Download - CLINICAL CASE PRESENTATION
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CLINICAL CASE PRESENTATION
Intern Eunice Bernadette M. Go
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General Data
• FA• 23/F• Single• RC• Muntinlupa• Consulted for the 3rd time
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Chief Complaint
• Right lower quadrant pain
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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
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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
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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
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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
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Past Medical History
• (-) Allergy• (-) HPN/DM/BA/PTB• (+) hospitalization, High School due to AGE• Meds: Tramadol
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Family Medical History
Alava Family Legend:9/16/09 /-deceased
L- lung cancerD- DMG- gastric CA
L 50D G
23 21 20
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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
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OB Gyne History
• Menarche at 13 yrs old, regular, 3-4 days, 4ppd
• (-) dysmenorrhea• LNMP: August 18, 2009• G0
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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
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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
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Diagnosis
• Abdominopelvic mass, T/C Gynecologic (Ovarian new growth)
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Plan
Dx: CBC
Tx: Tramadol 50mg BID as needed for pain
Referrals: OB Gyne Surgery
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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
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Course at the ER
A: T/C Gastric CA with metastasisP: Refer to Surgery and Family Medicine
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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
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Course at the ER
A: T/C Gastric CA with metastasisP: For admission
Tramadol 50mg BID for pain
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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?
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Clinical Dilemma
• Review of Clinical Practice Guidelines regarding abdominal mass