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CASE PRESENTATION

CASE PRESENTATION. Princes Flor N Fernando. MEDICAL HISTORY. 04/25/11; 04:30pm. General Data. R.T. 29/F Common-law wife Proj 3, QC RC Filipino Source of Referral: patient herself ❀Reliability: Good. Chief Complaint. Referred from OPD due to severe abdominal pain.

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CASE PRESENTATION

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  1. CASE PRESENTATION Princes Flor N Fernando

  2. MEDICAL HISTORY 04/25/11; 04:30pm

  3. General Data • R.T. • 29/F • Common-law wife • Proj 3, QC • RC • Filipino • Source of Referral: patient herself ❀Reliability: Good

  4. Chief Complaint • Referred from OPD due to severe abdominal pain

  5. History of Present Illness • G4P4 (3103) S/P NSD (May 2010) • Previously treated for PID

  6. History of Present Illness • 2 mos S/P NSD or 9 months PTA: • (+) Flank and pelvic/hypogastric pain • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 9, worsens with activity • Consulted Perpetual Hospital, Cebu • UTZ: inflamed FT • Given unrecalled meds • (+) Leukorrhea/mucopurulent, yellowish vaginal discharge • (-) dyspareunia, diarrhea, infective urinary symptoms

  7. History of Present Illness • 8 months PTA: • (+) Leukorrhea/mucopurulent, yellowish vaginal discharge • (+) Hypogastric pain + Right Upper quadrant pain • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 9, worsens with activity • Consulted Perpetual Hospital, Cebu • UTZ: ascending infection • Given unrecalled meds

  8. History of Present Illness • 7-6 months PTA: • Same symptoms persisted • (+) 70-lb weight loss [110-40lbs], chills, night sweats, easy fatigability, anorexia, nausea, vomiting, menorrhagia • Consulted Perpetual Hospital, Cebu • Given several unrecalled meds

  9. History of Present Illness • 5-4 months PTA: • (+) Leukorrhea/mucopurulent, yellowish vaginal discharge • (+) Hypogastric pain + Right Upper quadrant pain • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 9, worsens with activity • (+) documented fever >38 (relieved by paracetamol intake) • (+) joint pains • (+) cough, loss of voice (prescribed with Virlix & Ventolin) • Consulted Perpetual Hospital, Cebu • CXR done: Pneumonia • Given several unrecalled meds

  10. History of Present Illness • 3 months PTA: • (+) Leukorrhea/mucopurulent, yellowish vaginal discharge • (+) Hypogastric pain + Right Upper quadrant pain • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 9, worsens with activity • Documented low-grade fever + joint pains + cough • (+) menstrual irregularities • Consulted Chong Hua Hospital • UTZ done: polycystic ovary appearance (enlarged ovaries with increased number of small cysts) • No meds given • CT scan was recommended, but not done

  11. History of Present Illness • 2 months PTA: • (+) Leukorrhea/mucopurulent, yellowish vaginal discharge • (+) Hypogastric pain + Right Upper quadrant pain • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 9, worsens with activity • (+) Feeling of fullness, early satiety • (+) anorexia, nausea, vomiting • Consulted EAMC • Prescribed with Flagyl & Ofloxacin

  12. History of Present Illness • 1 month PTA: • Persistence of: • Leukorrhea/mucopurulent, yellowish vaginal discharge • Whole abdomen (all 4 quadrants) pain (Progressive peritonitis) • Sharp, intermittent, radiating to the back, 5-min duration, frequency of several times a day, rate of 10, worsens with activity • Increasing severity despite meds intake prompted her to consult

  13. Past Medical History • Adult Illnesses: Medical: None. Surgical: None • Immunizations: Unrecalled • Previous Hospitalizations: None, except for the time when she was giving birth. • ALLERGIES: Levofloxacin

  14. Menstrual History • M (Menarche) – 14 y/o • I (Interval) – 28 days, started to have irreg last Nov 2010 • D (Duration) – 5 days • A (Amount) – 5 pads/day • S (associated SSx) - dysmenorrhea

  15. Obstetric History

  16. Gynecological History • Previous surgical procedures: None • Cervical smears: None • Previous gynecological problems: PID • Intermenstrual/postcoital bleeding: None

  17. Contraceptive History • Does not use any form of contraception

  18. Sexual History • Coitarche: 17 y/o • Number of sexual partners: 2 • Sexually active (3x/wk) • Dyspareunia: None • Previous STI: None

  19. Family History • Father has HTN • Mother has asthma • One sibling had a myoma • (-) DM, thyroid dse, renal dse, cancer, arthritis, TB

  20. Personal/Social History • HS undergrad • Manages own business (store) • 1.6 pack-year smoker • R-OH: Red horse (1 bottle/wk) x 4 yrs • Diet: high in fiber • Caffeine 5 cups/day • No exercise

  21. Personal/Social History • Sleep: 8 hours/night • Type of residence: made of cement, crowded • Source of drinking water: Mineral water • Pets: None • Took Marijuana during teenage years

  22. Review of Systems

  23. PHYSICAL EXAMINATION (UPON ADMISSION)

  24. BP 100/70 • Gen: Conscious, coherent, NICRD • HEENT: AS, PPC • Lungs: SLE, CBS • CP: AP • Abdomen: Flabby, soft. (+) tenderness on all quadrants, (+) whitish, yellowish adnexae can’t be assessed due to guarding.

  25. PRE-OP DIAGNOSIS TUBO-OVARIAN ABSCESS; failed medical treatment G4P4 (3103)

  26. OPERATION/PROCEDURE PERFORMED Exlap; PFC; Peritoneal Fluid AFB; Peritoneal fluid GS/CS; Fimbriectomy

  27. Intra-op findings • Multiple whitish seedings uterus slightly enlarged • R FT edematous • R ovary enveloped by R FT & densely adherent to the lat pelvic walls • L ovary & FT is also densely adherent to the post uterine wall & rectosigmoid • LO 3x3 cms, RO 4x3 cms; both exuded cheesy like material in accidental rupture

  28. SPECIMEN SUBMITTED Peritoneal fluid AFB, peritoneal fluid GS/CS, R fimbriae, Ovarian GS/CS

  29. IMAGING & LABS

  30. TVUS (03/22/11) • Uterus is anteverted with sm contour & heterogenousechopattern 5.33 x 3.55 x 5.27 cm • Cervix measures 2.36 x 2.24 x 2.94 cm • Endometrium is thin & hypoechoic. (+) fluid interface of low level echoes win endometrial cav • W/in the L adnexal area is a complex structure measuring 5.2 x 5.1 x 5.9 cm

  31. TVUS (03/22/11) • (+) another complex structure seen w/in the R adnexal area meassuring 4.7 x 3.9 x 4.8 cm • (-) normal ovarian tissue seen • (+) min free fluid in the cul de sac. • IMPRESSION: PID (Tubo-ovarian abscess)

  32. TVUS (04/13/11) • Cervix: 2.33 x 2.2 x 1.9 cm • Uterus: 5.24 x 5.04 x 3.67 cm • Endometrium: 0.43 cm • Ovaries: • R: Not visualized located to the uterus • L: Not visualized located to the uterus

  33. TVUS (04/13/11) • Anteverted uterus normal in size with no myometrialpatho on 3d scan. • Uterine serosa is smooth & with no cleft/irreg noted • Endometrium is thin & homogenous measuring 0.43 cms.

  34. TVUS (04/13/11) • Both ovaries not visualized, instead, (+) complex adnexal masses occupying the R adnexae: 4.03 x 5.41 x 3.08 cm L adnexae: 5.37 x 4.03 x 5.06 cm • (+) moderate free fluid noted in the cul de sac • (+) tenderness with probe manipulation

  35. TVUS (04/13/11) • DIAGNOSIS: Normal sized anteverted uterus. Thin endometrium. Both ovaries not visualized. TOA, bilateral.

  36. UTZ: Bilateral complex masses in a px who had pyometrium…compatible with TOA

  37. Power Doppler UTZ: Increased flow to the wall of TOA. The hyperechoic regions are due to the flow of the purulent material.

  38. Coagulation Panel (04/18/11)

  39. UA (04/18/11)

  40. Bacteriology (04/19/11)

  41. CBC (04/19/11) 0.30 (0.36-0.47) 10.7 (5-5.10) 548 (150-450) 94 (120-160) ESR: 0-20

  42. POST-OP DIAGNOSIS Pelvic TB G4P4 (3103)

  43. COURSE IN THE WARDS

  44. CASE DISCUSSION

  45. TUBO-OVARIAN ABSCESS (TOA) : DEF • Usually one of the many consequences of PID • Result of a complete breakdown of ovarian and tubal architecture such that the separate structures are no longer identified ***(LT sequelae of PID) • Classically polymicrobial with predominance of anaerobic bacteria

  46. TUBO-OVARIAN ABSCESS (TOA) : PATHOGEN when both FTs are inflamed & occluded entire complex typically takes on a U-shape as it fills the cul-de-sac extending from 1 adnexalrgn to the other lat & post uterine borders of the uterus become obscured individual tubes and ovaries cannot be distinguished if the contralat side was not initially affected, it may become so

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