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Princess Aliza Gonzales
case of C.P.R., 82 y.o., P6005, menopause at 50 y.o., admitted for the first time on August 7, 2006 at 1637.
HISTORY OF PRESENT ILLNESS
2 weeks prior to admission, noted vaginal bleeding
Sudden onset Intermittent Scanty – consuming 1 thinly-soaked sanitary pad per episode No clots Red Non-foul
Not exacerbated by physical activity nor intake of drugs Not relieved by rest
Associated with vaginal discharge,
Minimal Watery Non-foul Whitish
Not associated with abdominal or hypogastric pain nor dyspareunia No medications taken No consult done
2 hours prior to admission, recurrence of vaginal bleeding
consulted a private physician
thus, advised admission
17 X 28-30 X 3-7 consumed 2-3 moderately-soaked pads per day. associated with premenstrual dysmenorrhea characterized as
localized, moderate, intermittent, crampy hypogastric pain occurring 1-2 days before the onset of menstruation disappeared on the day when bleeding began
by bed rest No medications taken Not associated with NAV, headache, breast pain, irritability, constipation, diarrhea Menopause at 50 y.o. with episodes of hot flushes, headache, fatigability and irritability which lasted for about half a year.
O r d e r 1
Year A of O deliv G ery
Type S Condition of e at birth delive x ry B W
Place of H Cx delivery and led by Home Home TBA No TBA No
1949 FT NSVD F Good
2 1950 FT NSVD F Good 3 1952 FT CS 2° M Good CPD 4 1954 FT NSVD M Died 30min. after birth due to 5 1957 FT NSVD M tight cord Good coil 6 1959 FT NSVD F Good
7 Hospital MD No to 8 Home TBA No Lb
TBA No TBA No
history of contraceptive use
First coitus at 23 y.o. Husband as the only sexual partner 3-4 times a week Last sexual contact was around 5557 y.o. Not associated with dyspareunia nor postcoital bleeding.
PAST ILLNESSES & OPERATIONS
M – HTN, had cervical polyp, had arthritis, no DM, no asthma, no heart and kidney diseases, no CA M – took Diovan OD for HTN, Colchicine for arthritis A – no food and drug allergies S – 1952, had CS 2° to CPD 2002, Polypectomy done at Los Angeles, U.S.A. H – previous surgery
Breast CA on the maternal side HTN on paternal side No heredofamilial diseases like DM, TB, asthma, kidney and heart diseases
Marital – married; living with husband and family of her youngest daughter Stress level – no significant recent life events; unemployed Life history information – had history of travel to Bohol, Manila, and Los Angeles
Habits – does not smoke nor drink alcoholic beverages, occasional coffee drinker, no history of illicit drug use Education – secondary education Husband – 84 y.o., businessman, non-promiscuous
Meals for the past 24 hours
Aug.6,2006 – Dinner:
2 cups rice, 1 medium-sized fish, 1 glass of water 2 pcs stuffed bread, 1 glass of milk 2 cups rice, 1 medium-sized fish, 1 serving vegetables, 1 glass of juice
Aug.7,2006 – Breakfast:
Aug.7,2006 – Lunch:
No change of appetite With dentures No allergy to foods, not choosy with foods Budget for food varies with availability with money
Ideal Body Weight (IBW)
IBW = ht (cm) – 100 – 5% = 5’(12’)(2.54cm) – 100 – 5% = 152.4 – 100 – 5% = 52.4 – (2.62) = 49.78 kg ~ 50 kg Actual wt = 74 kg
Total Energy Requirement (TER)
TER = IBW (30) + 300 = 50 (30) + 300 = 1500 + 300 = 1800 cal/day
Basal Metabolic Rate (BMR)
BMR = weight (kg) height (m)2 = 74 kg (1.52)2 = 74 kg 2.31 m2 = 32.0 kg/m2 ~ obese
General. on walker, no easy fatigability, had occasional headache, no fever, no dizziness, (+) blurring of vision Respiratory. No cough, no dyspnea Cardiovascular. No chest pain, no tightness, no palpitations
Gastrointestinal. No dysphagia, no weight loss Urinary. No urgency, no frequency, no dysuria Reproductive. (+) vaginal bleeding, (+) abnormal discharge, no pruritus nor pain
General. Patient was conscious, coherent, cooperative, afebrile, not in respiratory distress with the following vital signs: BP = 130/80 mmHg HR = 74 bpm Ht = 5’ RR = 18 cpm Wt = 74kg Temp.= 36.6ºC
Skin. Warm, senile turgor HEENT.
Head: symmetric, no scars, no fractures, thin grayish hairs Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, clear cornea Ears: no discharge, no foreign body, no tenderness,
body Mouth and Throat: lips pink, moist oral mucosa and tongue Neck. No venous engorgement, no tenderness, no rigidity, no lymphadenopathy
no discharge, no foreign
Breast. I - symmetrical, no skin retraction or dimpling, no swelling or discoloration, no discharge, brown areola with everted nipple P – no tenderness, no mass,
Chest and Lungs. I – No gross deformities, equal chest expansion P – equal tactile fremitus, no tenderness P – resonant A – clear breath sounds, no rales, no wheeze
Heart. I – no bulging of precordium P – PMI at 5th L ICS midclavicular line, no heave, no thrill P – dullness within normal limits A – distinct heart sounds, normal rate and rhythm, no murmur, no pericardial friction rub
Abdomen. I – flat, silvery striae, midline CS scar P – soft, no tenderness, no mass, no organomegaly P – tympanitic A – normoactive bowel sounds
cervix: pinkish, smooth, no ulcerations scanty, reddish, non-foul bleeding minimal, watery, whitish, non-foul discharge 1x1 cm, single, grayish-white, welldelineated mass at the external os
Bimanual Pelvic Exam
I – few grayish pubic hairs, no ulcerations, no edema, no swelling, no erythema, parous C – posterior, closed, firm, movable, nontender - well-delineated, soft, non-tender mass at the external os U – not enlarged, anteverted, soft, movable, no mass, no tenderness A – no mass, no tenderness
Extremities. (+) bipedal non-pitting edema, strong pulses
Color – yellow Transparency – hazy Albumin – trace Blood - ++ WBC – 0-2 hpf RBC – 5-10 hpf Epithelial cells – rare Bacteria – rare
Complete Blood Count (CBC)
WBC – 6.56 K/uL Neutrophils – 3.86 Lymphocytes – 1.77 Monocytes – 0.632 Eosinophils – 0.203 Basophils – 0.107
RBC – 4.57 M/uL HgB – 12.7 g/dL Hct – 39.8% Plt – 246 K/uL
Transvaginal Ultrasound findings:
The anteverted uterus is normal in size, regular in contour and heterogeneous in echopattern, with abundant echogenic calcifications distributed along the uterine walls. It measures approximately 4.8cm in longitudinal diameter, 2.4cm in AP diameter and 4.5cm in transverse diameter.
The closed heterogeneous cervix has a cervical length of 3.4cm and 3.5cm in width. Incidentally, there is a polypoid mass within the mid-cervical canal approximately 1.3 x 1.3 x 1.1cm in size, suggestive of endocervical polyp versus cervical pathology.
The heterogeneous endometrium is thin with a greatest thickness of approximately 0.5cm with an intact endometrial contour compatible with menopausal cycle. Both ovaries were not visualized. No evidence of adnexal nor uterine mass. There is no free fluid in the cul de sac.
82 y.o., multiparous Postmenopausal bleeding associated with vaginal discharge History of cervical polyp 1x1 cm, single, soft, non-tender, grayish-white, well-delineated mass at the external os
Transvaginal ultrasound findings
Normal-sized uterus, anteverted, with abundant echogenic calcifications around uterine walls Thin and intact heterogenous endometrium (0.6cm), compatible with menopausal cycle To consider endocervical polyp versus cervical pathology Both ovaries were not visualized No uterine nor adnexal mass
Atrophic vaginitis Endometrial polyp Endometrial carcinoma
Senile vaginitis Inflammation of the vaginal epithelium due to atrophy secondary to decreased levels of circulating estrogens Most common in postmenopausal women
Decreased estrogen production Atrophy of vaginal epithelium itching burning discomfort dyspareunia
Decreased estrogen production Decreased collagen content Urethrovesical junction Increased abdominal pressure Urinary stress incontinence Cardinal & uterosacral ligaments Lose tonicity Uterine decensus enterocele
Endopelvic fascia rectocele
Decreased estrogen production
Atrophic changes of the urinary tract epithelium
Urinary urge incontinenc e
Itching Vulvar burning Dyspareunia Discomfort Vaginal bleeding
Urinary urge incontinence Urinary frequency Dysuria Nocturia Urinary stress incontinence
Cystocele, rectocele, enterocele
Basis for Inclusion
82 y.o. Postmenopausal bleeding Vaginal discharge
Basis for Exclusion
(-) Itching (-) Vulvar burning (-) Urinary symptoms (-) Cystocele, rectocele, enterocele Mass at the external os
Are localized overgrowths of endometrial glands and stroma that project beyond the surface of the endometrium They are soft, pliable, and may be single or multiple. Most polyps arise from the fundus of the uterus
They may have a broad base (sessile) or be attached by a slender pedicle (pedunculated). The growths were discovered in all age groups, with peak incidence between the ages of 40 and 49.
Majority are asymptomatic Associated with wide range of abnormal bleeding patterns Occasionally, a pedunculated endometrial polyp with a long pedicle may protrude from the external cervical os
Polyps are succulent and velvety, with a large central vascular core The color is usually gray or tan but may occasionally be red or brown The tip of a prolapsed polyp often undergoes squamous metaplasia, infection, or ulceration
The clinician cannot distinguish whether the abnormal bleeding originates from the polyp or is secondary to the frequently coexisting endometrial hyperplasia.
Basis for Inclusion
82 y.o. Abnormal bleeding 1x1cm, single, soft, mobile, nontender, well-delineated, grayishwhite polypoid mass at the external os
Basis for Exclusion
(-) ulcerations at the tip of polypoid mass UTZ findings of endocervical polyp
Because most endometrial are asymptomatic,the diagnosis is not usually established until the uterus is opened following hysterectomy for other reasons. Are often discovered by vaginal hydrosonoraphy, hysteroscopy, and/or hysterosalphingography during the diagnostic workup of a woman with a refractory case of abnormal uterine bleeding.
most common gynecologic CA Phil: 3rd most common gynecologic CA Occurs primarily in postmenopausal women Increasingly virulent with advancing age Any factor that increases exposure to unopposed estrogen increases risk of endometrial cancer (ovary, breast,
Variants of normal anatomy and physiology
obesity 21-50 lbs = 3x >50 lbs = 10x nulliparity = 2x early menarche and late menopause >52 years = 2.5x Tamoxifen use = 2.5 – 9x Atypical hyperplasia = 29%
Frank abnormality and disease
DM = 3x HTN = 1.5x
Exposure to external carcinogens and unopposed estrogen treatment
DUB, PCOD, 1° Infertility due to chronic anovulation
Ovulation Progestin therapy Menopause prior to 49 Normal weight Multiparity
Other Risk Factor
LYNCH family CA syndrome nonpolyposis colorectal CA, Ovarian and Endometrial CA, Breast CA
75% beyond menopause 15% perimenopausal 10% still menstruating 90% will have vaginal bleeding or discharge Older patients with cervical stenosis – hematometra or pyometra 5% asymptomatic Obesity, hypertensive, diabetic
Basis for Inclusion
82 y.o. Postmenopausal bleeding Vaginal discharge Family history of breast cancer Hypertensive Obese
Basis for exclusion
Multiparity Menopause at 50 1x1 cm, single, soft, mobile, nontender, grayish-white, welldelineated mass protruding from external os UTZ findings of thin and intact heterogeneous endometrium compatible with menopausal cycle UTZ findings of endocervical polyp
Office aspiration biopsy
First step in evaluation of patients with abnormal bleeding 90-98% accurate Unreliable, 30-40% will be abnormal Endocervical cells on pap smear
6% will have endometrial cancer 13% endometrial hyperplasia
Hysteroscopy and D&C
Cervical stenosis Patient cannot tolerate office biopsy Bleeding recurs after negative biopsy Specimen obtained is inadequate Endometrial polyp or submucous myoma Endometrial thickness >5mm in a postmenopausal patient requires further evaluation
Most common benign neoplastic growths of the cervix Most common in multiparous women in their 40s and 50s Usually present as a single polyp, but multiple polyps do occur occasionally Majority are smooth,soft, reddishpurple to cherry red, and fragile
They easily bleed when touched Polyps may arise from either:
Endocervical canal – endocervical polyp
Usually have a narrow long pedicle Occur during reproductive years Cherry red in color
Ectocervix – cervical polyp
Usually have a short, broad base Usually occur in postmenopausal women Grayish-white in color
Usually secondary to inflammation or abnormal local responsiveness to hormonal stimulation Focal hyperplasia and localized proliferation are the response of the cervix to local inflammation.
Intermenstrual bleeding, especially following contact such as coitus or pelvic exam Sometimes associated leukorrhea emanates from the infected cervix Many are asymptomatic and recognized for the first time during a routine speculum exam Often the polyp seen on inspection is difficult to palpate because of its soft consistency
Basis for inclusion
82 y.o., multiparous Postmenopausal bleeding Leukorrhea Previous history of polypectomy 1x1 cm, grayish-white, well-delineated mass at the external os Ultrasound findings - polypoid mass within the mid-cervical canal approximately 1.3 x 1.3 x 1.1cm in size, suggestive of endocervical polyp versus cervical pathology
Most endocervical polyps may be managed in the office by grasping the base of the polyp with an appropriately sized clamp Polyp is avulsed with a twisting motion and sent to the pathology laboratory for microscopic evaluation
The polyp is usually friable. If the base is broad or bleeding ensues, the base may be treated with chemical cautery, electrocautery, or cryocautery After polyp is removed, endometrial sampling should be performed to diagnose a coexisting endometrial hyperplasia or carcinoma in both symptomatic and asymptomatic
COURSE IN THE WARD
On admission, patient was referred to IM Department for evaluation due to old age. She was diagnosed to have Essential HTN. She was given Co-Diovan 80mg 1tab OD.
Patient was operated on her first hospital day through fractional curettage with cervical punch biopsy and polypectomy under intravenous sedation. Pre-operative and postoperative diagnosis was cervical polyp.
Fractional curettage obtained a minimal amount of endometrial and endocervical tissue. Uterine depth was 8cm. EBL was 50cc. Specimen were sent for biopsy and findings showed Endometrial polyps, Chronic endocervitis and no diagnostic abnormality in the ectocervix.
Patient was discharged on her first post-operative day with improved condition – no complaints of vaginal bleeding or abnormal vaginal discharge.
. . . . . . . . . . . . . . .Thank you