IMU/SOM/SEM5/CLINICAL ATTACHMENT/SAMPLE of CASE REPORT/2013

CASE WRITE UP
PATIENTS DETAILS:
Initials: PK
Sex: Female
R/N number: HTJ 561143

Age: 46
Date of admission: 13/11/2011

CLINICAL HISTORY:
Presenting complaint:
Mrs.PK, a 46 year old nulliparous with a diagnosis of early stage of endometrial malignancy is
electively admitted for total abdominal hysterectomy and bilateral salpingo-opherectomy.
History of presenting complaint:
She was well until she experiences a heavy and prolonged bleeding for more than 20 days.
She also has inter-menstrual bleeding for a year but there is no post-coital bleeding or
abnormal vaginal discharge.
She sought medical attention at a nearby clinic where a urine pregnancy test was done and
negative. However, was told to have some abnormality in her uterus via an abdominal
ultrasound. She was then referred to the tertiary hospital.
She was further investigated and later found to have malignancy of her endometrium and a
right ovarian mass. The couple was then counseled about her condition where options of
treatment were also discussed. They both understood the implications of disease and agreed
to undergo a surgical intervention and further therapy.
Systemic Review
She has no significant loss of weight, or loss of appetite. Her breathing, urination or bowel
movements are normal. There is no palpitation, fainting attacks, shortness of breath or
lethargy.
Gynaecological and Sexual history:
She attained menarche at the age of 13. Her menstrual cycles have been irregular of 30- 90
day cycles for the last 10 years. The flows are scanty (2 to 3 days) but sometimes are heavy
(using more than 4 pads on the first 2 to 3 days). There was no dysmenorrhea. She had a
normal cervical screening about 7 months ago.
The couple has been trying to conceive for 4 years. This is her first marriage but a second for
her husband who does not have any children from the previous marriage. Her husbands first
wife passed away due to a disease of the reproductive organ. He is 54 years old and healthy.

IMU/SOM/SEM5/CLINICAL ATTACHMENT/SAMPLE of CASE REPORT/2013

They had sought medical consultation for the issue of subfertility 1 year after their marriage.
However, there was no clear explanation about the causes as she only had a blood test and
no other investigation was suggested for the couple.
They claim to have no sexual life problem though the activities were infrequent (once a week).
They do not have multiple sexual partners.
Past Medical history:
She is diagnosed with hypertension for about a year which was mild and well controlled with
single medication. There was no complication and she had regular 3 to 4 month follow ups.
Investigations for diabetes and hypercholesterolemia were negative.
Family history:
Patients mother is hypertensive and her father passed away due to heart attack at the age of
70. There is no family history of malignancy. She has 3 siblings whom are all healthy.
Social history:
She understands that after this surgery, she would not be able to conceive and she will be
surgically menopause. She is also aware of the prognosis of disease and future plan of
therapy. Nevertheless she is quite positive that she will be able to go through the ordeal with
good support and care from her husband.
The couple plans to adopt a child. There is no issue with their financial or emotional support
as they are surrounded by caring family members and friends.
PHYSICAL EXAMINATION
On examination, patient is comfortable and calm. Blood Pressure is 130/84, Pulse Rate is 85
& regular and Respiratory rate is 18. Her height is 152 cm and weight is 80kg. Her BMI is 34.6
kg/m2.
There is no pallor. The neck examination is normal. There is no cervical lymphadenopathy.
There is bilateral pitting edema at the level of the ankle. Cardiovascular, respiratory and
breast examinations are unremarkable.
On examination of the abdomen, the abdomen is not distended and there is no obvious
surgical scar. It is soft, and non-tender. No mass is palpable. There is no palpable inguinal
lymph node.
(Pelvic examination is not carried out but the previous documentation showed no
abnormalities in the vulva, vagina or cervix. The cervix is normal, long and tubular. There is no
adnexal mass)

IMU/SOM/SEM5/CLINICAL ATTACHMENT/SAMPLE of CASE REPORT/2013

PROVISIONAL DIAGNOSIS:
Endometrial carcinoma
The suspicion of endometrial malignancy is thought of as she presents with abnormal
menstrual bleeding at the age of 40 and has obesity. She also has subfertility issue which
could be related to anovulation problem as suggested by the irregularity of menstrual cycles.
Thus obesity and prolonged anovulation are associated with high level of oestrogen causing
hyperplastic changes of endometrium.
Differential Diagnosis:
Cervical abnormality
It is the commonest cause of abnormal vaginal bleeding among ladies of reproductive
age. Cervical malignancy is still the commonest cause of gynaecological malignancy among
women in Malaysia. However it is ruled out due to the normal finding of cervix on speculum
examination and cervical smear.
Pregnancy related complication
It could be related to signs of miscarriage. As the couple is attempting to conceive thus
the coitus was unprotected, the chance of pregnancy is significant. She also has irregular
cycles which makes it difficult to determine period of amenorrhea. However the recent urine
pregnancy test is negative.
PROBLEMS IDENTIFIED
1. Heavy and Prolonged vaginal bleeding can cause anaemia. As she is having a major
surgery, it is important that anaemia must be corrected and her haemoglobin is opttimised
2. Diagnosis of malignancy of her pelvic organ. It is important that counseling is done with
empathy and involves both couple. They would have to fully understand that removal of her
pelvic organs is an important treatment for her disease though they may still be hopeful to be
able to conceive naturally.
3. Her obesity and hypertension should be given much consideration as it may affect her
outcomes of surgery like anaesthetic complications, difficult surgery, thrombosis, infection etc.
Therefore, pre- operative assessment and preparation are vital and must be done with an
interdisciplinary approach.
PROGRESS OF PATIENT
The couple was counseled again about her condition, the need and implications of surgical
intervention and possible further therapy before an informed consent was taken by the
surgeon. The type of anaesthesia (general) and its possible effects were also informed.
They were told that she could be having Stage 1 endometrial carcinoma from the clinical
assessment but the final diagnosis would only be determined following surgery and
histopathological examination of tissues.

IMU/SOM/SEM5/CLINICAL ATTACHMENT/SAMPLE of CASE REPORT/2013

The preoperative assessment includes a chest X-Ray, ECG and renal function following her
hypertension and findings were normal. She had a FBC to rule out anaemia due to the
episodes of bleeding and serum glucose which were also normal.
Preparation before surgery includes stabilization of her hypertension, Nil by Mouth 8 hours
before surgery, anti reflux medication, antibiotic prophylaxis and thromboprophylaxis.
Intraoperatively, there was no surgical or anaesthetic complication. The estimated blood loss
was 300mls, her urine was clear and adequate and her vital signs remained stable.
There was an enlarged uterus. Uterus was dissected, showing a small tumor of 1cm with no
myometrial involvement. No enlargement of pelvic or para aortic lymph nodes. The uterus,
cervix, bilateral fallopian tubes and bilateral ovaries were sent for HPE.
Patient recovered well post-operatively without any complication. Her hypertension was well
controlled. Her pain was well managed with parenteral analgesia. She was given early feeding
and encouraged to ambulate within 24 hours. Chest and physiotherapy were provided as well.
Her wound was clean and dry thus she was allowed to be discharged 3 days after surgery.
She was advised to come back immediately to the hospital if there is any fever, pain or
bleeding. Otherwise a follow up of 4 weeks is given for further consultation and treatment.