Transcript CPC - sums.ac.ir

CPC
By:
Dr. Sarraf MD
Dr. Akbarzadeh Md
Dr. Khalili , Dr. Karami , Dr. Sabouri , Dr. Safari Poor
‫‪CASE 1‬‬
‫صغری رضایی‬
 30 Y/O
 G1L1 (1PC/S)
 LMP: 1.7.92
 C.C. : generalized abdominal pain
 The Pt transfered from Lamerd hospital
on admission the pt has following positive findings:
 Fever
 Nausea & vomiting
 Anorhexia
 Spotting
 OB HX:
 Primary infertility for 14 years
 G1: C/S
 GYN HX:
 Mense: regular
 Mearch: 13 year-old
 Contraception:
 Past M. HX.:
 No significant findings
 Past surgical HX.:
 PC/S
 Laparascopic procedure that failed due to
sever adhesion bands followed by laparotomy
for ovarian cystectomy (R/O Endometrioma)
about 3years ago
 Pathology report: simple seros cyst &
leuteal cyst
Phsycal Examination
 V/S:
 T:??!
 P.R.: 100/min
 B.P.: 100/60 mmhg
 R.R.: 18/min
HEENT: No significant
Heart: No significant
Lung: No significant
Abdomen:
 Mild tenderness in both lowe guardant & adenexa
 No guardig
 Rebound tenderness positive
V/E:
 Left adenexa palpable mass detected (about 15 cm)
LAB DATA
CBC:
 6.7.92
WBC: 11900
7.7.92
13.7.92
12500
21800
HB: 10.7
9.8
8.4
PLT: 560000
439000
664000
B/C: Negative
U/A: Normal
U/C: Negative
PT, PTT, INR : NL
LFT: NL
BHCG: Negative
Viral marker: Negative
Bun, Cr, Electrolyte: NL
Amylas: NL
LDH: 472
General surgeon consultation
 Mild generalized Abd. tenderness with out guarding & rebound tenderness
and recommended medication ( metronidazole+ cefteriaxon ) and
observation ( check CBC , V/S and serial examination )
PAP Smear: NL (18.7.92)
Abdomino-Pelvic sono.:
 9.4.92 By Dr. Paidar Mohammad-Reza; A 82x74 mm cyst with mild lobulated border & a thin
shelf like septum is seen in Rt ovary. Lt ovary is enlarged with 3 cyst, the largest is about 40 mm .
recommendation: correlation with previous sono. And MRI with and with out contrast.
 6.7.92 By Dr. Naserei; Moderat free fluid is seen in Abdomino-pelvic cavity. For brter evaluation
TVS was done.
TVS:
 Uterus: nl size & shape & parenchymal echogenicity grossly with out evidence of SOL
 Rt ovary: nl size & a large cystic structure is seen about 81x56 mm, with echogenic
content & some increased wall thickness infavor of hemorrhagic cyst, however
endometrioma is also in diferntial DX.
 Lt ovary: nl size & shap parenchymal echogenisity ,Smal cystic structure (16x9 mm)
seen & some free fluid in pelvic cavity. So according to the mentioned finding of
rupture ovarian cyst should be inconsideration.
Abdomino-Pelvic MRI:
 11.7.92 By Dr. Rasekhei; both ovaries are enlarged and containing multiple large cystic lesiont.
There are associated with thick septal and proteinecious content. The above mensioned finding are
associated with large amount of ascitis and peritoneal thickening infavor of bilateral ovarian serous
adenocarcinoma and peritoneal seedig of malignancy.
Abdominal Tap (11.7.92):
 cytology: no malignant cell
 Culture : positive (E-coli )
 EUA + D&C (16.7.92 ):
 A mobile mass like with uterous 18 wks in mid part
of abdomen
 Pathology report : no significant pathologic change
in prolifrative phase
 Colonoscopy & Endoscopy: NL
OPERATION
21.7.92
Pre op DX.:
 Bilateral adenexal mass
Post op DX.:
 Dens intra abdomino-pelvic adhesion of small & large bowel to
both adenexa and pelvic floor + bilateral tubo-ovarian abscess
+ bilateral hydrosalpynx +multiple collection between bowel
loop + obliterated posterior coldesac
 Kind of operation :
 EXPLOTORY LAPARATOMY + release of adhesion +
dranage of abscess + supra cervical hysterectomy + bilateral
salpingo-oophorectomy
‫‪CASE 2‬‬
‫عایشه ساخت پری‬
 62 Y/O
 G4D3L1
 LMP: Menopause since 20 year ago
 C.C. :abdominal pain & protrusion
 Date of admission: 27.1.92
 Present illness:
!
 OB HX. :
 All NVD
 GYN HX. :
 Menopause since 20 year ago
 Past Med. HX. :
 HTN, Thyroid problem, Cardiac problem, DM, Renal stone
 Past Surgical HX. :
 negative
 P/E
 V/S:




T.: 37.5
BP: 120/70 mmhg
HR: 82/min
RR: 16/min
 HEENT: no significant
 Heart: no significant
 Lung: no significant
 Abdomen:
 Lab data:
 CBC

WBC: 11200
HB:11.8
PLT: 462000
 BUN, Cr, Electrolyte, LFT, U/A, S/E
All not significant
 PAP smear: normal
 Tumor marker:
 CA-125: 831.5
(28.2.92)
 Abdomino-pelvc sono.(27.1.92): huge large hypoechoic mass with some
several cystic changes that occupy pelvic cavity and extended to umblical area with
moderate free fluid in pelvic cavity. Serous cyst adenocarcinoma should be considerd.
CT scan recommended.
 Spiral CT scan(29.1.92): large heterogenous echogenic mass lesion
(15x14x16 cm) arising from uterus highly suggestive for malignant uterin mass +
moderat free fluid and ascities.
 Abdominal Tap : cytology
suspicious to malignancy
 Endoscopy & colonoscopy: normal

The pt received 6 course of chemotherapy ( Taxol + Carboplatin ).The last one was in 1.7.92 .
CA-125
831.5
(28.2.92)
171.5
(18.4.92)
18.3
(23.5.92)
25.3
(17.6.92)
7.2
(28.7.92)
Operation
 Pre op. DX:
 Ovarian cancer on neoadjuvant chemotherapy
 Post op. DX:
 Peritoneal seeding on anterior pelvic wall + Lt ovarian mass
(4x5 cm) + adhesion on Lt ovarian fossa & posterior coldesac
and rectosygmoid colocn with involvment of capsul
 Kind of operation:
 Exploratory laparotomy + TAH + BSO + peritoneal
washing + release of adhisions + Lt ovarian mass
resection + partial omentectomy + Liver &
diaphragmatic smear that sampels sent to pathlogy
‫‪CASE 3‬‬
‫بی بی بیگ اینالو‬
 52 Y/O
 G7L6D1(two PC/S)
 LMP: 27.7.92 , Irregular
 C.C.:abdominal protrusion & menomtrorhagia
 Present illness:
 The pt presented with c.c. of Abd. Pain and protrusion ,also
she has AUB that abdomiopelvic sono. was done for him
(27.1.92) that abdominal mass detected (206x191x124 mm)
therefore CT scan &MRI recommended for him.
MRI was done that abdomen was normal and pelvic had
intramural myoma (2.5x3.5 cm) in fundal part of uterus also
multiloculated mass with heterogeneous signal on Lt side of
uterus associated with pressure effect was seen.
Open and close operation was don for him with imp. of of
myoma in Jahrom hospital by Dr Motreb (7.3.92) deu to large
and congess mass with sever adhesion of bowel loop to mayoma
and suspicious to malignancy the Pt refered to shiraz.
 OB HX. :
 G1
 G6
G6 :NVD
G7 : C/S
 GYN HX. :
 Mens irregular
 Contraception TL since 18 years ago
 Past Med. HX. :
 Past Surgical HX. :
 2times C/S
 Laparatomy (large myoma)
 P/E
 V/S:




T.: 37
BP: 120/70 mmhg
HR: 80/min
RR: 15/min
 HEENT: no significant
 Heart: no significant
 Lung: no significant
 Abdomen:
 Vaginal /E: uterus
25-26 wk, others: nl
 Lab data:
 CBC:
 WBC: 9700
 HB: 9.3
 PLT: 283000
 PAP smear: normal (8.3.92)
 Tumor marker: negative (21.5.92)
 Mamography: normal
 Colonoscopy & endoscopy: normal (25.3.92)
 Trucut biopsy:
 Liomyoma with area of hyalinization
with out any atypia or myotic activity
Operation
7.8.92
 Pre op. DX:
 Huge pelvic mass + myomatus uterus
 Post op. DX:
 Large uterus (26 wk) contained multiple intramural &
subserosal fibroma with dens adhesion to small and large bowel
and abdominal wall.
 Kind of operation:
 Exploratory laparotomy + TAH + BSO + peritoneal
washing + release of adhesions of small and large
bowel to uterus
‫‪CASE 4‬‬
‫فاطمه کارگر‬
 62 Y/O
 Nulligravid
 LMP: menopause
 C.C.:abdominal pain
 Present illness:
 The pt presented with c.c. of Abd. Pain and protrusion since
about 10 months ago that sonography and CT scan was done
for him that detected a large mass in pelvic cavity
 OB HX. :
 Nulligravid
 GYN HX. :
 Menopause
 Past Med. HX. :
 HTN
 IHD
 Past Surgical HX. :
 Negative
 Drug HX. :
 Metoral, Enalapril, Nitrocantin
 P/E
 V/S:




T.: 37.2
BP: 120/75 mmhg
HR: 85/min
RR: 14/min
 HEENT: no significant
 Heart: no significant
 Lung: no significant
 Abdomen:
 Vaginal /E:
 Lt adenexal mass
 uterus
Normal
 Lab data:
 CBC , LFT, BUN, Cr, Electrolyte were normal
 PAP smear: normal (8.3.92)
 Tumor markers:(29.4.92)
 CA-125: 264.8 U/ML
 CEA : 1.1 ng/ML
 CA19-9: 6.5
 CA15-3: 66.7
 Mamography: normal
 Colonoscopy & endoscopy: normal
 Biopsy(7.11.91):
 Papillary serous cyst adenocarcinoma
 The pt received 6 course of neoadjuvant chemotherapy , the last course 1n 12.4.92 .
 Tumor marker:
 CA-125
(29.4.92)
264.8
(6.7.92)
672
 Abdomino-pelvic sono.: (12.9.91)
 Large solid mass with sever ascites & umblical hernia
 Abdomino-pelvic CT scan: (27.9.91)
 Large lobulated mass( 12x10x8 cm) in Lt side pelvic
cavity arising around Lt ovary with mesenteric seeding
& sever ascites
 Abdomino-pelvic sono.: (14.2.91)
 Necrotizing center solid mass(80x50 mm)in Lt ovary
infavoer of serous cyst adenocarcinoma
 Abdomino-pelvic sono.: (16.5.92)
 Large size necrotizing solid mass (12x9 cm) in Lt pelvic
side
Operation(exploratory staging laparotomy)
21.7.92
 Pre op. DX:
 Lt ovarian mass(papillary serous cyst adenocarcinoma)
 Post op. DX:
 Large Lt ovarian mass(14x15cm) with dense adhesion to
rectosygmoid colon & small bowel + 4x5 cm umblical hernia
 Kind of operation:
 Exploratory laparotomy + TAH + BSO + peritoneal
washing + release of adhesions of small and large
bowel + partial omentectomy + Liver cytology