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CLINICAL CASE PRESENTATION

CLINICAL CASE PRESENTATION. Intern Eunice Bernadette M. Go. General Data. FA 23/F Single RC Muntinlupa Consulted for the 3 rd time. Chief Complaint. Right lower quadrant pain. HPI. 6 mos PTC – patient noted mass on RLQ, approx 3x3 cm, movable, nontender

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CLINICAL CASE PRESENTATION

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  1. CLINICAL CASE PRESENTATION Intern Eunice Bernadette M. Go

  2. General Data • FA • 23/F • Single • RC • Muntinlupa • Consulted for the 3rd time

  3. Chief Complaint • Right lower quadrant pain

  4. HPI 6 mos PTC – patient noted mass on RLQ, approx 3x3 cm, movable, nontender 5 mos PTC – noted increase in size of mass, (+) RLQ pain, intermittent, throbbing, VAS 2/10, resolves spontaneously (-) fever, (-) bowel changes, no meds/consult

  5. HPI 2 mos PTC – noted significant increase in size of mass, (+) weight loss, involuntary (+) RLQ pain, intermittent, throbbing, VAS 2/10, resolves spontaneously (+) consult at PGH (FMC-OPD), was referred to OB GYNE, work up was done A> Ovarian mass, given Tramadol 50 mg BID for pain and was advised surgery

  6. HPI 1 day PTC – patient’s RLQ pain recurred but this time it became severe VAS 10/10, radiating to all quadrants, throbbing, continuous (+) nausea, (+) vomiting,nonbilous, nonbloody approx 1 teaspoon per episode (+) early satiety, (+) soft stool, 2x (+) flatus prompted consult

  7. ROS (+) wt loss, 10% over the past 6 mos (+) anorexia (-)fever (-) cough/colds (-) difficulty of breathing (-) muscle or joint pain (-) urinary/bowel changes (-) melena (-)hematochezia

  8. Past Medical History • (-) Allergy • (-) HPN/DM/BA/PTB • (+) hospitalization, High School due to AGE • Meds: Tramadol

  9. Family Medical History Alava Family Legend: 9/16/09 /-deceased L- lung cancer D- DM G- gastric CA L 50 D G 23 21 20

  10. Personal and Social History • Currently unemployed, previously worked in an electronic company • (-) exposure to chemical or radiation • Smoker, 2 pack years • Non alcoholic • Denies illicit drug use/ promiscuity • Diet: rice, meat, vegetables

  11. OB Gyne History • Menarche at 13 yrs old, regular, 3-4 days, 4ppd • (-) dysmenorrhea • LNMP: August 18, 2009 • G0

  12. Physical Examination Awake, coherent, in pain BP 120/80 HR 120 RR 24 T 37.7 SHEENT: (+) pallor, anicteric sclerae, (-) CLAD Chest: Equal chest expansion, Clear breath sounds CVS: Adynamic precordium, tachycardic, normal rhythm, no murmur

  13. Physical Examination Abdomen: globular, no bowel sound appreciated, (+) poorly defined hypogastric mass, firm approx 10x9 cm, (+) tenderness on all quadrant on light palpation with point of maximal tenderness on RLQ Extremities: Full pulses, no edema, pink nailbeds

  14. Diagnosis • Abdominopelvic mass, T/C Gynecologic (Ovarian new growth)

  15. Plan Dx: CBC Tx: Tramadol 50mg BID as needed for pain Referrals: OB Gyne Surgery

  16. Course at the ER OB-Gyne Notes S: Abdominal pain O: Abdomen: globular, no bowel sound appreciated, (+) poorly defined hypogastric mass, firm approx 10x9 cm, (+) tenderness on all quadrant on light palpation with point of maximal tenderness on RLQ Abdominal UTZ showed normal ovary, to consider gastric CA with metastasis

  17. Course at the ER A: T/C Gastric CA with metastasis P: Refer to Surgery and Family Medicine

  18. Course at the ER Surgery Notes S: Abdominal pain O: Abdomen: globular, no bowel sound appreciated, (+) poorly defined hypogastric mass, firm approx 10x9 cm, (+) tenderness on all quadrant on light palpation with point of maximal tenderness on RLQ Abdominal UTZ showed normal ovary, to consider gastric CA with metastasis

  19. Course at the ER A: T/C Gastric CA with metastasis P: For admission Tramadol 50mg BID for pain

  20. Diagnostic Dilemma • In adult patients, what is the sensitivity and specificity of UTZ as compared to CT scan in diagnosing abdominal mass, using cross-sectional study?

  21. Clinical Dilemma • Review of Clinical Practice Guidelines regarding abdominal mass

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