CLINICOPATHOLOGIC CONFERENCE

Department of Obstetrics and Gynecology

A case of 49 year old woman who came in because of weakness and abdominal pain for several
months. Condition started six months prior to admission when she began to experience
indigestion, fatigue, weight loss (20%) and alternating diarrhea and constipation. No consult
was done. Three months prior to admission, she experienced abdominal pain, generalized,
colicky in character occurring anytime of the day. She self medicated with Mefenamic Acid 500
mg tablet 1 tablet every four hours and afforded temporary relief. No vaginal bleeding, dysuria,
nausea, vomiting, dizziness and shortness of breath noted. No “hilot”/abdominal manipulation
done. Consulted an albularyo and was given herbal concoctions but was not consumed due to
bitter taste. A week prior to admission, she noted a tender palpable mass in the left inguinal
area. No fever and other signs and symptoms noted. No medications taken. No consult done.
Several hours prior to admission, abdominal pain recurred with the same character and this time
not relieved with Mefenamic Acid, sought consult to the nearest hospital, hence, admitted.
Physical examination revealed a thin woman with the following vital signs: BP=120/70
mmHg, Heart rate of 124 bpm, Respiratory rate of 15bpm and temperature of 37C. She was a
former janitress but had been unable to work due to her illness. She was a diagnosed and treated
case of pulmonary tuberculosis (8 years PTA) and claimed to have excellent compliance to
medication and follow up check ups. She denied any significant surgical operations/history. Her
husband is a utility worker and claimed to be healthy. She is diabetic (for 10 years) with
Metformin 500 mg tablet once a day as maintenance and claimed to have good compliance and
maintained blood sugar level. Nonhypertensive and non-asthmatic. She denied any form of
allergies and other heredofamilial disorders. She had a 20 pack year history of smoking and
occasional alcohol intake. She denied any history of illicit drug use. Her gynecological history
revealed her last menstrual cycle was four months ago. No history of sexually transmitted
diseases. No history of abnormal pap smear(last pap smear was 5 years ago). She used
intrauterine contraceptive device and removed a year ago. Her Obstetrics history revealed six
spontaneous vaginal deliveries all fullterm without complications and all hospital deliveries.
She claimed that all her children are well. On admission, she was anicteric with pale palpebral
conjunctivae, poor dentitation and negative for cervical lymphadenopathy. Cardiovascular and
respiratory evaluations were unremarkable. Abdominal examination revealed a non-distended
abdomen with normally active bowel sounds. Palpation of the left lower quadrant revealed a
tender, fixed, firm mass. No guarding and rebound tenderness. Pelvic examination revealed no
vulvar and vaginal lesions noted. No discharges appreciated. No cervical lesions noted. The
uterus was fixed and difficult to assess. No rectal masses palpated. Neurologic examination was
unremarkable. Laboratory evaluations during admission revealed CBC [ Hemoglobin(8 g/dL),
Hematocrit(27%), WBC (12 x 10/uL) with a predominance of neutrophils. Urinalysis showed
(+2 bacteria). Serum sodium (134mmol/L) serum potassium(3mmol/L) and creatinine (1.2
mg/dL). Amylase, Lipase, Hepatitis Profile and CEA were within normal limits. ECG and
Chest xray were normal. On the second hospital stay, pelvic ultrasound was done and revealed
complex left adnexal mass. On the third hospital stay, CT Scan of the abdomen and pelvis
revealed a distorted uterus with complex masses of the left adnexa and inguinal region and a
solid right adnexal mass. On the fifth hospital stay, patient underwent a procedure.