In the Name of AllahMost Gracious, Most Merciful

الرحمن الله بسمالرحيم

Clinical Case Presentation

by

Dr. Mahmudul Hasan Monnaf

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Miss. Razia Khatun, 14 Years, School GirlFrom: Shahzadpur, SirajganjWas in Ward-28, RMCH

Miss. Razia Khatun, 14 years old unmarried, Muslim girl coming off a lower middle class family hailing from Shaktipur, Shahzadpur, Sirajganj got admitted into RMCH, Gynae Unit- II on 03 July 2013 with the complaints of –

A lump in the lower abdomen for one month. Lower abdominal pain for 3 days. Vomiting for once 3 days ago.

History of present illness:

Patient stated that, she was reasonably well a month back. Then she noticed an abdominal lump in the left iliac fossa. She suddenly developed pain in the left lower abdomen 3 days back which was severe, agonizing, continuous in nature. She also complained single episode of vomiting 3 days back. She got admitted into RMCH for better management.

History of past illness: She has no history of Tuberculosis, bronchial asthma, heart disease, renal disease, DM, pelvic operations etc.

Family History: She has no family history of Hypertension, diabetes, tuberculosis, carcinoma etc.

Personal History: She is non alcoholic, non smoker.

Drug History: Nothing significant.

Socio-economic History: She came of a lower middle class family.

Immunization History: Immunized according to EPI schedule.

Menstrual History: Age at menarche - 13 yearsMC - Regular (28 days cycle)MP - 3-4 days MF - AverageLMP - 17 June 2013

Physical Examination: General Examination: Appearance - Anxious Body Built - AverageWeight - 36 Kg Nutrition - Average Co-operation - Co-operative Anemia - AbsentJaundice - Absent Oedema - AbsentCyanosis - Absent

General Examination contd.Dehydration - Absent Temp - Raised (slight)Pulse - 96 b/min BP - 110/70 mmHg Respiration - 18/min Heart - NAD Lung - NAD Lymph Node - Not Palpable Thyroid - Not Enlarged

Systemic Examination: Systemic examination reveals nothing significant.

Local Examination: Per-abdominal examination: Inspection: • Abdomen was scaphoid shaped with a

moderate sized lump in the left iliac fossa. Flanks were flat.

• Overlying skin was normal in appearance.• No engorged vein was seen.

Palpation: • Local temperature was slightly raised,

tenderness present.• The mass was about 20×17 cm in size, cystic

in consistency, surface was smooth, margins were well defined, mobile in side to side direction but restricted from above downwards.

Percussion:Dull over the lump and resonant over the flanks.

Auscultation: Nothing significant

Pelvic Examination:Bimanual Examination:• A groove is felt between the uterus and the

mass. • The uterus is separated from the mass.• Movement of the mass per abdomen fails to

move the cervix.• The mass was palpable through anterior fornix.

Provisional Diagnosis

?Twisted Ovarian Cyst

Investigations:

Haematological Investigations:Hb% - 11.39 gm/dl, 71%ESR - 42 mm in 1st hour WBC - 7,700/cumm

Differential Count: Neutrophil - 65% Lymphocyte - 28% Monocyte - 04% Eosinophil - 03%

Biochemical Analysis:

RBS – 85 mg/dl, 4.72 mmol/L Serum Creatinine - 0.65 mg/dl, 57.46

µmol/L

Urine Analysis: Physical Color - Straw Appearance - Clear Sediment - Nil

Chemical Reaction - Acidic Albumin - Nil Sugar - Nil

Microscopic Epithelial cell - 3-5/ HPF Pus cell - 2-4/ HPF RBC - Nil

USG of Whole abdomen

USG Findings:None of the ovaries are visualized. A large cystic mass measuring about 12×10 cm is found in pelvic cavity along the midline. A thick septum is seen within the cyst. Outline of the cyst is mildly irregular but well defined. The cyst appears to be an ovarian cyst.

Impression: Suggestive of Ovarian Cystic Neoplasm.

Salient Feature: Miss. Razia Khatun, 14 years old unmarried, Muslim girl coming off a lower middle class family hailing from Shaktipur, Shahzadpur, Sirajganj got admitted into RMCH, Gynae Unit- II on 03 July 2013 with the complaints of Lower abdominal pain for 3 days. She also complained of a lump in the lower abdomen for one month and vomiting for once 3 days ago.

On general examination she is anxious, temperature is slightly raised, not anemic, not icteric.

Systemic examinations reveal nothing significant.

Abdominal examination revealed a lump in the left iliac fossa, about 20×17 cm in size, cystic in consistency, surface was smooth, margins were well defined, mobile in side to side direction but restricted from above downwards.

On bimanual examination, lump felt through the anterior fornix was separated from the uterus and the uterus was of normal size. Movement of the lump fails to move the cervix.

Investigations specially USG of whole abdomen creates impression for Ovarian Cystic Neoplasm. She is now admitted into RMCH for appropriate treatment.

Diagnosis

?Twisted Ovarian Cyst

Management: General Management:

Diet: NormalTab. Ciprofloxacin 500 mg

1 tab 12 hourly Tab. Tiemonium Methyl Sulphate 50 mg

1 tab 8 hourly Tab. Omeprazole 20 mg

1 tab 12 hourly before meal Tab. Ondansetron 8 mg

1 tab 8 hourly Inj. Nalbuphine Hydrochloride INN 20 mg

1 amp IM stat and SOS (with inj. vergon)

Definitive Treatment (Laparotomy)

On 08 July 2013 at 10:00 AM

Name of Operation: Left Sided Oophorectomy with Preservation of Right Ovary

Surgeon and Anesthetist: Doctors of the Gynae Unit-II

Anesthesia: SAB

With all aseptic precautions abdomen was opened by Pfannenstiel incision. After opening the peritoneal cavity there found left sided twisted huge (about 20*17 cm) ovarian cyst. Fluid is sucked out by giving Purse-string suture. The fluid was haemorrhagic and somehow straw-berry colored. Tumor stalk is clamped, incised and secured. Then left sided oophorectomy along with conservation of right ovary and both fallopian tube were done. After proper peritoneal toileting and having a drain tube inside abdomen was closed layer by layer. Resected ovarian cyst was sent for histo-pathological examination.

Findings on Laparotomy

Follow-up:Her post operative days were uneventful. On 8th POD (16 July 2013) stiches were off and patient got the discharge with advice.

Questions are always welcome!!

But I Can’t Guarantee for satisfactory answer

Tab. Acical-M(Calcium & Minerals)

Pivacain-D(Bupivacaine Hcl.+Dextrose)

Cap. Xeldrin(Omeprazole)

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