endometrial hyperplasia brought about by
excesses of estrogen relative to progestin. Overall, endometrial cells which are classified to
be complex atypical hyperplasia had the highest risk of progression to carcinoma which
might be the case for the patient. Simple hyperplasia had a 1% rate of progression to
cancer, complex hyperplasia without atypia had a 3% rate of progression to cancer, and
complex atypical hyperplasia had a 29% rate of progression to cancer.
Prognosis
The histologic grade and type of the tumor are major prognostic factors for endometrial
carcinoma. Grade 1 stage 1 endometrial adenocarcinoma has the best prognosis and almost
80% of all cases of Endometrial CA fall into a favorable category. Typical well differentiated
carcinomas have a 5-year survival rate of 90.9%.

Progress Notes
Date: 06/10/15
Subjective
Moderate
wound
pain. no complaint
of abdominal pain,
no flatus yet.

Objective
Stable vital signs
Regular cardiac
rate and rhythm,
no murmurs
appreciated
Presence of
Crackles, Ronchi on
lower lung field
lung fields
bilaterally.
Soft abdomen nontender,
normoactive bowel
sounds
Full and equal
pulses
Blood-tinged but
adequate urine
output

Assessment
Day one post
TAHBSO + BLND +
PFC
Rule out pulmonary
congestion,
pneumonia,
atelectasis

Plan
Maintain adequate
urine
output.
Furosemide
IV
40mg for diuresis
Encourage
deep
breathing exercises
Refer to anesthesia
for pain relief

Objective

Assessment

Plan

Date: 06/11/15
Subjective

Tolerable post op
pain aggravated by
cough, nausea and
vomiting,

Stable vital signs

Regular cardiac
rate and rhythm,
no murmurs
appreciated
Presence of
Crackles, Ronchi on
lower lung field
lung fields
bilaterally.
Soft abdomen nontender,
normoactive bowel
sounds
Full and equal
pulses
Blood-tinged but
adequate urine
output

Day two post

TAHBSO + BLND +
PFC

Increase oral fluid

intake
Encourage
deep
breathing
and
ambulation
Daily wound care

Objective
Stable vital signs
Regular cardiac
rate and rhythm,
no murmurs
appreciated
Presence of
Crackles, Ronchi on
lower lung field
lung fields
bilaterally.
Soft abdomen nontender,
normoactive bowel
sounds
Full and equal
pulses
Blood-tinged but
adequate urine
output

Assessment
Day three post
TAHBSO + BLND +
PFC

Plan
Encourage
deep
breathing
Daily wound care
Can eat soft diet if
with multiple flatus

Objective
Stable vital signs
Regular cardiac
rate and rhythm,
no murmurs
appreciated
Clear breath
sounds
Soft abdomen non-

Assessment
Day three post
TAHBSO + BLND +
PFC

Plan
Discontinue
IV
fluids
Insert 2 glycerin
suppositories
for
bowel movement
Daily wound care
Can eat soft diet if
with multiple flatus

Date: 06/12/15
Subjective
Minimal post op
pain voiding freely,
no flatus yet

Date: 06/13/15
Subjective
Minimal post op
pain voiding freely,
no flatus yet. No
bowel movement

tender,
normoactive bowel
sounds
Full and equal
pulses
Blood-tinged but
adequate urine
output
References:
Katz, V.L., et. al. 2007. Comprehensive Gynecology. 5th edition. USA: Mosby Elsevier.
Munro, M. G., et.al. 2011. FIGO classification system (PALM-COEIN) for causes of abnormal
uterine bleeding in nongravid women of reproductive age. Ireland: Elsevier.