A CASE STUDY ON LEIOMYOMAS

I. INTRODUCTION

Leiomyoma, also known as uterine fibroids or myomas, are non-cancerous growths in the uterus that is
often experienced by women during the childbearing years (MayoClinic).
Fibroid sizes ranges from a size undetectable by human eyes to bulky masses that can change the
contour of the large uterus. The growth can be a single fibroid to multiple ones. Multiple fibroids can grow
more that the uterus expands to the rib cage.
Many women do not recognize that they have uterine fibroids until it is accidentally diagnosed or
discovered during a pelvic exam or prenatal ultrasound.
The annual mortality rate per 100,000 people from uterine fibroids in Philippines has decreased by
41.9% since 1990, an average of 1.8% a year. This indicates an increase in the womens health
awareness. In a Philippine statistics report released by HealthGrove, in the year 2013, the mortality rate
caused by fibroids is 0.00768 per 100,000 people.
 II. DEMOGRAPHIC PROFILE
a. Name: Mrs. B.R.D.G.
b. Age: 51 years old
c. Date of Birth: October 16, 1965
d. Sex: Female
e. Marital Status: Married
f. Educational Attainment:
g. Address: Tangub, Ozamiz City
h. Source of Information: Mrs. B.R.D.G.
i. Significant Other: Mr. E.G
j. Attending Physician: Dr. Belinda N. Paares
k. Medical Diagnosis: G2P2 (2002), Abnormal Uterine Bleeding Sec. to Multiple Uterine
(Intramura with Submucos and Subserous Components)
l. Operation Performed: Exploratory Laparotomy, Total Abdominal Hysterectomy Bilateral
Salpinho-oophorectomy under combined Spinal-Epidural Anesthesia

III. CHIEF COMPLAINT

Patient sought medical consult due to abnormal uterine bleeding consuming a baby diaper and
3-4 sanitary pads also fully soaked associated with abdominal bloating.
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XII. DISCHARGE PLAN
a. Medication
The client is encouraged to follow the prescribed home medications.
Antibiotics to prevent post-operative infection
Analgesics to reduce pain and promote ambulation
b. Environment
The significant others are instructed to provide an environment conducive for recovery
and healing.
c. Treatment
To promote wound healing, the patient is advised to:
Shower as usual. Wash the incision site with mild soap and water. Do not scrub
the incision site to clean it. Pat it dry.
Do not use oils, powders or lotions on the incision site.
To prevent tension on the suture line, avoid lifting anything heavier than 5
kilograms for the first 6 weeks.
For bilateral oophorectomy, hot flashes, mood swings and irritability are
observable signs of hormonal disturbance.
d. Health Teaching
To promote faster healing, the patient is advised to observe the following health tips.
 ACTIVITY
After the procedure or surgery, it is by natural that she may feel tired. This could last for
a day or two. Rest is important during this time. Early ambulation is encouraged to
prevent complications of surgery like blood clot formation, pneumonia and gas pains.
Lifting objects more that 5kilos for the first 6 weeks is prohibited. Recovery is
progressive, and each day she may feel better.
WOUND CARE
Upon discharge from the hospital, the incision will already begun to heal. Suture removal
or staple removal may be done 7 days after the surgery. An appointment with the primary
care giver is necessary. Incision site can be cleaned with mild soap and water. It is not
necessary to cover the incision site after bathing.
SEXUAL INTERCOURSE
Sexual contact is prohibited for the first 6 weeks or unless advised by the primary
healthcare provider. Due to risk of infection and bleeding, vaginal douche is
contraindicated. Use of tampons also is not allowed.
e. Observable Signs and Symptoms
The client is advised to report or submit for medical consult if she experiences any of the
following signs and symptoms:
Fever above 38C
Chills
Bright red vaginal bleeding or vaginal bleeding that soaks more than 1 pad per
hour
A smelly discharge from the vagina
Trouble urinating or burning sensation when urinating
Severe pain or bloating in the abdomen
Redness, swelling or drainage at the incision site
Shortness of breath or chest pain
Nausea and vomiting
f. Diet
The client is encouraged to:
Eat fruits, vegetables and whole grains to prevent constipation
Drink 6-8 glasses of water a day