AUB Abnormal Uterine Bleeding Physical Examination BW 52

AUB )Abnormal Uterine Bleeding(

ใหกลมนสตรวมกนวเคราะหและแจงการตรวจรางกายทส ำคญ ทเกยวของกบปญหาของผปวยเพอใหไดแนวทางในการ วนจฉย Physical Examination BW = 52 kg, Ht = 145 cm, BMI = 24. 73 )Over weight( Vital sign : BT = 36. 7 , PR = 72 bpm , RR = 16 /min , BP = 110/70 mm. Hg GA : pale Conscious )not pale , good consciousness( HEENT : pale conjunctiva Sign of dehydration )not pale conjunctivae , no sign of dehydration( CVS : JVP Heart sound murmur Weak Pulse )Normal( RS : Clear (Clear both lungs, no adventitious sound) Abdomen : Scar Distention Bowel sound Soft Tender Guarding Rebound Mass Shifting dullness Hepatosplenomegaly (Mild tenderness at suprapubic area) EXT : Petechiae Ecchymosis Capillary refill )Normal( CVA : tenderness )Normal( Lymph node : lymphadenopathy all )Normal(

Gynecocology Breast : ด Size Symmetry Nipple Retractionคลำ nipple discharge Mass Tenderness (Normal) Pervaginal Examination MIUB Vagina : mucosa Discharge Lesion(blood stain discharge) Cervix : Cervical os clean Motion tenderness Lesion(Cervical close os , clean no tenderness) Uterrus : size Shape Av Consistency Tenderness Mass (slightly enlarge 6 -8 weeks, globular shape anteverse , firm consistency, mild tenderness) mass คลำไดไมชดเจน Adnexa : mass Tenderness (ปกต ovary 2*3 cm both) Cul-de-sac : bulging Nodule (No bulging) RV )Normal( PR : blood Melaena Sphincter tone (Normal)

ปวย และการวนจฉยแยกโรคตามลำดบความนาจะเปนจากมากไป นอย Problems list 1. Heavy menstrual bleeding )menorrhagia( with progressive dysmenorrhea 4 months PTA 2. Abdominal Discomfort 4 months PTA 3. Slightly enlargement of uterus with tenderness 4. Tenderness at suprapubic area 5. History of 1 year injected contraceptive use 7 year PTA 6. BMI = 24. 73 Overweight

Differential diagnosis 1. Adenomyosis with infertility with overweight 2. Myoma uteri with infertility with overweight 3. Endometrium polyp with infertility with overweight