Case Study

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CASE STUDY
I. PERSONAL DATA

Name: Juana Talion

Age: 45 years old

Birth Date:May 6, 1976

Address: Caramoran, Cataduanes

Civil Status: Married

Gender: Female

Religion: Roman Catholic

Date and time of admission: September 20, 2010 10:30am

Chief complaint: hypogastric mass

Tentative Diagnosis: myoma uteri

Attending physician: Dr. Espinola

II. HEALTH HISTORY

a. History of Present Illness
Juana Talion, was admitted at the EBMC due to a hypogastric mass. She underwent ultrasound examination and found out that she is having a myoma of the uterus. On September 10, she was admitted and scheduled for an operation, but then after the result of her complete blood count was released her physician also found out she is having anemia. The operation was postponed and rescheduled after her anemia has been treated. She was discharged on September 15, having normal blood counts, and given 5 days to rest and be ready for the operation scheduled on September 20. Upon admission on September 20, her vital signs were taken and had a normal result. (BP- 110/70CR-84RR-19temp-36.7°C)

b. History of Past Illness:
Juana Talion got married at age of 38, quite older than what is usual. Luckily she still got pregnant but two to three months later the fetus was aborted. She never went to the hospital to undergo ‘dilatation and curettage’ after the miscarriage. Instead she regularly had a massage therapy or “hilot”. They never stop trying to have a baby again but then they are not blessed to have one again. One day at age 40, she went to her personal massage therapist or “palahilot”. Her “palahilot” noticed a small lump on her left lower quadrant of the abdomen. She never thought that the lump would go larger but it did, and she also noticed that the lump traveled from the left side to the center portion. This time she went to the Pandan Hospital to have a check up, because of some discomfort that she feels, such as insomnia. At the hospital she was given a medical prescription of an antibiotic and a topic cream. The lump never seems to be getting smaller but rather it went way much bigger. From a “holen” it grew bigger to a “jackstone”, and then turned into a tennis ball.

III. ANATOMY AND PHYSIOLOGY OF THE ORGAN SYSTEM AFFECTED

ANATOMY OF THE FEMALE REPRODUCTIVE SYSTEM
The female reproductive system consists of external and internal structures. Other anatomic structures that affect the female reproductive system include the hypothalamus and pituitary gland of the endocrine system.

External Genitalia
The external genitalia (the vulva) include two thick folds of tissue called the labia majora and two smaller lips of delicate tissue called the labia minora, which lie within the labia majora. The upper portions of the labia minora unite, forming a partial covering for the clitoris, a highly sensitive organ composed of erectile tissue. Between the labia minora, below and posterior to the clitoris, is the urinary meatus. This is the external opening of the female urethra and is about 3 cm (1.5 inches) long. Below this orifice is a larger opening, the vaginal orifice or introitus (Fig. 1). On each side of the vaginal orifice is a vestibular (Bartholin’s) gland, a bean-sized structure that empties its mucous secretion through a small duct. The opening of the duct lies within the labia minora, external to the hymen. The area between the vagina and rectum is called the perineum.

Internal Reproductive Structures
The internal structures consist of the vagina, uterus, ovaries, and fallopian or uterine tubes (Fig. 2).

VAGINA
The vagina, a canal lined with mucous membrane, is 7.5 to 10 cm (3 to 4 inches) long and extends upward and backward from the vulva to the cervix. Anterior to it are the bladder and the urethra, and posterior to it lies the rectum. The anterior and posterior walls of the vagina normally touch each other. The upper...
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