OB-GYNE CASE

HISTORY
- Miss XY, 26yo, student, from Bacolod City was admitted last June 4, 2019.
- According to the patient’s statement, she was reasonably well 2 months back. Then she noticed
a feeling of heaviness in her lower abdomen, which was progressively increasing. She also complained
of lower abdominal pain, which was localized to the right side, associated with sudden mild dull pain
with no radiation and without any exacerbating factor. For these reasons, she was sought
consultation with a private physician and was advised to have MRI of the abdomen. MRI showed a
huge complex mass at the right adnexa (2000mL) 20x15x12cm occupying the abdomino-pelvic cavity,
without any adhesion within the surrounding structures, nor ascites.
- She is non-diabetic, nonhypertensive and non-asthmatic
- She had her menstruation at 13yo, lasting for 5-6 days, monthly with scanty flow. No
dysmenorrhea noted. Her LMP was 1st week of April 2019. She is single with no sexual partner.
- She had no previous surgeries and no medical illnesses. Her father is hypertensive and her
mother is diabetic.

PE:
- Height: 149cm, Weight: 61kg, BMI: 27.4
- NO anemia, jaundice, cyanosis, edema, clubbing of fingers, neck vein engorgement, no palpable
lymph nodes, thyroid not enlarged
- Temp: 98.6F, Pulse 80/min, RR: 16cpm; BP: 130/90mmHg
- Cardiovascular, Respiratory and Nervous system has no abnormalities
- Abdomen: enlarged, umbilicus inverted. A huge mass was found situated in the midline which
was firm in consistency and mobile in all direction. On percussion, it was dull at the center and flanks
were tympanic
- No vaginal/ speculum exam was done

On Admission:
Labs:
1. CBC
- Hgb 12.3g/dl Lymphocytes: 28.2%
- RBC count 4.28x106μL Monocytes 5.1%
- WBC count 6.66x103μL Eosinophils 2.6%
- Platelet count 287,000μL Basophils 0.2%
- Neutrophils 63.9%

2. Urinalysis
- Color: straw Appearance: clear
-Pus cell: 1-2/hpf Casts/crystals: none

3. Serum CA-125: 8.7U/L

4. Serum TSH 5.34
5. Serum FT4: 0.87
6. Serum creatinine: 0.8
7. Blood group: O (+)
8. HBsAg: Negative
9. VDRL: Nonreactive
10. Ultrasound of whole abdomen: Slightly bulky uterus. Huge semi-solid mass with thick
internal septations in pelvic cavity, more on right adnexa
Post-op OR Findings: