A&P Basics    BIOL 2404                  Case Study: Female Reproduction        Dr. Weis

Medical City                                                              Summary Record

History:

A 42 year old female was previously examined for menorrhagia of four months duration and occasional dysmenorrhea and back pain. Abdominal palpation was within normal limits and the uterus was retroverted and retroflexed.

Ultrasound of the ovaries revealed a 3cm cyst on the right ovary and a slightly enlarged left ovary.  PAP smear results revealed metaplasia.

Tentative Diagnosis: Ovarian Cyst, Endometriosis, early Cervical cancer,

                                    Possible Endometrial polyps

Ultrasound guided laparoscopy was performed.  The right ovarian cyst had disappeared. The endometrial tissue was found superficially along the left ovary and the peritoneum lining the Cul-de-Sac. There were minimal ovarian and tubal adhesions.

Internal examination of the uterus by endoscope revealed a few small endometrial polyps.  Electrocautery was performed and the polyps were brought down though the endocervical canal.  Due to the retroversion, some of the polyps were hard to access.

A biopsy of cervical tissue revealed no malingnancy.

Final Diagnosis:  Endometrial polyps, Endometriosis Stage II