GENERAL DATA

MA, a 42 year - old

Nulligravid
Single
From Las Pinas
 HISTORY OF PRESENT ILLNESS
Palpable mass at the level of umbilicus
10 months PTA Enlargement of abdomen
Transrectal ultrasound done revealing

Uterus: 10.54 x 10.32 x 9.59cm, retroverted, deviated to the left

Multiple myoma uteri (isoechoic masses without any intratumoral color:
Ml: 9.97 x 8.12cm, right lateral, intramural with 50% subserous and submucous component
M2: 4.97 x 2.88cm, posterior wall, intramural
M3: 9.12 x 8.57cm, posterofundal
M4: 5.44 x 4.85 x 5.35cm, anterofundal, 50% subserous
M5: 11.10 x 8.8 x 10.18 cm, right lateral subserous

Cervix: 3.01 x 2.11 x 1.69cm

Thickened endometrium 1.06cm, no color, borders distorted because of mass, probably premenstrual
endometrium
Right ovary not visualized
Normal looking left ovary with small few follicles. LO: 6.46 x 4.70 x 6.47 cm, located at upper quadrant of
patient's abdomen with several follicles
 HISTORY OF PRESENT ILLNESS
With abdominal pain, PS 7/10, radiating to the back
( ) consult with AP: advised medical management prior to
9 months PTA surgery
Started on GNRH agonist

Persistence of symptoms
6 months PTA s/p 3 doses of GNRH agonist
Repeat transrectal ultrasound done revealing

Uterus: 23.24 x 15.32 x 22.01cm

Ml: 13.53 x 14.89 x 7.02cm, fundal subserous. There is a huge pelvoabdominal mass reaching 4 finger
breadths below the xiphoid process with approximate measurement of 23.24 x 15.32 x 22.01cm,
irregularly shaped with varying degrees of echogenicity, some structures with cystic and calcific
changes probably representing a huge myoma uteri with cystic and calcific degeneration.

Cervix: 2.36 x 2.82 x 1.86cm

Endometrium: not visualized in this scan

Right ovary: 3.75 x 2.54 x 2.58cm

Left ovary: not visualized
Review of Systems

General: (- ) fever, ( - )chills, (- ) fatigue, (-) anorexia, (- ) weight loss

Skin: (-) rash , (- )lesion
HEENT: (- )sore throat,(- )nasal discharges,(- ) hearing loss
Cardiovascular system: (- )chest pain, ( - ) palpitations, (- ) orthopnea,
(- ) easy fatigability
Gastrointestinal- ( - )Nausea, (- )vomiting, (- ) diarrhea, (- ) constipation,
(- ) hematochezia, (-) melena
Genitourinary-(- ) dysuria (- ) urinary frequency, (- ) urgency ( - ) nocturia
Musculoskeletal- (- ) muscle pain,(- ) joint pain, ( - ) edema

*
 Physical Examination
General Survey: Awake, ambulatory, not in respiratory
distress

Vital Signs:
BP: 120/80 mm/ Hg HR: 84 bpm
RR: 19 cpm °
T- 36.2 C
02 sat- 99%

BMI: 34.2 kg/m 2

 Physical Examination
ABDOMEN:

Palpation: Distented by a huge pelvoabdominal mass measuring 28 x 26cm, doughy,

irregularly shaped, more to the right, slightly movable, non-tender
Abdominal girth: 108cm

PELVIC EXAMINATION:

Inspection: Equally distributed hair, no lesions/masses

Speculum Examination: Not done
Internal Examination: Vagina is nulliparous and smooth. Cervix was small, closed,
uneffaced, more to the left, and pulled upwards, uterine size difficult to assess
because of the huge pelvoabdominal mass
RVE: Smooth parametria, no nodulations, well- formed cul de sac