A gynecology case study
CC: “I have been having a heavy and painful menstrual period that lasts for more than a week, progressive abdominal discomfort, and gradual abdominal distension.”
The client, R. N. is a healthy 32yo Caucasian female. The client visits a gynecological clinic following a heavy and painful menstrual period that lasts for more than a week, progressive abdominal discomfort, and gradual abdominal distension for the last six months. The client further reports irregular menstruation and spotting between monthly periods. She takes Acetaminophen 325 mg to manage the abdominal pain. R. N denies aggravating or relieving factors. She denies nausea, weight loss, vomiting, constipation, or anorexia. The client denies changes in bowel movement, frequent urination, pain with urination, increased urge to urinate, and production of a small amount of urine. She denies bloody or pink vaginal discharge. The client denies experiencing similar symptoms in the past.
Pertinent Past Medical History (PMH)
Current Medication: Acetaminophen 325 mg 2 tablets every 6 hours taken to manage abdominal pain.
Allergies: No known allergies
Medication intolerance: Denies medication intolerance
Past Medical Conditions: Denies history of chronic illnesses.
Hospitalization: No hospitalization history
Pertinent Past Medical History (PMH):
Menstruation: Her menarche occurred at 14 years. She has regular and heavy menstrual periods accompanied by severe cramping. Menstrual cramps are severe during the first day and reduce over time. She has a 4-days cycle. Her last monthly period was 26th July 2022.
Contraception: Denies taking oral contraceptives.
Vaginal and Cervical Cytology: Last Pap smear test was in 2021 and the results were normal. The last STI testing was in 2020 with normal results.
Obstetric History Denies pregnancy history.
Sexual History: Not sexually active for the last three years.
GYN Procedures: Denies gynecological problems.
Health Maintenance: The client takes a healthy diet rich in fiber and low calories. She jogs for 30 minutes every morning and visits the gym over the weekend. She also accompanies her sister to the swimming pool during her free time. Goes for Pap smear and STI testing regularly. The last Pap smear test was in 2021 and the results were normal. The last STI testing was in 2020 with normal results. She goes for eye and dental examinations annually. Her last eye examination was in October 2021 and the results were normal. Her last dental examination was in February 2022. No dental caries was identified during the examination.
Family History (FH): She is the firstborn in a family of two. Her both parents are alive. Father is 67 years old with a history of high blood pressure, type 2 diabetes mellitus (T2DM), and obesity. Her mother is 62yo with cervical cancer, ovarian cysts, and high blood cholesterol. Her younger sister is 23yo at college, and healthy. Her maternal grandfather died of cardiac arrest at 88 years. Her maternal grandmother died of hypertension at 83 years. Her paternal grandfather died of a stroke at 92 years. Her paternal grandmother is alive at 95 years with hypertension, obesity, and arthritis.
Social History (SH): The client is a banker, working at one of the leading banks in the city. She lives with her younger sister in her three-bedroom apartment located within the city. She spends time at her parent’s house over the weekends and on public holidays. The client has been single for the last three years after breaking up with her boyfriend in 2019 June following a disagreement. She enjoys spending time with her family and friends. The client is a social drinker. She takes 3 to 5 beers when she goes out for dinner with her friends. The client denies smoking cigarettes. Additionally, she denies using other illegal substances, including cocaine, marijuana, and heroin. She takes a glass of coffee daily with dinner. She is a strong Christian and actively participates in religious activities.
Review of Systems (ROS)
General: The client denies weight loss, weakness, or night sweats.
Head: Denies headaches, head trauma, migraines, nodules, or lesions to the scalp. Denies light-headedness or changes in hair color or texture. Denies facial numbness or pain.
Eyes: Denies eye pain. Denies eye discharge or blurred vision.
Ears: Denies ear drainage. Denies hearing loss.
Nose: Denies difficulty with smell or nasal blockage.
Throat: Denies difficult swallowing. Denies jaw pain.
Neck: neck stiffness.
Skin: Denies skin dryness, itchiness, or rashes.
Breast: Denies masses or nipple discharge.
CV: Denies chest discomfort or irregular heartbeat.
Lungs: Denies cough, wheezing, inability to take a deep breath or hemoptysis.
GI: Denies nausea, vomiting, constipation, or anorexia. Denies changes in bowel movement.
GU: Denies frequent urination, pain with urination, increased urge to urinate, and production of a small amount of urine. She denies bloody or pink vaginal discharge.
PV: Denies numbness or tingling in the extremities.
MSK: Reports lower back pain. Denies muscle pain.
Neuro: Denies weakness, tremors, or numbness. Denies memory loss.
Endo: Denies increased hunger or thirst.
Psych: Denies anxiety or suicidal ideations. Reports mild distress and agitation.
Vitals: TEMP – 98, B/P – 130/84, RR- 19, O2SAT – 97%, Weight 262lbs, Height 5ft 8in,
General: The client is a 32yo female who presented to the clinic. She is well nourished, well-developed, well-groomed, and neat. She has long, black, and well-maintained hair. The client looks younger than her actual age. She is polite with clear spoken words. The client speaks in a low tone and mains eye contact throughout the clinical interview. She depicts a strong thought process. Her affect and judgment are good. Her self-reported mood is “Sad.” She appears in mild distress. She is alert and oriented to time, person, place, and situation. She is future-oriented. She denies suicidal thoughts and does not seem anxious.
Head: No deformities to the scalp. Long and black hair.
Eyes: Her both pupils are round and equal. Bilateral pupil size at 2mm.
Ears: No drainage on external auditory canals.
Nose: Clear nasal turbinates with no lesions.
Throat: Palpated posterior cervical nodes. No shoulder drooping.
SKIN: No discolored spots. No rashes or swelling
CV: Regular rate and rhythm with no gallop rhythms or murmurs.
Lungs: No anterior or posterior wheezing. No retraction or signs of respiratory difficulty.
Abdomen: Examination of the abdomen indicated the presence of non-tender, irregular, and mobile mass, arising from the pelvis. The mass corresponds in size to the uterus at 24 weeks gestation. A large fibroid measuring 16 cm x 10 cm had enlarged the uterus. Normal ovaries and fallopian tubes.
GU: No signs of blood in the urine. No vaginal discharge.
PV: No noticeable deformities. Strong, equal, and regular pulses.
MSK: Normal back curvature. Ability to bed comfortably detected.
Neuro: Normal gait is normal. Depicts 5/5 motor throughout the session. Can move all extremities comfortably and easily.
Psych: Sad mood noted. Appears in mild distress.
- Laboratory analysis: The results indicated that blood hemoglobin concentration was 12.6 g/dL. The probability of being pregnant was excluded.
- Transabdominal ultrasonography: The results indicated a hypoechoic mass measuring 18 cm × 14 cm and globular uterine enlargement. No visualization of ovaries and adnexa since they were obscured by the bulky and enlarged uterus. No hydronephrosis or ascites was noted.
- Exploratory laparotomy: The diagnosis was conducted to detect fibroid uterine after counseling and written informed consent. The results were positive.
Based on the presented clinical manifestation, physical examination results, and results of diagnostic tests, the client’s possible diagnoses are as follows;
- Uterine leiomyomas – Primary diagnosis.
- Endometrial carcinoma
Uterine leiomyomas also known as fibroids are the primary diagnosis for this client. This condition is characterized by benign growths, representing the most prevalent neoplasms of the uterus. The growth of leiomyomas is stimulated by estrogen and progesterone hormones (Borahay et al., 2017). The prevalence of fibroids rises during the reproductive years and decreases after reaching menopause. Fibroids contain higher concentrations of progesterone and estrogen receptors, and aromatase than normal myometrial tissue (Borahay et al., 2017). Fibroid growth is attributed to various risk factors, including being exposed to exogenous estrogen, early menarche, obesity, and pregnancy. In this case, obesity, administration of hormonal agents, and pregnancy were excluded as contributing factors. The client reported consuming broiler chickens and red meat regularly, increasing the risk of developing fibroids.
Uterine leiomyomas are characterized by various clinical manifestations, including heavy menstrual bleeding, prolonged menstrual periods lasting over a week, pain or pressure in the pelvic region, frequent urination, constipation, leg pains and lower backache, and difficulty emptying the bladder (Egbe et al., 2018). The client reports a heavy and painful menstrual period that lasts for more than a week, progressive abdominal discomfort, and gradual abdominal distension for the last six months. She further reveals irregular menstruation and spotting between monthly periods. Additionally, a physical exam indicated nontender, irregular, and mobile mass, arising from the pelvis. The mass corresponds in size to the uterus at 24 weeks gestation. A large fibroid measuring 16 cm x 10 cm had enlarged the uterus. Furthermore, transabdominal ultrasonography results indicated a hypoechoic mass measuring 18 cm × 14 cm and globular uterine enlargement. Therefore, uterine leiomyomas qualify as the client’s primary diagnosis.
Adenomyosis is another potential diagnosis for this client. It is characterized by heavy or prolonged menstrual bleeding, chronic pelvic pain, severe cramping or menstruation accompanied by sharp pelvic pain, and painful intercourse (Gordts et al., 2018). Upon visiting the gynecologic clinic, the client reports a heavy and painful menstrual period that lasts for more than a week, progressive abdominal discomfort, and gradual abdominal distension for the last six months. She further reveals irregular menstruation and spotting between monthly periods. Thus, the client qualifies for this diagnosis. However, this condition is ruled out following the absence of significant symptoms, including chronic pelvic pain.
The client also qualifies for this diagnosis, which is characterized by painful periods, pelvic pain and cramping, pain with intercourse, pain with urination or bowel movements, excessive bleeding, or infertility (Smolarz et al., 2021). Upon visiting the gynecologic clinic, the client reports a heavy and painful menstrual period that lasts for more than a week, progressive abdominal discomfort, and gradual abdominal distension for the last six months. She further reveals irregular menstruation and spotting between monthly periods, qualifying for this diagnosis. However, this disorder is ruled out due to the absence of pertinent symptoms, including pain with urination or bowel movements, excessive bleeding, or infertility.
Endometrial carcinoma is another potential diagnosis for this client. This condition is characterized by abnormal vaginal bleeding that is not related to menstruation, postmenopausal bleeding, painful or difficult urination, pain during intercourse, and pain and mass in the pelvic region (Lu & Broaddus, 2020). The client qualifies for this diagnosis since she reported progressive abdominal discomfort. Additionally, transabdominal ultrasonography results indicated a hypoechoic mass measuring 18 cm × 14 cm. Nonetheless, this condition is ruled out due to the absence of significant symptoms, including abnormal vaginal bleeding.
The treatment plan aimed at removing the hypoechoic mass measuring 18 cm × 14 cm from the client’s uterus. The procedure involved elevating the uterus out of the abdominal cavity and a fundal incision was performed to achieve a myomectomy of the large tumor. Continuous catgut sutures closed the excision site, while the abdomen was closed in layers. Whitish nodules characterized by the whorled appearance and fibroelastic consistency were observed upon cutting the specimen, suggesting benign leiomyoma. Formal histopathology was recommended for the specimen. Histopathological examination results revealed a benign fibroid of the uterus. The client’s postoperative course was uneventful. She was discharged 10 days postoperative. The client was prescribed Acetaminophen 325 mg 2 tablets every 6 hours for managing postoperative pain. She was advised to discontinue the painkillers once the post-operative pain was manageable. The client was scheduled for a six-month follow-up, and ultrasonography would be repeated during this clinic to assess the state of her uterus. The client was counseled concerning her future fertility and recurrence before being discharged. The client was provided with family planning counseling despite denying being sexually active. She was also advised not to conceive in the next year to allow complete wound healing and full recovery. Lastly, the client was advised to use protection during sexual intercourse to reduce the risk of contracting STIs.
Borahay, M. A., Asoglu, M. R., Mas, A., Adam, S., Kilic, G. S., & Al-Hendy, A. (2017). Estrogen receptors and signaling in fibroids: role in pathobiology and therapeutic implications. Reproductive sciences, 24(9), 1235-1244. Doi: 10.1177/1933719116678686.
Egbe, T. O., Badjang, T. G., Tchounzou, R., Egbe, E. N., & Ngowe, M. N. (2018). Uterine fibroids in pregnancy: prevalence, clinical presentation, associated factors and outcomes at the Limbe and Buea Regional Hospitals, Cameroon: a cross-sectional study. BMC research notes, 11(1), 1-6. DOI:10.5772/intechopen.88473
Gordts, S., Grimbizis, G., & Campo, R. (2018). Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertility and sterility, 109(3), 380-388. https://www.fertstertdialog.com/users/16110-fertilityand-sterility/posts/29040-25436.
Lu, K. H., & Broaddus, R. R. (2020). Endometrial cancer. New England Journal of Medicine, 383(21), 2053-2064. DOI: https://doi.org/10.1016/S0140-6736(22)00323-3
Smolarz, B., Szyłło, K., & Romanowicz, H. (2021). Endometriosis: epidemiology, classification, pathogenesis, treatment, and genetics (review of literature). International Journal of Molecular Sciences, 22(19), 10554. https://doi.org/10.3390/ijms221910554.