Abnormal Uterine Bleeding

Introduction

AUB may be defined

Under the category AUB may display in
as any variation
of AUB, further several pattern such
from the normal
definitions may be as menorrhagia,
menstrual cycle, and
subdivided based on metrorrhagia,
includes changes in
volume of menometrorrhagia,
regularity and
menstruation, hipominore,
frequency of
regularity, frequency, hiperminore,
menses, in duration
duration, chronicity, oligominore, or
of flow, or in
and timing related to poliminore
amount of blood
reproductive statuS
loss.
Case Report

Patient Identity
Name : Ny I
Age : 50 years old
Ethnic : Sundanese
Religion : Islam
Occupation : Housewife
Education : Elementary School
Date of admission : June 7 2016
Chief complaint
Patient complain about her bleeding. The bleeding happen
for 3 4 months

History of Present Illness

Patient complaint about her bleeding for 3 4 months.
The bleeding happen intermittent and sometimes happen
accidently with no cause. Patient feel pain when bleeding
and it happen in the night. In one day, patient changes her
wrap for 3 times cause her bleeding. Patient has already
examine her bleeding in kimia farma but didnt has any
treatment.
 History of Past Illness
History of hypertension : chronic,
uncontrolled
History of diabetes mellitus : denied
History of allergy : denied
History of epilepsy : denied
History of urinary tract/kidney disease : denied
History of trauma : denied
History of surgery : denied
 History of menstrual cycle

Menarche
15 years old
Menstrual cycle
30 days, regularly, with duration 6-7 days, 2-3 tampons a day,
dysmenorrhea (-)
First day of last menstrual
February 15 2016

Marital History
married once, last for 32 years

Contraception History
Patient used oral contraception in 12 years ago for 4 years
after 3rd pregnancy because her second and third pregnancy
miscarriage occured.
Physical Examination

General condition : Look good

Level of consciousness : Compos mentis

Vital sign
Blood pressure : 130/80 mmHg
Heart rate : 79x/minutes
Respiration rate : 20x/minutes
Temperature : 37,3 Celcius
Weight : 75 Kg
Height : 155 cm
BMI : 31,22 Kg/2 (Obesity 2)
General Examination
Eyes : icteric sclera (-), anemic conjunctiva (+)
Mouth : wet mucosa oral, no signs of inflamation
Thorax
Heart : cardiomegaly (-), regular heartbeat, murmur (-), gallop (-)
Lung : simetric, vesicular breath sounds +/+, rhonchi -/-, wheezing
-/-
Mammae : areola hyperpigmentation -/-, nipple retraction -/-,
Abdomen
Inspection : convex, signs of acites (-)
Palpation : pain (-), mass(-),
Percussion : timpanic of all abdomen region
Auscultation : bowel sounds (+), 8 times / minutes
Extremities :
Upper extremities -/-, bottom extremities -/-, CRT <2 seconds,
upper extremities physiologic reflex +/+, bottom extremities
physiologic reflex +/+, patologic reflex -/-
Gynecologic Examination
First day of menstrual period :
February 15 2016
Inspection : vulvovaginal is within
normal limits
Pelvic inspection :
Inspeculo
Vulva : within normal limits
Vagina : within normal limits, but pooling of fresh
bleed
Portio : erotion (-), fluxux (+),
Cervix : polyp (-), bleeding from inside ostium
uteri
Vaginal Toucher : portio thick and rigid, no
dilatation