DEPARTMENT OF

OBSTETRICS & GYNAECOLOGY

CASE WRITE UP GYNAECOLOGY

YEAR 3/2020

GROUP 1 COHORT 5

LECTURER’S NAME : PROF DATO’ DR. MOHAMED ROUSE B. ABD MAJID

CASE : OVARIAN DERMOID CYST

PREPARED BY : FARAH NUR AISYA BT FADZIL

MATRIC NUMBER : M183000334

DATE : 4th APRIL 2021

PATIENT’S IDENTIFICATION DATA

Name : Puan Aisyah Binti Daud

Age : 34-year-old
Race : Malay
LMP : 14th November 2019

Puan Aisyah Binti Daud, 34-year-old, Malay lady, para 3, married for 10 years. Last
childbirth (LCB) was 2 years ago. Her last menstrual period (LMP) was on 14 th November
2019, with normal 5-6 days flow. Her menses was regular. No menorrhagia and no
dysmenorrhea.

HISTORY OF PRESENTING ILLNESS (HOPI)

Patient was electively admitted for laparoscopic cystectomy KIV salphingoophorectomy due
to dermoid cyst.

She was well until 2 days ago, when she first noticed a palpable mass over her left lumbar
region while she was taking a bath. She said that the size of the mass was correspond to a size
of an orange. The mass was painless and firm when she touched it. It was not disappeared or
healed since it was first noticed. She mentioned that whenever she had her urinary bladder
full, the mass will become more prominent, and it also moved down once she passed urine.
Otherwise, she denied any other mass on the other site, and any changing in sizes of the mass.

She also complained of sudden and persistent abdominal discomfort due to the mass that
localized at left lumbar region with pain score less than 1/10. The pain was dull in nature.
However, she denied using any medications to ease the discomfort. claimed that the pain did
not affect her daily activities or disturb her sleep. The pain also did not increase in severity.

On further questioning, patient claimed that she had no post coital bleeding, intermenstrual
bleeding, per-vaginal bleeding, or foul smelling per vaginal discharged. She also denied no
abdominal pain, vomiting, diarrhoea, and constipation She also did not have any urinary
frequency, dysuria, hesitancy, or urgency.

She denied any history of fall, trauma, or abdominal massage.

There was no fever, loss of weight and loss of appetite.

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Due to this condition, she went for a checked up at nearby GP clinic, and was told that there
was a right ovarian dermoid cyst, measuring 6.5 cm x 6.0 cm. After that, she was referred to
Klinik Pakar O&G HSAH for further management.

Presently, patient came to Hospital Sultan Abdul Halim O&G Clinic on 15 th December 2020
after being referred from SP Family Clinic. She was electively admitted to Wad Kenanga 9
for laparoscopic cystectomy KIV salphingoophorectomy due to dermoid cyst.

PAST GYNAE HISTORY

Patient attained menarche at 12-year-old, with menses 5-6 days, normal flow with regular 28
days cycles. She had no menorrhagia and no dysmenorrhea. Hence, she denied any post-
coital bleeding (PCB), no intermenstrual bleeding (IMB), and no sexually transmitted
disease. Her last PAP smear done was in 2015 and was told normal. She was not on any
contraception.

Patient had no previous gynaecological problem and no gynaecological operation done

before.

PAST OBSTETRIC HISTORY (POH)

She had delivered 3 times at term via spontaneous vertex delivery (SVD). In 2012, she
delivered her first child, a baby boy with birthweight 3.3 kg. She delivered her second child
in 2015, which also a baby boy with a birthweight 3.4 kg. Her third child, which was a baby
girl was delivered in 2018 with a birthweight 3.12 kg. All her children do not have any
complications after delivery. She had breastfed all her children until they reach 2-year-old.

PAST MEDICAL HISTORY

Patient has no DM, hypertension, asthma, and heart disease.

PAST SURGICAL HISTORY

Patient has no previous surgical problem and no previous surgical operation done before.

FAMILY HISTORY

Both of her parents are still alive. Her father is 56-year-old while her mother is 50-year-old.
Her father has diabetes mellitus and under KK follow up, and her mother do not have any
underlying diseases.

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She is the first child from 3 siblings. All her siblings have no hypertension, DM, asthma, and
heart disease.

However, patient mentioned that her aunty from her maternal side has a breast cancer and
already done mastectomy on her right breast 6 years ago. Otherwise, there was no other
family history of malignancy.

DRUG / ALLERGY HISTORY

Patient was not on any over the counter (OTC) medications or any traditional medications.
She has no history of allergy to drugs or seafood.

PERSONAL / SOCIAL HISTORY

Patient was married for 10 years. Patient is a teacher, and her husband is a businessman.
Their total income is approximately RM 10000 monthly. Both of patient and her husband’s
education level is degree. Both patient and her husband do not smoke, drink alcohol or in the
case of drug abuse. She stays in Bandar Laguna Merbok, Sungai Petani, in a double-storey
house, with basic amenities, clean tap water supply, good electricity and using flushed toilet
system. The distance from her house to the nearest health clinic is 2 km. She had good
support from her family, and family in law, if needed, as they are staying nearby.

SYSTEMIC REVIEWS:

Respiratory System

Patient had no shortness of breath, wheezing, or early morning coughs.

Cardiovascular System

Patient had no palpitations, orthopnea or paroxysmal nocturnal dyspnea.

Central Nervous System

Patient had no headache, blurring of vision, fits or muscle weakness.

Musculo-Skeletal System

Patients had no bone pains, joint pains, back pains, or muscle pains.

Endocrine System

Patient had no tremors, no heat or cold intolerance, no polydipsia / polyuria

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SUMMARY

My patient 34-year-old, Malay lady, electively admitted for laparoscopic cystectomy KIV
salphingoophorectomy due to dermoid cyst.

CLINICAL EXAMINATION

General Examination

Patient is comfortable, lying supine on bed, slightly prop-up 30’ and supported with 1 pillow.
She is not in pain or in any distress.

Her blood pressure is 103/62 mmHg, pulse rate is 76 bpm, regular rhythm, normal volume.
Patient is not dyspnoeic with respiratory rate of 16 breath per min. She is afebrile with
temperature of 37’C. Patient is normal built with weight of 73 kg. Her BMI is 27 kg/m2.

There is branula attachment over dorsum of her right hand, attached to a Dextrose Saline drip
infusion.

There is no clubbing and no peripheral cyanosis. The capillary refill time is < 2 seconds.

She is not pale and no jaundice.

Her hydration status is good. There is no central cyanosis. Her oral hygiene is good and no
dentures.

There is no goitre and her JVP is not raised. Supra-clavicular and cervical lymph-nodes are
not palpable bilateral.

There is no ankle edema bilateral.

Other Systems Examination:

Respiratory System

The air-entry are equal bilateral. Lungs are clear bilateral. There is no crepitations and no
rhonchi.

Cardiovascular System

1st and 2nd heart sound are heard and normal. There is no murmur.

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Breast Examination

The breasts are symmetrical bilateral. The nipples are everted and not deviated. There is no
nipple discharge. There is no mass palpable bilateral.

Specific System Examination:

Abdomen Examination

The abdomen appeared distended over left iliac region. The abdomen moves symmetrical
with respiration. The umbilicus is centrally placed and inverted. There is no dilated veins, no
pulsatile mass seen. There is no surgical scar seen and cough impulse is negative.

The abdomen is soft and non-tender.

There is a mass palpable over the suprapubic region, which correspond to 18 weeks of uterus,
centrally placed and is slightly deviated to the left iliac region, firm in consistency, non-
tender, smooth surface, well defined margin, measuring 12 cm x 12 cm, mobile sideways and
up-and-down. I could get below the mass.

Liver and spleen are not palpable. Both kidneys are not ballotable.

Shifting dullness is negative.

Bowel sound is heard and normal. There is no bruit heard over the abdominal mass.

Vaginal Examination

Cervix tubular, os closed, no per vaginal bleeding seen and no per vaginal discharge seen.

Speculum Examination

Vulva-vaginal no abnormalities detected (VVNAD), uterus is 22 weeks size, ante-verted.

Cervix tubular, os closed.

No adnexal mass or tenderness bilateral.

Cervix does not move with abdominal mass.

PROVISIONAL DIAGNOSIS

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Dermoid cyst

DIFFERENTIAL DIAGNOSIS

Uterine fibroid

INVESTIGATION

A. Blood
1. Full blood count
Value Normal
Hb 12.8 g/dl 12-15
Hct 39.2 % 36-48
Plt 261 150-450
Result: Normal

2. Renal profile
Value Normal
Na 145 mmol/L 135 - 150
K 4.1 mmol/L 3.5 - 4.5
Cl- 96 mmol/L 80 - 100
Creatinine 68 umol/L 45 - 90
Urea 2.8 mmol/L 2.0 – 7.0
Result: Normal

3. Liver function test

Result Normal range
Total Protein 78 57-82 g/L
Albumin 38 35-50 g/L
Total bilirubin 19 5-21 g/L
ALT 32 7-55 U/L
AST 29 8-48 U/L
ALP 80 45-115 U/L
Result: Normal

4. Coagulation profile
Value Normal

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 PT 12.8 sec 11 - 14
INR 1.0 < 1.1
APTT 38.4 sec 30 - 40
Result: Patient do not have any coagulation disorder.

5. GSH (preparation for operation)

B. Urine
1. UFEME (to rule out any infection)
Result Unit Normal Range
Specific gravity 1.014 /uL 1.000-1.020
pH 7 /uL 5-7
Leukocytes 8.4 x 10^9/L Leu/uL Negative
Nitrite Negative Negative
Protein + G/dL Negative
Glucose Normal Mg/dL Normal
Ketone Negative Negative
Urobilinogen Normal Normal
Bilirubin Negative Umol/L Negative
RBC 0.4 Mg/dL 0-1
Hemoglobin 11.9 g/dL 12.0-15.5
Result: There is leucocyte and protein trace in the urine.

C. Imaging
1. Trans-abdominal ultrasound scan (done on 15/12/2020)
● Uterus is retroverted, slightly pushed to the right.
● Size of uterus 6.1 cm x 3.1 cm
● Endometrium was not thickened.
● There is a uniloculated cyst with some calcificd area posteriorly,
measuring 6.3 cm x 6.5cm.
● Color Doppler: no internal vascularity
● No ascites
Impression: Left dermoid cyst

IMMEDIATE AND SUBSEQUENT MANAGEMENT

Based on the diagnosis:

Left dermoid cyst.

Plan:

1. To admit gynaecological ward

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 2. Put patient on temperature / blood pressure / pulse rate chart
3. Set IV line
4. Trace all blood and ultrasound investigations
5. Inform anaesthetists for preoperative assessment

Treatment:

Patient was electively admitted for laparoscopic unilateral cystectomy KIV

salphingoophorectomy and sent for HPE. Patient was admitted 1 day before operation for
pre-operative assessment. Thorough assessment was required.

Throughout her stay, her Hb level was 13.2 g/dL. Bowel was prepared for 1 day, also prior to
operation she was given T. Ativan 1/1 ON. She was also infused with IV Maxalon 10mg
prior to OT call, and IV Ranitidine 50mg tds.

Other investigation had trace, and anaesthetist had reviewed for pre-op assessment.

Operation: Laparoscopic unilateral cystectomy KIV salphingoophorectomy

Gynaecological Surgery Procedure Info:

1) Operation started: 3.37 pm.

2) Operation ended: 4.36 pm.
3) Patient was put under GA & lithotomy position. She was cleaned and draped.
4) Vaginal approach: Bladder emptied using catheter.
5) Abdominal approach: Skin incision made at subumbilical region.
a. Verres needle inserted to create pneumoperitoneum.
b. Followed with insertion of 5 mm port.
c. Another 2 ports inserted at right and left iliac fossa.
d. Laparoscope introduced, with findings as below:

i. Intra-operative findings:
− Uterus normal size, retroverted, mobile
− Bilateral fallopian tube normal
− Right ovary normal
− Left ovary with presence of left-dermoid cyst size about 7 cm x 7 cm
containing sebum, hair, scalp, gum, cyst.
− Liver surface normal

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 − Pouch of Douglas free had no free fluid.
− No endometriotic spot
− EBL: minimal
ii. Post op:
− Repeated Hb: 12.5 g/dL
No complications arise intra-operative.

MANAGEMENT AND PROGRESS OF PATIENT IN WARD

Treatment in ward:

1. Unilateral cystectomy KIV salphingoophorectomy

2. Prior to operation, she was given:
− T. Ativan 1/1 ON
− IV Maxalon 10mg
− IV Ranitidine 50mg tds

Progression in ward:

Patient ambulating in ward, tolerating orally well, no nausea, no vomiting, no shortness of

breath, no chest pain, no abdominal pain tolerable and PU and BO freely.

Patient was well post-op. BP was 120/80 mmHg and PR was 86 bpm. Ambulating well post-
op. Wound inspection D2 showed operation wound clean and not inflamed.

Then allowed for discharge

Patient was discharged well with:

1. Medications
- T. Unasyn 375 mg BD x 6/7
- T. voltaren 50 mg TDS x 4/7
- T. gelusil 11/11 TDS x 4/7
2. Advised to be compliant towards follow-ups and medications.
3. TCA to gynaecology clinic after 6 weeks at 2.50 pm to review HPE on 9th February 2021.
4. To trace and review investigation results on TCA (9th February 2021)

FOLLOW UPS

Patient has been scheduled for a follow-up 6-week post-op. If there are any complications

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arise such as bleeding, patient is required to attend to clinic immediately and will be further
managed.

DISCUSSION

My patient 34-year-old, Malay lady, electively admitted for laparoscopic cystectomy KIV
salphingoophorectomy due to dermoid cyst. She was well until 2 days ago when she noticed
palpable mass over her left lumbar region associated with sudden and persistent abdominal
discomfort. Patient came to Hospital Sultan Abdul Halim O&G Clinic on 15th December
2020 after being referred from SP Family Clinic.

A cyst is an abnormal growth that develops as a closed sac somewhere in the body. A
dermoid cyst is a specialized type of cyst that contains skin and skin appendages, which
include hair follicles and sweat glands. Dermoid cysts have different names depending on
where in the body they form and what types of structures are inside them. For example, a
dermoid cyst that contains many types of cells, such as skin, hair, teeth, fat, bone, and nerve
cells, is called a teratoma.

Dermoid cysts of the ovary, also known as benign or mature teratoma may develop in the
ovaries in women during the childbearing years. It can be single or can occur in both ovaries.
Their size ranges from about half an inch to very large tumours that fill the abdomen. They
are the most common ovarian mass diagnosed in young adult women.

Many dermoid cysts of the ovary do not directly cause symptoms. However, if a dermoid cyst
grows, it may result in complications due to invasion upon neighbouring structures. Some
women with a dermoid cyst may have abdominal pain, abnormal vaginal bleeding, difficulty
urinating, or a dull ache in the lower back and thighs. In some cases, a dermoid cyst may
grow large enough to put pressure on or twist the ovary (ovarian torsion). This may result in
abnormal pain and bleeding. An enlarged dermoid cyst can also cause pain in the pelvic
region, and pressure on the bladder may result in difficulty urinating. A small percentage of
dermoid cysts can progress to cancer. Treatment of choice for a dermoid cyst is surgical
removal.

REFERENCES

1. Ten Teachers. 2011. Gyanecology 20 th edition. Edited by Philip N. Baker and Louise
C. Kenny. Published by Hodder &amp; Stoughton Ltd.
2. https://www.healthgrades.com/right-care/skin-hair-and-nails/dermoid-cyst

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DISCHARGE SUMMARY

Final Diagnosis: Final, 15/12/2020, Left dermoid cyst, unspecified, discharge, laparoscopic
unilateral cystectomy KIV salphingoophorectomy
Notes for follow up if any: DOA: 9/02/2021
Aisyah Binti Daud
34-year-old, Malay lady
Para 3, married for 10 years
LMP was on 14th November 2019
Last childbirth 2 years ago
E/A on for laparoscopic cystectomy KIV salphingoophorectomy due to dermoid cyst on
15/12/2020.

======================================= =======
Problem lists:
1. Left dermoid cyst
= = = = = = = = = = = = = = = = = = = = = = = = == = = = = = = = = = = = = = = = = = = = =
Progression in ward:

Patient electively admitted on 15/12/2020 for laparoscopic cystectomy KIV

salphingoophorectomy due to dermoid cyst. Intraoperatively was uneventful.

Intraoperatively noted left ovary with presence of left-dermoid cyst size about 7 cm x 7 cm
containing sebum, hair, scalp, gum, cyst.

Post operatively, repeated Hb of 12.5 g/dL.

Subsequently, patient was allowed discharged on day 4 post-operative as she was well with
no active complaints prior to discharge.

Plan upon discharge:

 Allow discharge
 TCA to gynaecology clinic after 6 weeks at 2.50 pm to review HPE on 9th February 2021
 To trace and review investigation results on TCA (9th February 2021)
 To complete medications:

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 1. T. Unasyn 375 mg BD x 6/7
2. T. voltaren 50 mg TDS x 4/7
3. T. gelusil 11/11 TDS x 4/7

REFERRAL LETTER

To:
Medical officer in charge,
O&G Specialist Clinic,
Hospital Sultan Abdul Halim Mu’adzam Shah,

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Sungai Petani, Kedah.

Dear Dr,

Thank you for seeing this patient.

Diagnosis: Left dermoid cyst

Admitted to hospital for laparoscopic unilateral cystectomy KIV salphingoophorectomy for

left dermoid cyst. Patient was well until 2 days ago, when she first noticed a palpable mass
over her left lumbar region which correspond to a size of an orange. She has been under
O&G at Hospital Sultan Abdul Halim Mu’adzam Shah for dermoid cysts after being referred
from SP Family Clinic.

On examination, there was a mass palpable over suprapubic region, which correspond to 18
weeks of uterus, centrally placed and is slightly deviated to the left iliac region, firm in
consistency, non-tender, smooth surface, well defined margin, measuring 12 cm x 12 cm. The
mass is mobile sideways and up-and-down and could get below the mass.

Subsequently, patient was allowed discharged on Day 4 post-operative as she was well with
no active complaints prior to discharge.

Patient request to have her follow up at your hospital, as it is nearer to her home.

I would like to refer this patient to you for her further follow up and treatment, and your hand
care.

Thank you.

farah
Medical officer O&G Department HSAH

20 December 2020

PRESCRIPTION SLIP
Name : Aisyah Binti Daud
RN : SP00703778
Diagnosis : Left dermoid cyst
Treatment 1. T. Unasyn 375 mg BD x 6/7
2. T. voltaren 50 mg TDS x 4/7
3. T. gelusil 11/11 TDS x 4/7

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 farah
Medical officer O&G Department HSAH
20 December 2020

PROFESSIONALISM

Professionalism is a core quality to be developed and understood as part of becoming a

doctor. It brings together many aspects of how a medical student learns about and contributes
to the care of patients.

a. Professional judgement: As a medical student, I must behave professionally by

being responsible, open-minded, honest, and always learn from mistake, so that I can
make an improvement on myself.

b. Communication issues: During history taking, I need to use Layman’s term instead
of medical terms as the patient might not be able to understand the questions that was
being asked and they might give out the wrong answer.

c. Spiritual issues: I must take care of the patient modesty and privacy when
performing physical examination as most of my patients are Muslim.

d. Ethical issues: As a medical student, I must ask for patient’s permission before
continuing to ask her questions. After obtaining all the information, it is crucial to
protects patient confidentiality.

CRITICAL APPRAISAL

Dermoid cyst is the common type of germ cell tumours of the ovary. It is also called as cystic
teratoma and usually it is a benign condition. In most cases, dermoid cyst occurs bilaterally. It
can be combination of all tissue types, for example, mesenchymal, epithelial and stroma.
Typically, dermoid cysts contain a diversity of tissues including hair, teeth, bone, thyroid, etc.

Dermoid cysts may occur at any age but the prime age of detection is in the childbearing
years. The average age is 30-year-old. Up to 15% of women with ovarian teratomas have
them in both ovaries. Dermoid cysts can range in size from a tiny size of a centimetre up to
45 cm in diameter. These cysts can cause the ovary to twist (torsion) and imperil its blood
supply. The larger the dermoid cyst, the greater the risk of rupture with spillage of the greasy
contents which can create problems with adhesions, pain etc. Although the large majority

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(about 98%) of these tumours are benign, the remaining fraction (about 2%) can becomes
cancerous (malignant).

Removal of the dermoid cyst is usually the treatment of choice. This can be done by
Laparoscopic Cystectomy KIV. Salphyngoophorectomy. However, if ovary is viable,
cystectomy can be performed (often via laparoscopy). Torsion (twisting) of the ovary by the
cyst is an emergency and calls for urgent surgery.

REFLECTION AND LONG-LIFE LEARNING

Obstetrics and Gynaecology posting was the second posting for Group 1 Cohort 5. From this
posting, I can conclude that approaching women with gynaecological problem was slightly
different from pregnant mother. Even the physical examination and history taking were also
differ from each other. There were some components in history taking in gynaecology that
was being added compared to other department. For example, we need to include the patient
past gynae history. Hence, it was crucial to know patient’s last menstrual period, last
childbirth or whether patient had menopause or not. If patient could not remember it, try to
get the information from the family members. I found it was important to know the main
complaint of patient and ask more details about the symptoms that the patient experienced.
History taking was not as easy as I expected, but with a lot of practiced, I think that my
history taking skills keep getting better.

Therefore, during physical examination of the abdomen in gynaecology, I still have some
difficulties to identify the mass and to describe the mass. I hope that, in the future, I have
many chances to see patient that presented with gynaecological masses so that I can keep on
practising on how to examine the mass properly and systematically.

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