FULL NAME:kudryashova lyubov vladimirovna

Age: 08.24.1970 (51 years old)

Marital status: married

Profession: pensioner

Place of residence: vulica lienina 29 ,vitebsk

Date of admission to the hospital: 09/09/2021

Diagnosis upon admission : endometrial polyp

Clinical diagnosis : endometrial polyp

Complaints at admission: pain in the lumbar region, swelling of the mammary glands, bleeding from the
genital tract.

Heredity is not burdened.

Life story

She grew and developed normally, and did not lag behind her peers in her studies. As a child, she
suffered from measles, chickenpox, parotitis, scarlet fever. According to the patient, the living conditions
are good (she lives with her husband in an apartment). Nutrition is adequate and sufficient. No bad
habits. From chronic diseases - hypertension, varicose veins of the lower extremities. There were no
serious injuries. The operation is denied. Allergic anamnesis is not burdened. Heredity is aggravated by
the presence of uterine fibroids in mother and grandmother.

Blood group B (III), Rh (+).

Obstetric and gynecological history

Menstruation from 12 years old, established in about a year, menstrual cycle 28 days, menstruation for
3 days. - painful, moderate. After the onset of sexual activity, their character did not change. The last
menstruation is very profuse, painless, in October 1998, postmenopausal. There were no general health
disorders.

Sexual life from 18 years old, regular. She has been married since the age of 18, the first marriage,
registered, continues to this day. My husband is 56 years old, according to the patient, suffers from
chronic bronchitis. She was protected from pregnancy by a physiological method. Sex life, according to
the patient, has been absent for 10 years.

6 pregnancies: 2 abortions, 2 spontaneous abortions, 2 births.

From gynecological diseases - salpingo-oophoritis, associated with hypothermia in 1996, was treated in
a hospital. Uterine fibroids since 2004

The function of the urinary system is not impaired. Periodically there are constipation (depending on the
food taken).

The course of the present disease:

For the first time complaints of pain in the lumbar region, swelling of the mammary glands, bleeding
from the genital tract appeared in February 2020. Bleeding lasted 2 weeks. In January 2020 she applied
for treatment. With ultrasound and hysteroscopic studies - uterine fibroids. A separate diagnostic
curettage was performed - a histological examination of scrapings revealed a glandular fibrous polyp of
the endometrium, cervical dysplasia of the 2nd degree, in connection with which depot-provera therapy
was carried out. After the 3rd injection on 29.06.2021, the bleeding was repeated and continued for 1.5
months. Received candles with indomethacin in the vagina. Hospitalized at 61 GKB for further
examination and treatment. On 6,09, 2021, the bleeding was repeated and continues to this day.

Physical examination data

The patient's condition is satisfactory, the consciousness is clear, the position is free, the facial
expression is normal, the physique is hypersthenic. Height 165 cm, weight 81 kg. Body temperature
36.6.

The skin is pale pink, there is no jaundice, the color of the visible mucous membranes is pale pink, there
is no jaundice. The moisture content of the skin is increased. The face is hyperemic.

Subcutaneous fat is overdeveloped and evenly distributed.

Muscles - the degree of development is moderate, the severity is moderate, the muscle tone is normal.

Bones - there is no soreness when feeling and there is no deformation.

Joints - the configuration is not changed, there are no swelling, soreness and crunching when moving,
the skin over the joints is not changed.

Respiratory system

Examination: breathing through the nose, difficult (due to chronic vasomotor rhinitis); discharge from
the nasal passages is not observed. Soreness with pressure and tapping at the root of the nose in the
places of the frontal sinuses and maxillary cavities is absent.

Larynx: on examination, the larynx is normal; when feeling the area of the larynx, pain is not noted.

The rib cage is conical, without deformations, moderately elastic. The right and left halves of the chest
are symmetrical, they move synchronously when breathing. The supraclavicular and subclavian fossa are
marked weakly equally expressed on the right and left. The clavicle and shoulder blades are at the same
level. The auxiliary respiratory muscles are not involved in the act of breathing. The breathing type is
mixed.

Respiratory rate 18 / min.

On palpation of the chest. cl. no soreness was found, elasticity was good, voice tremor was not
weakened, felt in symmetrical areas with equal strength.

Percussion pulmonary sound.

Auscultatory breathing is hard, carried out in all parts of the lungs, wheezing is not heard.

The cardiovascular system.

Examination of the neck: there is no pulsation of the carotid arteries, a positive venous pulse, a "dance"
of the carotid and no pulsation in the jugular fossa.

Examination of the region of the heart: the chest in the region of the heart is not changed, heart hump,
cardiac. there are no aftershocks. The apical impulse is strengthened and diffuses in 5 m.

Expansion of relative dullness to the left by 1 cm.

Auscultation of the heart: the 1st tone above the apex is weakened. Heart rate - 88 / min. Vascular
examination: pulse on the right. and the left radial arteries synchronous, 88 / min, the rhythm is correct,
tense, full.

Varicose veins. The capillary pulse is not detected.

Blood pressure is 140 and 80 mm Hg. Art.

The digestive system.

Swallowing is free, painless, appetite is good, taste is not changed, thirst is not increased, does not feel
pain when chewing.

Intestinal activity is regular. According to the patient, the stool without pathological impurities, shaped
consistency, is brown. Constipation is rare.

Examination of the oral cavity: the smell is normal. The mucous membrane of the inner surface of the
lips, cheeks, soft and hard palate is pink in color. Rashes and ulceration are absent. Gums pale pink, do
not bleed. Tongue of normal size and shape, pink in color, not coated, moist. The pharynx is pink in
color, the palatine arches are well contoured, the tonsils do not protrude beyond them. The mucous
membrane of the pharynx is not hyperemic, with a smooth surface, and moist.

Palpation of the lower edge of the liver, gallbladder, pancreas was not possible due to the pronounced
layer of subcutaneous fat.

Urinary system.

Examination revealed no pathological changes. The kidneys are not palpable. Pasternatsky's symptom is
negative on both sides.

Hematopoietic organ system.

Examination: pallor and subectery of the skin and mucous membranes were not noted. Lymph nodes
are not enlarged, mobile. There are no language changes.

There is no soreness when tapping the sternum and tubular bones.

The spleen is not palpable.

Endocrine system.

On examination, exophthalmos and an increase in the size of the neck in the thyroid gland were not
observed.

The thyroid gland is not palpable.

Neuropsychic condition.

Consciousness is clear, comes into contact easily, intellect is normal, speech is not disturbed.

No disturbances in sensitivity, motor sphere were found. Hearing and smell are within the age norm.
Reflexes are lively, no pathological ones were found.

Good sleep.

Gynecological examination data

The external genitals are well developed. There is a prolapse of the walls of the vagina 1-2 st. The cervix
is cylindrical, not eroded. The body of the uterus is dense, increased to 6 cm, painless. The appendages
are not palpable. The vaults are deep. Discharge from the genital tract is bloody, moderate.

Additional examination methods

1. About Shareable blood test:

Lab. indicators

10/09/2021
norm

Erythrocytes

Hemoglobin

Hematocrit

4.99 M / ml

13.4 g / dl

50.3%

3.9-6.5

12.0-17.5

36-54

Neutrophils

Leukocytes

Monocytes

Eosinophils

basophils
segmented

ESR

stab

74

eighteen

7%

63

15

40-75

2-10

1-6
0-1

2. About Shareable urinalysis:

indicators

11/09/2021

Transparency

Rel. density

Colour

glucose

ketone bodies

bilirubin

NS

Slime

Protein fraction

Urobilinogen

Nitrates
Erythrocytes

leukocytes

Full

1025

Straw yellow

No

No

No

5.5

moderately

traces

3/2 umd / n

-
-

3. Coagulogram

prothrombin index 102%

prothrombin time 15 (n 14.7)

fibrinogen 2.0

APTV 38 "

Thrombotest grade V

4. Biochemical blood test

indicators

meaning

norm

Total protein

Urea

General bilirub.

Direct bilirub.
Creatinine

Amylase

ALT

AST

Alkaline phosphatase

7.8

5.7

22

67

61

87

thirty

thirty

3.7
6.7-8.7 g / dl

1.7-8.3 mmol / l

5-20 μmol / l

0-4 μmol / l

44-115 μmol / l

0-220 U / l

-40 U / l

-38 U / l

64-306 U / l

6. Blood group B (III) Rh (+)

7. Ultrasound of the pelvic organs

The body of the uterus is 52 x 66 x 79 mm, with an uneven contour, a cellular echo structure. M-ECHO
10 mm. On the back wall, the node is up to 34 mm, without a clear capsule.

Left ovary 25 x 26 mm. The right ovary is not visualized.

8. Extended colposcopy
Leukoplakia of the cervix.

9. WFD of the endometrium: scraping of the endometrium, endocervix and biopsy of the cervix.
(19.12.03 g.)

1.A piece of the cervical mucosa is covered with stratified squamous epithelium of uneven thickness
with focal parakeratosis. Dysplasia of the 1st-2nd degree In the stroma, edema, hemorrhage. Focal
lymphoplasma cell infiltration with an admixture of neutrophilic leukocytes.

2. a small piece of the mucous membrane of the cervical canal of normal structure.

3. the endometrium is atrophic. Glandular fibrous polyp of the endometrium. Scraps of the mucous
membrane of the cervical canal.

Conclusion: exacerbation of chronic endocervicitis. Focal dysplasia of the epithelium.

10. WFD of the endometrium: scraping of the endometrium, endocervix and biopsy of the cervix.

(04.16.04 g.)

The cervical canal is expanded to the size of Gegar's dilator No. 12. The length of the uterine cavity along
the probe is 7 cm.

1.A piece of the mucous membrane of the cervix is covered with stratified squamous epithelium with
symptoms of parakeratosis. Focal lymphoplasma cell infiltration with thinning and dystrophic changes in
the epithelium was noted.

2. a small piece of the mucous membrane of the cervical canal of normal structure.
3. large fragments of endothelial glandular-fibrous polyp with precidual changes in stromal elements as
a result of hormonal treatment in scraping. The glands of various sizes are lined with 1-row weakly
proliferative epithelium.

11. Chest X-ray

The pulmonary fields are transparent. Structural roots. The diaphragm with smooth contours, the
sinuses are free. Left ventricular hypertrophy. The aorta is somewhat deployed.

12. ECG

Signs of overload of the right atrium and left ventricle.

Diagnosis:

Main: Recurrent hyperplastic process of the endometrium.

Competing main: endometriosis of the body of the uterus.

Concomitant diseases: cervical leukoplakia.

Dysplasia of the cervix of the 1st-2nd stage.

Mime of the uterus.

Hypertensive disease of the 2nd stage.

Complications: Postmenopausal uterine bleeding.

Rationale for the diagnosis:

1. Recurrent hyperplastic process of the endometrium:

on the basis of complaints

clinical picture (recurrent uterine bleeding in postmenopausal women)

data of histological examination (in scraping large fragments of endothelial glandular fibrous polyp)

repeated RFE with histological examination

2.endometriosis of the body of the uterus:

on the basis of ultrasound (The body of the uterus with an uneven contour, cellular echostructure. M-
ECHO 10 mm.)

3. uterine fibroids:

based on complaints (pain in the lumbar region, bleeding from the genital tract.)

ultrasound data of the pelvic organs (On the back wall of the node up to 34 mm, without a clear
capsule.)

4. leukoplakia of the cervix:

based on data from extended colposcopy

5.Dysplasia of the cervix of the 2nd degree:

based on histological examination data

Differential diagnosis

1. submucosal fibroids: characteristic of the submucosa mimes prolonged heavy menses, cramping pain
in a patient is not observed. A history of 2 spontaneous abortions, complaints of bleeding from the
genital tract in postmenopausal women, and an enlarged uterine body according to a bimanual study
may indicate the presence of submucosal fibroids. However, ultrasound revealed a node up to 34 mm
along the posterior wall, without a clear capsule; the expansion of the uterine cavity, characteristic of
submucous fibroids, was not noted. Hysteroscopic examination also does not confirm this diagnosis.
Histological examination of endometrial scrapings about WFD confirms the diagnosis of endometrial
hyperplastic process.

2. endometrial cancer: uterine bleeding in postmenopausal women may testify in favor of endometrial
cancer, but this clinic is not specific and may also be characteristic of endometrial hyperplastic
processes. According to ultrasound data, M-ECHO 10 mm (at a rate of up to 4 mm in postmenopausal
women) may be suspicious of endometrial cancer. However, histological examination of endometrial
scrapings in WFD confirmed the diagnosis of endometrial polyp.

Treatment

Considering the presence of a hyperplastic process of the endometrium, its recurrent nature, the
presence of complications (bleeding in postmenopausal women), the absence of the effect of hormonal
therapy (depot-provera), in combination with an organic pathology of the uterine body - the presence of
a myomatous node of the uterine body up to 34 mm, as well as the presence of background
(leukoplakia) and precancerous (2nd degree dysplasia) diseases of the cervix, postmenopausal age of the
patient, surgical treatment is indicated. A radical operation in the amount of a panhysterectomy is
optimal.

Presumptive pathogenesis

The leading place in the pathogenesis of endometrial hyperplastic processes is given to absolute or
relative hyperestrogenism. It, in turn, may be caused by hormone-producing tumors of the ovaries (no
data were obtained for this during the examination), incorrect use of COCs (according to the patient,
they were not used). However, HPE can also develop with disorders of tissue reception - infectious and
inflammatory changes in the endometrium (the patient has a history of salpingo-oophoritis, 2 abortions,
2 spontaneous abortions, which could well contribute to the formation of a chronic inflammatory
process of the endometrium).

In the development of uterine fibroids, it is possible to assume the hereditary nature of the disease (the
patient's history indicates the presence of uterine fibroids in the mother and grandmother), as well as
possible chronic endometrial diseases (myomatous nodes form around inflammatory infiltrates in the
endometrium).

The occurrence of leukoplakia and dysplasia of the cervix can be caused by trauma or inflammatory
processes (2 history of abortions, 2 spontaneous abortions, 2 births).

11. EPICRISIS Patient:

Kudryashova Lyubov Vladimirovn, 51 years old, was admitted on 13/09/2021 in Vitebsk gynecological
hospital referred for surgical treatment with a diagnosis of endometrial polyp, uterine myoma. Clinically
examined, no changes were found in general clinical blood and urine tests. Ultrasound revealed:
endometrial polyp, uterine myoma. Hysteroscopy was performed. Produced separate endometrial
scraping with curettes No. 4.2, polypectomy. Conclusion: Endometrial polyp, polyp of the cervical canal,
uterine myoma intramural - submucous form. Final diagnosis: Endometrial polyp, polyp of the cervical
canal, intramural uterine myoma - submucous form.

12. RECOMMENDATION *

Dispensary observation by a gynecologist of the ZhK 1 time per quarter. * Ultrasound scan once every 6
months. * Compliance with a healthy lifestyle (normalization of sleep, good nutrition, physical activity,
rejection of bad habits, weight control). * Periodic intake of vitamins and minerals in the winter-spring
period (gendevit, pentovit, aevit, folic acid).