Q: 43/F having abdominal pain, and other history given in handwritten A: I now have all the information needed to give a complete, well-structured clinical summary. Here is the full case analysis: --- Clinical Case Summary - Ramilaben H. Thakor, 43/F --- Patient Details - Name: Ramilaben H. Thakor - Age/Sex: 43 years / Female - Date of Consultation: 03/08/2026 VED Hospital, Kheda - Consulting Doctor: Dr. Dhiren M. Shah, M.D. Gynecology, Reg. No. G-7513 --- History Parameter Details ------ Chief Complaint Abdominal pain for 2 months Obstetric History G3P3 - 3 Full-Term Normal Deliveries 2 male, 1 female; last delivery 19 years ago Tubal Ligation Not done Past Surgical History Appendectomy done 20 years ago LMP 1.5 months ago Menstrual History Regular cycles; cycle length 30-35 days; flow for 3-4 days; normal flow --- Examination - Per Abdomen PA: Soft, Non-Tender --- USG Abdomen & Pelvis Report 20 July 2026 - Dr. Ketal Dhamecha, MD Radiologist Normal findings: - Liver - normal size, echotexture; no focal/diffuse lesion; no IHBR dilatation; portal vein normal - Gallbladder - well distended, no gallstones, normal wall, CBD normal no CBD stone - Pancreas - normal morphology; no mass or calcification; main PD not dilated - Spleen - normal size and echotexture; no focal lesion; splenic vein normal - Both kidneys - normal size, shape, position; cortico-medullary differentiation preserved; no calculus or hydronephrosis - No para-aortic lymphadenopathy - No abnormal bowel pattern - Urinary bladder - well distended; normal wall thickness; no calculus, mass, or diverticulum - Both ovaries - normal size and echotexture; no adnexal mass - No free fluid in abdomen or pelvis Significant findings on TVS: - Uterus is bulky - Volume 104 cc normal uterine volume in a parous woman 80-120 cc, but the heterogeneous echotexture is the key finding - Heterogeneous myometrial echotexture - classic sonographic sign of adenomyosis - Anterior wall fibroid: 2.4 x 1.9 cm - intramural - Endometrium - normal in thickness - Nabothian follicles noted in cervix benign, incidental Impression: 1. Bulky uterus with changes of adenomyosis 2. Uterine fibroid anterior wall, 2.4 x 1.9 cm --- Diagnosis Adenomyosis with uterine fibroid presenting as chronic pelvic/abdominal pain. Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium, causing hypertrophy and inflammation. It is found more commonly in multiparous patients as in this case - Para 3 and in the later reproductive years. On ultrasound, it appears as heterogeneity in the myometrium and blurring of the junctional zone - exactly as described in this patient's USG report. Adenomyosis frequently coexists with uterine leiomyoma, as seen here. Sabiston Textbook of Surgery, p. 2983 --- Investigations Advised Pre-operative workup Investigation Purpose ------ UPT Urine Pregnancy Test Rule out pregnancy LMP 1.5 months ago, TL not done - circled/highlighted, urgent CBC Assess for anaemia common with adenomyosis/fibroids Blood Group & Cross-match Pre-op blood grouping BT, CT, INR Coagulation profile for surgical fitness HIV, HBsAg Infectious disease screen pre-op Serum Electrolytes Pre-anaesthesia baseline Chest X-ray Pre-anaesthesia ECG Cardiac evaluation pre-op Physician Fitness Anaesthesia fitness clearance Note: The UPT is circled on the note - given LMP was 1.5 months ago and TL was never done, ruling out pregnancy is the first priority before scheduling surgery. --- Plan Step Detail ------ Procedure Advised TLH - Total Laparoscopic Hysterectomy definitive treatment for adenomyosis + fibroid in a parous woman who does not need future fertility Admission Admit the patient OT Schedule Tomorrow at 4:00-5:00 PM NBM Nil by Mouth From 9:00 AM Enema 6:00 AM and 9:00 AM --- Clinical Correlation Why TLH is the right approach here: - Patient is 43/F, parous P3, with no desire for future fertility implied by history and clinical context - USG confirms adenomyosis - heterogeneous uterus, bulky 104 cc - Uterine fibroid coexisting anterior wall, 2.4 x 1.9 cm - small but symptomatic in context - Symptom: Chronic abdominal pain for 2 months - Hysterectomy is the surgical intervention of choice for adenomyosis in patients who have failed medical management and do not desire future fertility Sabiston, p. 2984 - TLH offers advantages over open surgery: decreased postoperative pain, shorter hospital stay, and reduced blood loss Schwartz's Principles of Surgery - Uterine size is not prohibitively large, making TLH technically feasible Key pre-operative concern: LMP was 1.5 months ago with no TL done - UPT must be negative before proceeding to OT. This has been appropriately flagged by the clinician circled on the note. --- Summary Table Domain Finding ------ Primary Diagnosis Adenomyosis + Uterine fibroid AUB-A + AUB-L USG Key Finding Bulky uterus 104 cc, heterogeneous echotexture, 2.4x1.9 cm anterior fibroid Symptom Chronic abdominal pain x 2 months Parity G3P3, last delivery 19 years ago Cycle Regular, normal flow, 30-35 day cycle Abdomen Soft, non-tender Planned Surgery Total Laparoscopic Hysterectomy TLH Pre-op Priority UPT to rule out pregnancy first
