CLINICAL CASE PRESENTATION

Intern Eunice Bernadette M. Go

General Data

• FA• 23/F• Single• RC• Muntinlupa• Consulted for the 3rd time

Chief Complaint

• Right lower quadrant pain

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

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

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(+) flatusprompted consult

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

Past Medical History

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

Family Medical History

Alava Family Legend:9/16/09 /-deceased

L- lung cancerD- DMG- gastric CA

L 50D G

23 21 20

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

OB Gyne History

• Menarche at 13 yrs old, regular, 3-4 days, 4ppd

• (-) dysmenorrhea• LNMP: August 18, 2009• G0

Physical Examination

Awake, coherent, in painBP 120/80 HR 120 RR 24 T 37.7SHEENT: (+) pallor, anicteric sclerae, (-) CLADChest: Equal chest expansion, Clear breath

soundsCVS: Adynamic precordium, tachycardic, normal

rhythm, no murmur

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

Diagnosis

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

Plan

Dx: CBC

Tx: Tramadol 50mg BID as needed for pain

Referrals: OB Gyne Surgery

Course at the ER

OB-Gyne NotesS: Abdominal painO: 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 RLQAbdominal UTZ showed normal ovary, to consider gastric CA with metastasis

Course at the ER

A: T/C Gastric CA with metastasisP: Refer to Surgery and Family Medicine

Course at the ER

Surgery NotesS: Abdominal painO: 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 RLQAbdominal UTZ showed normal ovary, to consider gastric CA with metastasis

Course at the ER

A: T/C Gastric CA with metastasisP: For admission

Tramadol 50mg BID for pain

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?

Clinical Dilemma

• Review of Clinical Practice Guidelines regarding abdominal mass