My patient, Madam Hashim, 45 year old Para 0+2, housewife with known history of uterine fibroid for ten years was electively admitted for total abdominal hysterectomy bilateral saphingoopherectomy (TAHBSO). She has background history subfertility for 15 years and hypertension.
RELEVENT CLINICAL HISTORY
The uterine fibroid was incidentally found 10 years ago in 2000 during further management at University Malaya Medical Centre (UMMC) for miscarriage. But the size of uterine fibroid was still small. She could not see or feel the mass at that time. No treatment was given at that time. She was told to go regular follow up afterwards. However, she defaulted. Until 5 years ago, the mass was gradually increased up to the umbilicus level. She went to general practitioner (GP) because her distended abdomen. She was referred to UMMC but defaulted again because of no pain or per vaginal bleeding. In between she never went to any follow up regarding her problem.2 years later, her abdomen was getting worse which was distended make her uncomfortable. It was associated with menorrhagia especially on day 1 until day 3 with 5-6 fully soaked pad flooding and blood clots. Then, she came to UKMMC as asymptomatic anaemia and distended abdomen.
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She was first seen at UKMMC on June last year which is 6 months ago. She still had her menses at that time. On assessment, she was noted mild pallor and her Hb was 9.5 g/dl with uterus size of 34 weeks size of gravid uterus. Based on assessment and scan result, she was counseled for GnRH analogue for 6 cycles and proceeds for TAHBSO. She was informed regarding purpose and side effect of GnRH analogue. She was agreed upon. Pipelle sampling and pap smear was done at UKMMC. Beside that, she was found to have high blood pressure and started Atenolol 50 mg.
She had subfertility for 15 years and the problem had never been investigated. However, there was no compressive symptoms of abdominal distention for instances altered bowel habit and change in urinary frequency. no symptoms suggestive anaemia such as giddiness, headache and palpitation. She has no dyspareunia and abdominal pain. There was no loss of appetite and loss of weight and other symptoms of metastasis such as back pain, bone pain and shortness of breath.
MENSTRUAL HISTORY
She attained menarche at 12 years old. She had regular cycle of 28-30 days with normal flow of 7 days without flooding or blood clots. Her last menstrual period was on 9th July 2009. Previously her menses was normal until 3 years ago she had prolonged menses for 15 days and heavy bleeding especially on day 1 until day 3 with 5-6 pads fully soaked with flooding and blood clots. The bleeding was decreased in amount day by day and stopped on day 15 with minimal spotting. There was no dysmenorrhea, intermenstrual bleeding and post-coital bleeding. No per vaginal discharge noted. Pap smear was done on September last year with normal result. She never practiced any contraceptive methods.
PAST OBSTETRIC HISTORY
In year 2000, she had history of complete miscarriage at 5 weeks which was diagnosed at UMMC. Subsequently, in year 2002 she had history of incomplete miscarriage at 14 weeks. Dilatation and curettage was done at UMMC.
PAST MEDICAL HISTORY
She had been diagnosed as hypertension last year and treated with Atenolol 50 mg OD. No known other medical illness such as diabetes mellitus and cardiovascular disease.
PAST SURGICAL HISTORY
Past surgical history was unremarkable.
DRUG HISTORY
She was on antihypertensive; Atenolol 50 mg OD since last year and completed 6 cycles of GnRH analogue Zoladex. Last cycle was on 25th November 2009.No known drug allergy.
FAMILY HISTORY
Both parents already passed away due to unknown cause. There is no family history of malignancy. All her siblings are alive and currently well and healthy. There was no family member with similar problem.
SOCIAL HISTORY
She is a housewife. Previously she worked as a clerk at private company whereas her husband is a pensioner of supervisor at Car Company. They have been married for 15 years. Both of them are non alcohol consumer. She does not smoking whereas her husband is a smoker. The total income was about RM 2500.
SUMMARY
My patient, Madam Noraini Hashim, a 46 year old Para 0+2 housewife with subfertility for 15 years and a known case of symptomatic uterine fibroid who presented with abdominal distention at suprapubic region that was gradually growing for 10 years and menorrhagia for 3 years was admitted for TAHBSO.
RELEVENT CLINICAL EXAMINATION
General
She was lying comfortably supine on the bed. She was alert, conscious and cooperative. She does look obese. She has no pallor, jaundice and cyanosis. Her hydration status was good. No sign of chronic anaemia such as koilonychia, angular stomatitis and atrophic glossitis. There was no bilateral pedal oedema or calf tenderness. Otherwise her vital signs were within normal limit.
Blood pressure: 135/90
Pulse rate: 84 beat per minutes (regular rhythm and good volume: normal)
Temperature: 37 ° C
Respiratory rate: 20 breath per minute (not tachypneic,normal)
Height: 150 cm
weight: 80 kg BMI= 35.56kg/m² (obese)
SYSTEMIC
Central nervous system examination
My patient was alert and oriented to person, time and place. Her speech was normal. All her cranial nerves were grossly intact. There was no muscle wasting or fasciculation. Both upper and lower limb showed normal muscle tone, muscle power, reflexes, sensation and propioception.
Cardiovascular system examination
She was appropriately exposed and propped up 45 degrees. There was no collapsing pulse, radio-radial delay or radio femoral delay. The jugular venous pressure was present and not raised. The apex was palpable and not displaced, located at the fifth intercostal space, 1 cm medial to the midclavicular line. No thrill and parasternal heave. First and second heart sounds were audible with absence of extra heart sound or cardiac murmur. All peripheral pulses are present.
Respiratory system examination
She was appropriately positioned at 45 degrees as before. The trachea was centrally located. There were no skeletal abnormalities or previous surgical scar. The chest was moving symmetrical bilaterally with respiration on anterior and posterior view. The chest expansion, vocal fremitus and vocal resonance were equal bilaterally. There was vesicular breath sound without adventitious sounds such as wheezing or crepitations.
Breast and thyroid examination
My patient was appropriately exposed and positioned. Both breasts were about symmetrical bilaterally without skin changes. The nipples were inverted and look normal. The breasts were not tender. There was no mass or no axillary lymphadenopathy palpable. No thyroid enlargement or lymphadenopathy. Otherwise, the neck looks normal.
Abdominal examination
On inspection, there was abdominal distention at the suprapubic region. There was no previous surgical scar, dilated vein or skin pigmentation. The abdomen is soft and non tender. There was suprapubic mass that corresponds to 32 weeks size of gravid uterus and measures about 23x 23 cm. It was non tender and firm. The margin is regular but lobulated with smooth surface. It was unable to get below the mass and the mass is mobile side to side but not vertically. It is well circumscribed and dull on percussion. There was no ascites and no hepatosplenomegaly. The kidneys were not ballotable. There was no bruit over the mass. The bowel sound is normal.
Pelvic examination
There was no abnormality detected on the vulva and vagina. There were no signs of pruritus, erythema, erosion, skin lesion and growth. The cervix looks healthy and cervical os was closed. On bimanual examination, the cervix was tubular. There was no hardness or irregularity. The cervix was moved away when examiner moved the mass towards the xiphisternum. There was fullness of both adnexa and pouch of Douglas. Uterosacral ligament was not thickened.
Per rectal examination
It revealed fullness of pouch of Douglas. No rectal involvement. There was good anal tone and smooth anal mucosa.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Provisional diagnosis: Uterine fibroid
Points for:
She is 46 years old: fibroid are common and being detectable clinically in 20% of women over 30 years of age.
She has risk factors for fibroid which are nulliparity and obesity.
She has subfertility for 15 years.
She presented with painless abdominal distention and menorrhagia which is typical symptoms in uterine fibroid.
Per abdomen reveled the mass is firm, well defined, can be moved side to side and unable to get below it.
Points against:
There was no family member with similar problem.
No compressive effect in spite of huge uterine fibroid at 34 weeks for instances increase in urinary frequency or altered bowel habit.
Differential diagnosis:
Leiomyosarcoma
Points for:
She had heavy bleeding for past 3 years.
There was huge suprapubic mass.
Points against:
The mass was not rapidly enlarging.
There was no symptoms suggestive malignancy such as loss of appetite, loss of weight, abdominal pain and bone pain.
She did not look cachexic.
The abdomen was not tender upon palpation.
Endometriosis and fibroid
Points for
Prolonged menses and heavy bleeding
Subfertility for 15 years
Points against:
No cyclical pattern of abnormal bleeding from rectum, bladder and umbilicus.
No pelvic pain through out the cycle and no deep dyspareunia.
Pouch of Douglas was not tender.
No thickening of uterosacral ligament.
Adenomyosis
Points for:
She has menorrhagia.
Adenomyosis is often diagnosed in late thirties and early forties.
Points against:
Adenomyosis are usually occurring in multiparous.
No spasmodic dysmenorrheal and bleeding usually star s even before the actual menses.
The mass can only grow to about 14 weeks of size ( the mass is due to collection of blood within myometrium).
The mass is usually tender especially around perimenstrual period.
No alteration of echogenecity within myometrium on ultrasound.
Ovarian benign tumor
Points for:
She had abdominal distention.
Increased menstrual blood loss.
Points against:
She did not complain of abdominal pain.
No pressure effect symptoms; no changes in bowel and urination system.
On physical examination, the mass was unable to get below it.
Ovarian carcinoma
Points for:
Subfertility for 15 years
She has several risk factors of ovarian carcinoma such as nulliparity and not on oral contraceptive.
Points against:
Ovarian carcinoma occurs high in post-menopausal women and early menarche less than 11 years old.
No family history of malignancy of ovarian, breast or colorectal.
She did not have constitutional symptom of malignancy for instances cachexic, loss of appetite and loss of weight and fever.
No compressive symptoms such as shortness of breath, chronic lower abdominal pain, increased of urinary frequency and urinary retention.
STATE RELEVENT INVESTIGATION WITH REASONS
Full blood count:
To assess haemoglobin level pre and post operations for anemia and to look for any sign of infection indicated by total white cell counts and neutrophil level. Platelet level is also counted to look for bleeding tendency.
Blood group cross match:
It is important if blood transfusion is necessary.
Coagulation profile:
It is to assess the coagulation function.
Renal profile:
It is to look for obstructive nephropathy. (Compressive effect of the mass to the urinary system)
Liver function test:
It is to assess the liver function before operation.
Blood glucose level
It is to screen for hyperglycemia since my patient never check before.
Lipid profile
It is to look for hyperlipidemia.
Electrocardiogram:
Assessment of cardiovascular function pre operation as screening since my patient is 46 years old
Chest X-ray:
It is to assess the condition of the lungs before operation.
Pap smear:
To rule out cervical carcinoma
Pipelle sampling:
To rule out endometrial carcinoma
CA 125:
It is to exclude underlying ovarian epithelial carcinoma.
Ultrasonography of the pelvis: transabdominal or transvaginal ultrasound.
– To look or uterus size and orentation
– To confirm that the mass is uterine origin.
– assess the fibroid in term of number, size and site.
– measure the endometrial thickness to rule out endometrial hyperplasia.
– To look both Right and Left ovary size and any features of malignnacy
RESULTS OF INVESTIGATION AND STUDENT’S COMMENT
Full blood count
%
Result
Units
Range
White cell count
7.5
x 109 /L
(4.0-10.0)
Red cell count
4.82
x 1012 /L
(4.2-5.4)
Hemoglobin
13.7
g / dL
(12.0-16.0)
Hematocrit
41.0
%
(36.0 – 52.0)
Mean Cell Volume
84.9
Fl
(77.0-91.0)
MCH
28.4
Pg
(26.0-32.0)
MCHC
33.4
g /dL
(32.0-36.0)
RDW
16.5
%
(11.3-14.6)
Mean platelet volume
8.2
fl
(6.3-10.2)
Platelet
307
x 109 /L
(150-400)
Neutrophil
50.7
3.8
x 109 /L
(2.0-7.0)
Eosinophil
9.0
0.7
x 109 /L
(0.02-0.5)
Basophil
0.7
0.1
x 109 /L
(0.02-0.1)
Lymphocytes
31.7
2.4
x 109 /L
(1.0-3.0)
Monocytes
5.0
0.6
x 109 /L
(0.2-1.0)
Impression: patient is not anaemic. There is no infection and no bleeding tendency.
2. Blood group cross match:
Patient’s blood group is O rhesus positive. There was 2 pints of blood prepared.
3. Coagulation profile
Test
Result
Units
Range
PT(patient)
12.9
Seconds
(11.4-14.2)
PT(control)
12.7
Secs
(12.2-16.2)
INR
1.02
Ratio
(2.4-4.0)
APTT(patient)
56.4
Seconds
(31.3-46.1)
APTT(control)
38.7
Secs
(31.3-46.1)
APTT Ratio
1.46
Ratio
(0.89-1.32)
Impression: All within normal limit. No coagulation disorder.
4. Renal profile
Test
Result
Unit
Normal range
Na+
140
mmol/L
135 – 150
K+
4.3
mmol/L
3.5 – 5.0
Urea
4.2
mmol/L
2.5 – 6.4
Creatinine
57
mmol/L
44 – 80
Uric acid
372
umol/L
149-450Impression: All electrolytes within normal range. No increase of urea and creatinine level to suggest obstructive uropathy.
5. Liver function test
Result
Unit
Range
Albumin
45
g/L
(35-50)
Total protein
78
g/L
(67-88)
Bilirubin total
4
umol/L
<23
ALT
24
U/L
<44
ALP
84
U/L
(32-104)
Impression: Liver function was within normal limit.
6. Blood glucose level
Result
Units
Range
Random glucose
6.1
mmol/L
4.0-7.8
Impression: Blood glucose within normal limit. She is not hyperglycemic.
7. Lipid profile
Results
Units
Range
Triglycerides
4.33 ( ↑ )
mmol/L
<1.40
Total cholesterol
6.13 ( ↑ )
mmol/L
<5.7
HDL-cholesterol
0.82 ( ↓ )
mmol/L
>1.20
LDL-cholesterol
3.34
mmol/L
<3.80
Impression: There is hyperlipidemia indicated by increased triglyceride and total cholesterol level and decreased HDL-cholesterol.
8. ECG (electrocardiogram)
Result: normal sinus rhythm. Comments: the cardiovascular system was normal.
9. Chest x-ray
Results: Clear lung field. No focal lesion and pleural effusion. Heart is within normal size. Comments: no significant abnormality.
10. Cervical smear:
Result: satisfactory smear for cytological evaluation. It is negative for intraepithelial lesion or malignancy. No endocervical or metaplastic cells present.
Comments: Patient has no malignancy but Pap smear should be repeated.
11. Pipelle(endometrial) sampling
Result: Section shows mainly blood clots with tiny strips of endometrial epithelium. Unsatisfactory material for diagnosis
Comments: Unsatisfactory sample of endometrium.
12. Transabdominal ultrasonograph
Result: uterus size: 17 x 14.7 cm; ET: 10 mm; anterior: 5.3 x 5.4 cm; posterior: 6 x 5.2 cm, 12 x 14.7 cm, fundal: no fibroid; right ovary 2.3x 3.5 cm; left ovary: 2.2 x 3.3cm. POD: normal. Comments: There was large huge multiple uterine fibroid. The ovaries are normal.
13. CA125- It was not done.
IDENTIFY THE PROBLEMS IN TERM OF PRIORITY
Abdominal mass and discomfort due to huge uterine fibroid worsening 3 years ago.
Subfertility for 15 years (Para 0 + 2 and planned for TAHBSO)
Newly diagnosed hypertension
IMMEDIATE AND SUBSEQUENT MANGEMENT
Madam Noraini Hashim was electively admitted for further surgical management for uterine fibroid on 19th January 2009. She was hospitalized 2 day prior operation. Her vital signs were monitored and a number of investigations were assessed to identify the problems that may increase the operative risk. She was seen by anaesthetist for the assessment of patient’s fitness for operation. She was informed briefly concerning the nature of the operation, benefits, outcome, indications and possible complications that may arise. TAHBSO is indicated for large uterine fibroid instead of hysterectomy. Informed consent was obtained for TAHBSO. She was aware that the she cannot bear children herself after the procedure and may experience climateric symptoms and other menopausal symptoms later. Details of pre-operative preparation were bowel preparation and nil by mouth start on 12 mid night before operation. IV line and CBD were established. Her vital sign was monitored. Thromboembolic dexterent(TED) sock was applied prior operation for prophylaxis deep venous thrombosis.
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She underwent surgery on 19th January 2009. TAHBSO was done as planned. Intra-operative finding were there was huge and multiple uterine fibroid which is highly vascularized. The fibroid were right broad ligament fibroid 6 x 6 cm, 3 anterior fibroid measured 8×8, 2×2 and 2x2cm and posterior fibroid 12 x 15 cm. Both ovaries looked normal. The biopsy of uterus and cervix was taken and sent to the histopathological laboratory.
After operation, she was kept nil by mouth. Her vital signs were monitored half and hourly until stable and change to 4 hourly. She was infused 2 pints of normal saline and 2 pints of Hartman. Epidural analgesia was continued for 1 day. Subcutaneous heparin 5000IU BD was given for thromboembolic prophylaxis. Once she tolerated orally, change to tablet arcoxia 120mg OD. Cloxacillin 500 mg QID was given for 1 week. Pad chart and input & output chart were established in the ward.
FINAL CONCLUSION/ PLAN FOR FURHER MANAGEMENT/ PATIENT’S PROGRESS
At 20th January 2010, day 1 post TAHBSO, she was well, alert and conscious. Epidural analgesia and CBD were off while oral analgesia was continued. She did not feel nausea and did not vomit. There was minimal pain at the operation site. She was encouraged to tolerate orally and ambulate. On inspection of her wound, it was clean, the dressing not soaked. Abdomen is soft and mild tenderness at the operation site. Her vital sign were monitored. Her blood pressure was ranging 120-160/65-90 which is not stable. She was afebrile throughout hospitalization. She used 2 pads which were half soaked.
On day 2 post operative, she was getting better. She already ambulated and tolerate orally. She was comfortable and could pass urine and bowel open. However, there was slight pain at the operation site. The medications were continued which are
Tablet Atenolol 100 mg/dl
Tramadol HCL 50 mg
Cloxacillin sodium 250 mg
Etoricoxib 120 mg tablet
Her vital signs were monitored as well as inspection of operation site. She was asked regarding menopausal symptoms for instances hot flushes and night sweat. She denied any of them. She was planned to discharge tomorrow.
After discharged, she was asked to come back after 10 days for suture removal and 6 weeks later to review histopathological result. She was informed regarding wound care and advised to come to hospital earlier if she develops fever.
PREVENTIVE AND COMMUNITY HEALTH ASPECT
A fibroid is a benign tumor of uterine smooth muscle known as leiomyoma being the most common tumor found in the women about 20 percent especially after 30 years of age. The etiology of uterine fibroid is not known yet. A range of hypothesis accounting for the pathogenesis of fibroids has been explored regarding hormones interaction, cytogenetic features and environmental factors. However, there are risk factors for clinically significant fibroids which can be divided into modifiable and non modifiable. Thus, reduction of modifiable risk factors can help to prevent uterine fibroid to occur.
The non modifiable factors are genetic, age and race. Those have family history of fibroids especially first degree relatives are increased risk of developing the disease. Average age for fibroids to become symptomatic is 35-50 years. Women who are of childbearing age are at increased risk of developing fibroids. African American women are 2-3 times more likely to have uterine fibroids and increased risk for developing the condition at a younger age than the rest of the population of women with uterine fibroids. Asian women have a lower incidence of symptomatic uterine fibroids.
The modifiable risk factors are obesity, dietary intake, cigarettes smoking, oral contraceptives and pregnancy and child birth. There has been some research on these risk factors. Some studies have suggested that obese women are higher risk of fibroids. Thus, leading a healthy life style can prevent of overweight. Promotion of healthy life style includes balanced diet and regular exercise. In addition, consumption of beef, red meat and ham has been associated with the presence of uterine fibroid. However, there are recent research has shown some protective value to uterine fibroids which are green vegetables, fruit and fish. Cigarette smoking was associated with decreased risk of fibroids; smokers of 20 cigarettes a day had a risk roughly two thirds that of non-smokers.
Risk of fibroids decreased consistently with increasing number of term pregnancies; women with five term pregnancies had only a quarter of the risk of women who had had none. So far, pregnancy and childbirth seem to have a protective effect. Risk also decreased consistently with increasing duration of oral contraception use; the risk of fibroids was reduced by some 31% in women who had used oral contraceptives for 10 years. Changes in a woman’s hormone levels may impact fibroid growth. Therefore, pregnant or OCP can reduce estrogen level and subsequently reduced the growth of fibroid. Foremost, uterine fibroid will shrink after menopause when hormonal levels are decreased.
DISCHARGE SUMMARY: NORAINI HASHIM
MRN : N251432 VISIT ID : 201001223841
NRIC : 640811055490 AGE : 46
GENDER : FEMALE RACE : MELAYU
DISCHARGE DATE: 22/01/2010 DISCHARGE TIME: 10:27
DISCHARGE TYPE: NULL DISCHARGE LOCATION: WARD
GYNE 2
CASE SUMMARY:
DATE OF ADMISSION: 17TH JANUARY 2010
DATE OF DISCHARGE: 22TH JANUARY 2010
46 year old, Para 0+2 electively admitted for total abdominal hysterectomy and bilateral saphingoophorectomy (TAHBSO) for huge uterine fibroid discharged on day 3 post operative.
She was diagnosed uterine fibroid 10 years ago incidentally found out after miscarriage at PPUM. She defaulted for follow up due to asymptomatic uterine fibroid until 3 years ago, she presented with worsening abdominal distention and menstrual disturbances to GP. She was referred PPUKM for further management. She was first seen in PPUKM June last year. After thorough assessment, revealed abdominal mass corresponds at 34 weeks gravid uterus she was counseled regarding GNRH analogue and already completed 6 cycles before operation.
TAHBSO was done at 19th January 2010 with intra operative findings are:
huge and multiple uterine fibroid
right broad ligament fibroid 6×6 cm
Anterior fibroid 8 x 8 cm, 2 x 2 cm and 2 x 2 cm.
posterior fibroid 12 x 15 cm
both ovaries looked normal, 2 x 2 cm and 3 x 3 cm
estimated blood loss: 450cc
Hb post operative: 12.1 g/dL
Upon discharge, she is well, comfortable and no acute complaints. She already ambulating and tolerate orally. Her vital signs were stable. The wound was clean, dry and no discharge.
Discharge plan and medication:
continue tablet Arcoxia and tablet cloxacillin
to come again after 6 weeks at gynecology clinic to review histopathological result
suture removal at day 10 at daycare
keep in view ERT after know the HPE
memo to KK for biweekly BP monitoring and continue follow up
DIAGNOSIS
Diagnosis 1: 46 YEAR OLD PARA 0+2 POST TAHBSO FOR HUGE UTERINE FIBROIDS WITH BACKGROUND HISTORY OF HYPERTENSION.
_______________________________
NIK AMINAH NIK ABDUL KADIR
HOUSE OFFICER
0 & G DEPARTMENT, PPUKM
REFERRAL LETTER
NAME : NORAINI HASHIM MRN : N251432
NRIC : 640811055490 AGE : 46
GENDER : FEMALE RACE : MELAYU
ADMISSION DATE: 17/01/2010
DISCHARGE DATE: 22/01/2010 DISCHARGE TIME: 10:27
DISCHARGE TYPE: NULL DISCHARGE LOCATION: WARD
GYNE 2
TO: MEDICAL OFFICER IN GYNECOLOGY CLINIC PPUKM
Dear doctor,
Thank you for seeing this patient, Madam Noraini Hashim, a 42 year old, Para 0+2 housewife with a known case of multiple uterine fibroid for 10 years who presented with menstrual disturbance and abdominal distention for last 3 years. She was admitted for further surgical management.
Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) was done on 19th January 2010. Intra-operatively, found huge multiple uterine fibroid which are right road ligament fibroid, anterior fibroid and posterior fibroid. Both ovaries looked normal. Biopsy of uterus, cervix, both fallopian tubes and both ovaries were taken. Upon discharge, patient was well and comfortable with stable vital signs. The operative wound was clean, dry and no discharge.
Please kindly assess operation site and review her histopathological results. Thank you.
_________________________
NIK AMINAH NIK ABDUL KADIR
HOUSE OFFICER
O & G DEPARTMENT, PPUKM
MOCK PRESCRIPTION: FOR PATIENT ON DISCHARGE
NAME : NORAINI HASHIM MRN : N251432
NRIC : 640811055490 AGE : 46
GENDER : FEMALE RACE : MELAYU
ADMISSION DATE: 17/01/2010
DISCHARGE DATE: 22/01/2010 DISCHARGE TIME: 10:27
DISCHARGE TYPE: NULL DISCHARGE LOCATION: WARD
GYNE 2
Tablet Arcoxia (Ranitine) 120 mg once a day for 1 week
Tablet Cloxacillin 50o mg QID to complete 7 days
Folic acid 5 mg OD for 1 week
Ascorbic acid 60 mg daily
Vitamin B complex OD for 1 week
Ferrous Fumarate 200 mg twice a day for 1 week
______________________________
NIK AMINAH NIK ABDUL KADIR
HOUSE OFFICER
O & G DEPARTMENT, PPUKM
PROFESSIONALISM
COMMUNICATION ISSUES
A good communication skill is important to develop rapport with my patient. Luckily, Madam Noraini Hashim is a friendly person; she is very approachable and cooperative. Thus, effective history taking can be gained easily. Because of her problems started 10 years ago, she had difficulty to remember the detail. However, she managed to tell me the chronology of the problem after I encourage her. She admitted that she had defaulted from follow up twice for her fibroid. At that time, she did not realize the risk and consequence of uterine fibroid. In addition, she did not find her abdominal distention as a problem until its growing to the 34 weeks size of gravid uterus which makes her uncomfortable. When she presented to PPUKM, she has been investigated thoroughly and informed regarding her problem and further management. She looks very keen about her disease. Thus, well understanding communication between doctor and patients is important in delivering the message. She will be more compliant to the management plan if she well understands about her disease.
SPRIRITUAL ISSUES/COMPLIMENTARY MEDICINE
Madam Noraini Hashim is a very spiritual and open minded person. She accepted her illness and agreed for further management that will make her sterilize. She realized that she did not have chance to get children anymore. Hence, she always prays to God to strengthen her inner spirit. Fortunately, she has very supportive husband. They share the problem together and believe that the illness is a test for human being. Therefore, family support plays a role in emotional and spiritual development.
MEDICAL ETHICS
Medical ethics is the study of moral values and judgment as they apply to medicine. Consent must be taken from the patient. I was there when the doctor discuss with her and take the informed consent. She was told everything regarding TAHBSO for instances benefit, indications, the procedure, risk and the complications that may be raised later. She was informed about this management in the c
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