Case Presentation Rectal Examination

							    CASE
PRESENTATION
           DR SAVITHA M
           DR SUDHA

 M.S.RAMAIAH MEDICAL
       COLLEGE
      PATIENT DETAILS
 NAME         : MRS X
 AGE           : 48 yr
 EDUCATION : Uneducated

 HUSBAND      : Late Mr Muniyappa
 OCCUPATION : Labourer

 PLACE         : Sultanpalya
 S - E STATUS : Lower class
              CASE HISTORY
CHIEF COMPLAINTS:
Post menopausal bleeding per vagina since
 3 months
White discharge per vagina since 2 months

   HISTORY OF PRESENTING ILLNESS:
    She attained menopause 5 years back
    Apparently normal till 3 months back when noticed
    spotting per vagina.
            CASE HISTORY
History of consulting local doctor and taking
medication for the same, details not known.

Since one month she complaints of excessive
 bleeding per vagina , uses 3-4 pads per day , H/o
  passing clots present.
Not associated with pain abdomen
            CASE HISTORY

History of foul smelling white discharge pv since 2
 months, minimal in amount, occasionally blood
 tinged .
No history of post coital bleed
No history of loss of weight or loss of appetite
        CASE HISTORY
MENSTRUAL HISTORY:
Age of menarche - 13yr
Menopause       - 5 yr
Previous cycle  - regular
Post menopausal
 bleeding       - 3 months
            CASE HISTORY
 MARITAL HISTORY:
Age at marriage -15 yr
Single partner ,
No pre or extramarital contacts
Husband died 2 year back ,
For husband she is single partner ,
No history of polygamy .
           CASE HISTORY
 OBSTETRIC HISTORY:
Para -5, living-5
Age at first conception-16 yr.
 PAST HISTORY :

 No history suggestive of STD and PID.

 No H/O of hypertension ,diabetes mellitus,
  tuberculosis.
             CASE HISTORY
   No history of use of oral contraceptives
   HIV status unknown
   Undergone tubectomy 17 yr back

FAMILY HISTORY: Nothing significant
            CASE HISTORY
   PERSONAL HISTORY:
                mixed diet
                appetite –good
                sleep –adequate
                bowel habits -regular
                bladder habits –normal
           No h/o of tobacco usage
          No h/o of substance abuse
        EXAMINATION
GENERAL PHYSICAL EXAMINATION:
 Moderately built and nourished

  conscious, co operative
 Pallor +

 No Icterus

 No pedal edema

 No lymphadenopathy
             EXAMINATION
   Pulse: 90 bpm
   BP: 120/80 mm Hg
   Breast: soft, no lump, discharge
   Thyroid: Clinically euthyroid
   Systemic examination:
   CVS: S1S2 heard, no murmur
   RS: Normal vesicular breath sounds
          air entry bilaterally equal
       EXAMINATION

Per abdomen:
               Obese abdomen
               No visible pulsation,
               All quadrant moving
                equally with respiration
               Infra umbilical vertical
                scar 1cm of
                tubectomy, healed by
               primary intention
Palpation: Soft
           no tenderness
           no organomegaly
           no mass palpable
           no free fluid
           BS +
          EXAMINATION
Local examination:
External genitalia normal for the age
Pubic hair distribution normal
No vulval excoriation
No skin lesions
              EXAMINATION
   Per speculum :
     - An exophytic mass,measuring approx 8 x 5
       cm, filling whole of the vagina upto introitus
     - Anterior lip of Cervix visualised.
     - Vagina appears healthy
     - Foul smelling white discharge +
     - Bleeds on touch
            EXAMINATION
Per vaginal examination :
 A friable mass, firm in consistency measuring
  8 x 5 cm, replacing the posterior lip of cervix
 Anterior lip of the cervix felt separate
 No pedicle felt
 Non tender
 Bleeds on touch
 Uterine size could not be made out
          EXAMINATION
 Per recto-vaginal examination:
 The Mass measuring 8 x 5cms was felt
  anteriorly, firm in consistency.
 Medial 1/3rd of parametrium indurated on
  both sides.
 Rectal mucosa free.
                  SUMMARY
   48 year old , post menopausal lady with history
    of post menopausal bleeding pv and blood
    tinged white discharge pv. With exophytic
    growth arising from posterior lip of cervix
    measuring around 8 *5 cm ,bleeds on touch
    .with involvement of medial 1/3 rd of
    parametrium
         EXAMINATION

IMPRESSION:

 Para5, Live 5 , postmenopausal
 lady with carcinoma cervix
stage II B
         INVESTIGATIONS
   Hb-10.4gm%
   TC-6500cells/cumm
   DC-N-70%,L-28%,E-2%M-0
   BUN-20mg/dl
   Sr.CREAT-0.8mg/dl
   HIV-neg ,HBsAG-neg
   CHEST X RAY- N
   URINE ROUTINE- N
   USG- CERVIX HYPERTROPHIED
         UTERUS NORMAL SIZE
          KIDNEYS AND URETER NORMAL
          LIVER NORMAL
          NO FREE FLUID IN POD
    BIOPSY-LARGE CELL NON
    KERATINIZING SQUAMOUS CELL
    CARCINOMA