1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. physiology of mestural cycle and menopause
1.2.1.1. 1
1.2.2. abnormal vaginal bleeding in pre-meneposal woman
1.2.2.1. definition
1.2.2.2. differential diagnosis (causes)
1.2.2.3. manifestation
1.2.2.3.1. pelvic discomfort
1.2.2.3.2. "lousy" feeling
1.2.2.4. investigations
1.3. 30 minutes
2. Step 8
2.1. Diagnostic decision
2.1.1. fibroid in the uterus (myoma) with iron deficiency anemia
2.2. Mechanism
2.2.1. genetic and envioromental factors .. including obesity .. vessel formation of the fibroid in the uterus
2.3. Presentation
2.3.1. heavy bleeding with pelvic discomfort .. lousy feeling with intermenstural bleeding
2.4. Supporting data
2.4.1. yltrasound
2.4.2. CBC
2.4.2.1. blood film
2.4.3. hysterscopy
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complaint
3.1.1.1. started 6 weeks ago
3.1.1.2. menstural problems started 5 yrs ago .. increased steadlly
3.1.1.3. increase in volume .. increase use of pads
3.1.1.4. change the pads every 1-2 hours a day .. use 2 at a times
3.1.1.5. periods repeats every 28 day .. lasts for 10 days
3.1.1.6. intermenstural bleeding for one day .. it was painless
3.1.1.7. recent present of large clots
3.1.1.8. bleeding not related to intercourse .. no acute pain also
3.1.1.9. pelvic discomfort worsen at the time of mensuration
3.1.1.10. nausea and tirdness during periods .. increased between periods
3.1.1.11. menarche at the age 13 .. started irregular then become regular
3.1.1.12. mild spasmodic dysmenorrhea ..
3.1.1.13. series of accidental heavy bleeds
3.1.2. Previous medical / surgical history
3.1.2.1. mild acne of the age of 16 .. dissolved at the age of 20
3.1.2.2. contraceptive history
3.1.2.2.1. sexually active at the age of 19
3.1.2.2.2. started taking combined oral C ate the age of 20
3.1.2.2.3. stopped the OCP at the age 23
3.1.2.2.4. IUCD inserted at the age 33
3.1.2.2.5. periods become heavier after the IUCD
3.1.2.2.6. at the age of 36 IUCD removed .. she conceived quicly
3.1.2.2.7. another pregnancy after the IUCD removal .. breast fed the female infant
3.1.2.2.8. progestrone pills for contraceptive .. frequient spotting
3.1.2.2.9. had tubal ligation .. performmed by laproscope
3.1.2.2.10. laproscope showed tiny subserrosal myoma at the fundus .. ovaries were normal
3.1.2.3. glandular fever at the age of 16
3.1.2.4. appendectomy at the age of 9
3.1.3. Drug history / allergy
3.1.4. Family history
3.1.4.1. her father died of heart attack at the age 57
3.1.4.2. her mother is well .. had an hysterectomy at the age of 44
3.1.4.3. 2 sisters .. 47 and 49 .. the older have irregular periods
3.1.4.4. her grandmother died of overian cancer at the age 76
3.1.5. Social / occupational history
3.1.5.1. married .. have 2 children (11 and 8)
3.1.5.2. non smoker .. non alcoholic
3.1.5.3. no meneposal symptoms
3.1.5.4. works part time as reception .. happy at home and work
3.1.5.5. fulfilling sexual life
3.1.5.6. menstural problems affect her work sometimes
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. vitals
3.1.7.1.1. BMI is 34
3.1.7.1.2. BP 130/80
3.1.7.1.3. weight is 92
3.1.7.2. inspection
3.1.7.2.1. not pale
3.1.7.3. abdominal
3.1.7.3.1. no mases
3.1.7.3.2. normal
3.1.7.4. vaginal
3.1.7.4.1. speculum .. small cyctocele
3.1.7.4.2. normal cervix
3.1.7.4.3. uturs anteverted .. mobile smooth and regular in shape .. slightly enlarged
3.1.7.4.4. no adenexal mases or tinderness
3.1.8. tests results
3.1.8.1. CBC
3.1.8.1.1. iron deficiency anemia
3.1.8.2. ultrasound
3.1.8.2.1. a submucous myoma with clearly reduced echogenicity
3.1.8.3. hysterscopy
3.1.8.3.1. submucous myoma protruding into the uterine cavity
3.1.8.4. cutterige showed severe menorrhgea