TOLEDO, MEEVIE LOVE D.

NMD 3
OB-GYNE CLINICS

Clinical Case # 3:

A 42-year-old G3 P3 female presents with a history of abnormal bleeding and pelvic pain. She
was well until approximately age 35, when she began developing dysmenorrhea and progressive
menorrhagia. The dysmenorrhea was not fully relieved by NSAIDS. Over the next several years, the
dysmenorrhea and menorrhagia became more severe. She then developed intermenstrual bleeding
and spotting, as well as pelvic pain, which she describes as a constant feeling of pressure. She also
complains of urinary frequency. Past gynecological history is otherwise non-contributory. She delivered
three children by caesarean section, the last with a tubal ligation at age 30. Her past medical history is
unremarkable.
Physical Examination reveals a well-developed, well-nourished woman in no distress. Vital
signs and general physical exam are unremarkable. Abdominal examination reveals an irregular-sized
mass extending into halfway between the pubic symphysis and umbilicus and to the right of the midline.
Pelvic exam reveals a normal appearing vagina and cervix. The uterus is markedly enlarged, firm,
irregular, and occupying the right side of the lateral pelvic sidewall. The examiner is unable to palpate
normal ovaries due to the mass.

Guide questions:

1. What is your primary impression? Justify your answers.

G3P3 (3003). S/p 3 CS; To consider Myoma Uteri.

I’m considering Myoma Uteri for this case because leiomyomas are the most common benign
neoplasms of the uterus. An increasing age is a risk factor and the patient is already 42 years old. The
clinical picture of the patient in this case which is consistent with the symptoms of leiomyoma include:
progressive menorrhagia, intermenstrual bleeding and spotting, pelvic pain described as a constant
feeling of pressure and urinary frequency. The physical examination supports this claim because of the
existence of an irregular-sized mass extending halfway between the pubic symphysis and umbilicus
and to the right of the midline. Moreover, a markedly enlarged, firm, and irregular uterus which
occupies the right side of the lateral pelvic sidewall was noted.
 2. What are the differential diagnoses that can be considered in this case?

Rule-in Rule-out

Endometrial polyp Endometrial polyps have a peak Endometrial polyps was ruled-out
incidence between ages 40 and because majority of the cases do
49. The patient in this case is 42 not present with a pelvic pain.
years old. Based on the patient’s Polyps are composed of
history, she had progressive endometrial tissue. These are
menorrhagia, and succulent and velvety, with a
intermenstrual bleeding and large central vascular core. This
spotting which are symptoms of does not fit the presentation of
the presence of endometrial the patient in this case which has
polyps. an irregular-sized mass and a
markedly enlarged, firm, and
irregular uterus which occupies
the right side of the lateral pelvic
sidewall.
Adenomyosis Adenomyosis was ruled-in It was ruled out because the
because of the progressive patients with adenomyosis more
menorrhagia. often present with a diffusely
enlarged uterus. The uterus is
typically smooth, globular, and
boggy. The patient in this case
has a markedly enlarged, firm
and irregular uterine finding.
Leiomyoma Leiomyoma was ruled-in because Cannot be ruled out
the patient is already
42 years old. She also has a
history of progressive
menorrhagia, intermenstrual
bleeding and spotting, pelvic pain
described as a constant feeling of
pressure and urinary frequency
which are all symptoms of
Leiomyoma. Her physical
examination also revealed an
rregular-sized mass extending into
halfway between the pubic
symphysis and umbilicus and to
the right of the midline. Upon
examination, it was also noted
that the uterus is markedly
enlarged, firm, irregular, and
occupying the right side of the
lateral pelvic sidewall.
Ectopic Pregnancy This was ruled in because of the This was ruled-out because the
bleeding and the existence of the patient has already undergone a
mass extending into halfway tubal ligation 12 years ago.
between the pubic symphysis and
umbilicus and to the right of the
midline.
 3. What is the best diagnostic confirmatory test for this case? Justify your answers.

The best diagnostic confirmatory test is transvaginal ultrasound because it gives a clear view of
the uterus. It can also show the size of the ovaries and uterus, uterine masses or tumors, and the
thickness of the endometrium. Moreover, during an examination, the woman is in a dorsal lithotomy
position and has an empty bladder. Because the transducer is closer to the pelvic organs than when a
transabdominal approach is employed, endovaginal resolution is usually superior. Furthermore, it can
easily differentiate fibroids from a pregnant uterus or adnexal mass

4. What is your final diagnosis? Justify your answers.

G3P3 (3003). S/p 3 CS. Myoma Uteri.

After carefully considering all the differential diagnoses, Myoma Uteri is my final diagnosis
because it is the most consistent condition that matches with the clinical picture of the patient: 1.) 42
years of age, 2.) History of progressive menorrhagia, intermenstrual bleeding and spotting, pelvic pain
described as a constant feeling of pressure and urinary frequency and 3.) Physical examination result
sof an irregular-sized mass extending into halfway between the pubic symphysis and umbilicus and to
the right of the midline and a markedly enlarged, firm, irregular, uterus which occupyies the right side of
the lateral pelvic sidewall.