CPC By: Dr. Sarraf MD Dr. Akbarzadeh Md Dr. Khalili, Dr. Karami, Dr. Sabouri, Dr. Safari Poor

بهار سوج

زاگرسیا زیبای طبیعت

91

CPCBy :

Dr. Sarraf MD

Dr. Akbarzadeh Md

Dr. Khalili , Dr. Karami , Dr. Sabouri , Dr. Safari Poor

CASE 1رضایی صغری

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 DATACBC:

6.7.92

WBC: 11900 HB: 10.7

PLT: 560000

7.7.92

12500

9.8

439000

13.7.92

21800

8.4

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

OPERATION21.7.92

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

بهار یاسوج 91سد

CASE 2پری ساخت عایشه

62 Y/O

G4D3L1

LMP: Menopause since 20 year ago

C.C. :abdominal pain & protrusion

Date of admission: 27.1.92

The pt presented with c.c. of Abd. Pain

and... ?

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-125831.5

(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

بهار یاسوج91

CASE 3اینالو بیگ بی بی

52 Y/O

G7L6D1(two PC/S)

LMP: 27.7.92 , Irregular

C.C.:abdominal protrusion & menomtrorhagia

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.

Present illness:

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 :NVD G6 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

Operation7.8.92

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

بهار 91یاسوج

CASE 4کارگر فاطمه

62 Y/O

Nulligravid

LMP: menopause

C.C.:abdominal pain

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

Present illness:

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