Comprehensive Case Presentation of a Patient with Heavy Menstrual Bleeding
Mrs. X, a 38-year-old clerk, presented with heavy menstrual bleeding lasting for 8 days in a cycle associated with fatigue and tiredness. She had a history of regular cycles but no relief with previous medical management. No other concerning symptoms reported. Menstrual and obstetric history revealed relevant details. Further investigation and management are necessary for this patient.
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Presentation Transcript
AUB case presentation AUB case presentation Dr. Tejaswini J Dr. Poornima R S General Hospital Jaynagar Bangalore
Name -Mrs X Age 38yrs Address Devarachikanahalli Bangalore Karnataka Occupation Clerk in a dental clinic Marital status Married ML 16yrs Non consanguineous marriage Husband s name Mr. Y Husband s occupation fruit vendor Socio economic status lower middle class Religion Hindu Parity para 2 living 2 Date of admission 5/5/23 Date of examination 6/5/23
Chief complaints c/o heavy menstrual bleeding since 6 months. History of present illness Patient was apparently alright 6 months back Later she developed heavy menstrual bleeding since 6 months lasting for 8 days in a cycle . Her cycles were regular 24-30 days cycle and she changed 6-8 pads per day ,she also gives history of changing pads in the night ,passage of clots measuring about a coin size , associated with squeezing type of pain in the lower abdomen after the onset of menstruation, this pain subsided after few hours after the onset
This was associated with easy fatigability and tiredness. .She was on medical line of management for the above mentioned complaints but her symptoms did not subside .No intrauterine device was inserted. Patient was not investigated further . Now she has come to us for further management No history of dyspareunia , white discharge per vagina , intermenstrual bleeding , post coital bleeding , mass per abdomen , mass per vagina, amenorrhoea followed by bleeding.
No history suggestive of pressure symptoms like increased frequency ,urgency of urination or bowel symptoms ,hair loss ,weight gain , lethargy , palpitation , tremors , loss of appetite , weight loss , excessive facial hair , acne , intake of long-term medications , bleeding gums , easy bruisability ,epistaxis ,swelling of knees.
Menstrual history Age of menarche 14 years Last menstrual period 15/4/2023 Previous cycles Regular cycles /24-25days cycle/4-5 days / 3-4pads per day / no clots / dysmenorrhoea + Present cycles Regular cycles /24-30 days cycle /7- 8days /6-8pads per day/clots + / dysmenorrhoea +
Obstetric history Para 2 Living 2 Full term normal vaginal deliveries Last child birth 14 yrs back She underwent post partum sterilization after 1 month
Past history No history of diabetes mellitus ,hypertension , tuberculosis ,epilepsy , bronchial asthma No history of surgeries in the past No history of blood transfusion in the past Family history No similar complaints in the family No history of gynaecological malignancies in the family
Marital history / sexual history Married for 16years , non consanguineous marriage Sexually active Personal history Bowel Regular Bladder regular , no urinary disturbances Sleep adequate Diet mixed Appetite good ,No habits , not on any regular medications like anti- epileptics,anti depressants , anti- coagulants ,NSAIDs
SUMMARY Mrs X aged 38yrs clerk by occupation coming from low socio- economic status admitted with history of heavy menstrual bleeding since 6months . Her last menstrual period was 15/4 /23 ,periods are regular but persisting for 8 days occuring in 21-25days interval . No significant negative history , family history and past history .Most probably this is a case of AUB (L) AUB (A) AUB (M)
General physical examination Patient is conscious, alert and co operative Moderately built and nourished Height 167cms Weight 80kgs BMI 28.7kg/m2 Spine , thyroid and B/L breast appear normal Pallor (+) Icterus (-) Cyanosis (-) Clubbing (-) Lymphadenopathy - (-) Edema (-)
Pulse rate 98beats per minute Blood pressure 120/70mmHg Respiratory rate 16cycles per minute Temperature 37 c Systemic examination Respiratory system Bilateral normal vesicular breath sounds heard Cardiovascular system S1 and S2 heard , no murmurs Central nervous system conscious, oriented ,higher mental functions are normal
Per abdomen examination Inspection All quadrants of abdomen move equally with respiration umbilicus is central inverted ,no visible sinuses , pulsations ,engorged veins A transverse suprapubic scar measuring about 2cms seen healed by primary intention All hernial orifices are intact and normal
Palpation All inspectory findings confirmed. In the hypogastric region ,uniformly enlarged mass with a smooth surface measuring about 16 weeks size gravid uterus having well defined margins on all sides except lower margin ,firm in consistency , mobile from side to side , non tender.
Percussion Dull note over the mass , no free fluid in abdomen Auscultation bowel sounds heard
Local examination Inspection Vulva and vagina appear normal Per speculum examination Vagina healthy ,cervix posterior and healthy ,no visible mass , no descent Bimanual examination - Uterus mobile ,around -16 weeks size ,all fornices free , no fornicial tenderness , no cervical motion tenderness Per rectal examination unremarkable
Summary Summary Mrs X aged 38yrs clerk by occupation coming from low socio-economic status admitted with history of heavy menstrual bleeding since 6months . Her last menstrual period was 15/4 /23 ,periods are regular but persisting for 8 days occuring in 21-25days interval . On examination vitals stable and she appears anaemic
On abdominal examination there was a lower abdominal swelling ,situated midline ,almost globular ,firm in consistency , margins are well defined except lower margin which could not be reached ,surface is smooth, dull on percussion Bimanual examination shows a pelviabdominal mass seems to be arisen from the uterus about 16weeks size gravid uterus
Provisional diagnosis Mrs.X 38yrs old P2L2 with anaemia with probably AUB(L)
