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Case of Patient LC

Identifying Data

68 years old

G4P4 (4004)

Widow

Bulacan
Reason for Admission

Ovarian mass
(+) Hypertension (2016)
Past
Medical Highest BP 140/100

History Usual BP 110-120/80-90

Maintained on Losartan 50mg OD


Family History

(+) Hypertension mother, siblings

(-) Diabetes, Asthma, Thyroid disease, Cancer, Heart disease


Personal and Social Elementary graduate

Unemployed
History
Nonsmoker, Non-
alcohol beverage
drinker

Denies use of Illicit


Drugs
Menarche: 16 years old
Menstrual
History Interval (Subsequent menses): regular, every 30
days

Duration: 4 days

Amount: 4 pads per day, moderately soaked

Symptoms: (+) Dysmenorrhea

Menopause at 43 years old


Denies OCP use
Gynecologic
History
G4P4 (4004)

G1 1975, full term, forceps-assisted


vaginal delivery

Obstetric History G2 1979, full term, forceps-assisted


vaginal delivery

G3 1988, full term, vaginal delivery

G4 1991, full term, vaginal delivery


THREE MONTHS PRIOR
History of
Present Accidental fall

Illness Work ups done to look for injuries

Ultrasound revealed incidental finding of left


ovarian mass

Referred to gynecologist

Advised surgery, but postponed due to financial


issues
(-) abdominal enlargement, distension, or any
History of palpable mass
Present
(-) abdominal / pelvic pain, or discomfort
Illness
(-) urinary problems such as dysuria, retention,
polyuria, urgency

(-) GI symptoms such as bloating, nausea, early


satiety, diarrhea or constipation

(-) vaginal bleeding

(-) weight loss


DURING THE INTERIM
Present
History Patient remained asymptomatic.

Denies of associated GI symptoms, abdominal


distension, urinary problems.
ONE MONTH PRIOR
Present
History able to obtain an SS card in our institution

consulted at SLMC-OPD under the OB-GYN service

Further work up and management was done

still denies abdominal pain or discomfort, distension, GI


or urinary symptoms, weight loss

Advised for TAHBSO, possible frozen section of the


ovary, possible completion surgery (peritoneal fluid
sampling) omentectomy, bilateral lymph node dissection
and fixation
General: no fever, weakness, weight loss
Review of
Systems Skin, Hair, Nails: no skin lesions, cyanosis,
jaundice

HEENT: no dizziness, BOV, hearing loss, mouth


bleeding, neck stiffness

Respiratory: no DOB, cough

Cardiovascular: no chest pain, palpitations

Breast and Axillae: no mass, tenderness


GI: normal bowel movement
Review of
Systems Urinary: no dysuria, hematuria

Genital: no active lesions

Vascular: no varicosities

MSK: no bone or joint pains

Neurologic: no fainting, seizure

Endocrine: no temperature intolerance

Hematologic: no easy bruising, bleeding


Conscious, coherent, not in cardiorespiratory
Physical distress
Examination
Vital signs are stable
on Admission
Anicteric sclerae, pink palpebral conjunctiva

Clear breath sounds

Adynamic precordium, with regular rate and


rhythm

Flabby, soft abdomen, nontender, nondistended,


no palpable masses.
Internal examination: Cervix firm, with firm solid
PE on nodular mass, fixed to posterior cul de sac 6cm.
Admission
Recto-vaginal: 6cm of inferior pole of said nodular
mass is palpable.
Paps Smear
(9/28/16)
Transvaginal
Ultrasound
(10/25/16)
Human Epididymis Protein
Biomarkers
(11/02/16) 80.50pmol/L

HE4
& Cancer Antigen (CA 125)
CA 125
21.4U/mL
SUBJECTIVE OBJECTIVE
Salient 68 year old Not in distress
Features G4P4 (4004)
Hypertension (2016)
BP 140/80
flabby soft abdomen, nontender,
HBP 160/100 nondistended, with no palpable
UBP 120/90 mass
Incidental finding of ovarian mass Internal examination: Cervix
(L) firm, with firm solid nodular mass,
(-) abdominal pain, fixed to posterior cul de sac 6cm.
pain/discomfort, GI/urinary Recto-vaginal: 6cm of inferior
symptoms, vaginal pole of nodular mass is palpable.
bleeding/discharge, weight loss. TVS UTZ showing left ovarian
new growth with solid component,
suggestive of benign nature.
Paps Smear unremarkable
HE4 & CA125 unremarkable
68-year-old G4P4 (4004), Ovarian New Growth,
INITIAL Left ovary, rule out Malignancy, Anterior Vaginal
DIAGNOSIS Wall Prolapse Stage II, Hypertension, controlled
Left salpingo-oophorectomy, frozen section of left
Operation ovary, total abdominal hysterectomy right salpingo-
oophorectomy, uterosacral ligament fixation,
appendectomy, under combined regional-general
anesthesia

No intraoperative complications noted

Patient tolerated the procedure well

Estimated blood loss of 445 cc


No ascites
Intraoperative
Left ovary 13 x 9 x 7 cm, freely movable, occupying the posterior cul de
findings sac, twisted 3x on the left infundibulopelvic

> superior cystic component 6 x 9 x 5cm

> inferior nodular solid component 7 x 9 x 7cm

Left fallopian tube stretched out but seems normal

Uterus pink, smooth and small, 4 x 4 x 2.5 cm

Right ovary and fallopian tube were grossly normal

Endometrium thin

Cervix measured 3 x 2 x 2 cm

Appendix 8 x 0.5cm, normal looking


Intraoperative Frozen section (L ovary) Benign Transitional Cell
findings Tumor (Benign Brenner Tumor) with Mucinous
Cystadenoma Component
POST- 68-year-old G4P4 (4004) Benign Transitional Cell
OPERATIVE Tumor (Benign Brenner Tumor) with Mucinous
Cystadenoma, Left Ovary, Anterior Vaginal Wall
DIAGNOSIS
Prolapse Stage II, Hypertension, s/p Left Sapingo-
oophorectomy, Frozen Section of Left Ovary, Total
Abdominal Hysterectomy Right Salpingo-
oophorectomy, Uterosacral Ligament Fixation,
Appendectomy under combined Regional-General
Anesthesia (11/04/2016)
Patient seen sleeping, but easily arousable, able to engage in
Post- conversation

operative Denies of difficulty in breathing

Course Notes slight abdominal discomfort and pain

No signs of distress

Afebrile

BP range of 130-140/70-80

HR range of 60-65

RR 18-20

O2 sat at 100%