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CPC

CPC. By: Dr. S arraf MD Dr. Akbarzadeh Md Dr. Khalili , Dr. K arami , 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 .

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CPC

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  1. CPC By: Dr. Sarraf MD Dr. AkbarzadehMd Dr. Khalili , Dr. Karami , Dr. Sabouri , Dr. Safari Poor

  2. CASE 1 صغری رضایی

  3. 30 Y/O • G1L1 (1PC/S) • LMP: 1.7.92 • C.C. : generalized abdominal pain • The Pttransfered from Lamerd hospital

  4. onadmission the pt has following positive findings: • Fever • Nausea & vomiting • Anorhexia • Spotting

  5. OB HX: • Primary infertility for 14 years • G1: C/S • GYN HX: • Mense: regular • Mearch: 13 year-old • Contraception:

  6. 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

  7. 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

  8. Abdomen: • Mild tenderness in both lowe guardant & adenexa • No guardig • Rebound tenderness positive • V/E: • Left adenexa palpable mass detected (about 15 cm)

  9. LAB DATA • CBC: • 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

  10. PT, PTT, INR : NL • LFT: NL • BHCG: Negative • Viral marker: Negative • Bun, Cr, Electrolyte: NL • Amylas: NL • LDH: 472

  11. 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 )

  12. 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.

  13. 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.

  14. 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 )

  15. 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

  16. 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

  17. Kind of operation : • EXPLOTORY LAPARATOMY + release of adhesion + dranage of abscess + supra cervical hysterectomy + bilateral salpingo-oophorectomy

  18. سد یاسوج بهار 91

  19. CASE 2 عایشهساختپری

  20. 62 Y/O • G4D3L1 • LMP: Menopause since 20 year ago • C.C. :abdominal pain & protrusion • Date of admission: 27.1.92

  21. Present illness: ! • The pt presented with c.c. of Abd. Pain and... ? ? ! ?

  22. 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

  23. 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

  24. Abdomen: !???

  25. 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)

  26. Abdomino-pelvcsono.(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

  27. 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)

  28. 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 coldesacand rectosygmoidcolocn 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

  29. یاسوج بهار91

  30. CASE 3 بی بیبیگاینالو

  31. 52 Y/O • G7L6D1(two PC/S) • LMP: 27.7.92 , Irregular • C.C.:abdominal protrusion & menomtrorhagia

  32. Present illness: • The pt presented with c.c. of Abd. Pain and protrusion ,also she has AUB that abdomiopelvicsono. 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.

  33. Open and close operation was don for him with imp. of ofmyoma in Jahrom hospital by DrMotreb (7.3.92) deu to large and congess mass with sever adhesion of bowel loop to mayoma and suspicious to malignancy the Ptrefered to shiraz.

  34. 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)

  35. 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

  36. Abdomen: !??? • Vaginal /E: uterus 25-26 wk, others: nl

  37. Lab data: • CBC: • WBC: 9700 • HB: 9.3 • PLT: 283000 • PAP smear: normal (8.3.92) • Tumor marker: negative (21.5.92)

  38. Mamography: normal • Colonoscopy & endoscopy: normal (25.3.92) • Trucut biopsy: • Liomyoma with area of hyalinization with out any atypia or myotic activity

  39. 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

  40. یاسوج بهار 91

  41. CASE 4 فاطمه کارگر

  42. 62 Y/O • Nulligravid • LMP: menopause • C.C.:abdominal pain

  43. 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

  44. OB HX. : • Nulligravid • GYN HX. : • Menopause • Past Med. HX. : • HTN • IHD • Past Surgical HX. : • Negative • Drug HX. : • Metoral, Enalapril, Nitrocantin

  45. 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

  46. Abdomen: !??? • Vaginal /E: • Lt adenexal mass • uterus Normal

  47. 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

  48. Mamography: normal • Colonoscopy & endoscopy: normal • Biopsy(7.11.91): • Papillary serous cyst adenocarcinoma

  49. 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

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