S I LLI MAN UNI V E RSI TY ME DI CAL S CHO O L

GYNECOLOGY WORKSHEET SUBMITTED to Dr. Gem Austria

SUBMITTED by (1) Cruz, Bea Celina; (2) De la Pena, Nesil; (3) De leon, Jan Gil; (4) de los Santos, Rosheil Mae
HEALTH HISTORY
A IDENTIFYING DATA
A.M., 12 year old girl from Mabinay, Neg Or. Came to the emergency room complaining of severe right lower quadrant pain noted a few hours
prior to admission.
B HISTORY OF PRESENT ILLNESS
Patient was apparently well until about five (5) hours prior to admission when she complained of sudden onset of right lower quadrant pain
described as continuous and intense noted while patient was playing with some friends. Patients mother while trying to apply efficascent oil in her
abdomen noted a mass in the hypogastric area described as hard and very painful. When she asked by her mother about the mass, the patient
claimed that she noticed the bulge in her hypogastric area for a few months but kept silent about it. The family then decided to bring her to the
hospital for admission.
C PAST MEDICAL HISTORY
No serious illness in the past. Had one previous admission when she was 8 years old because of diarrhea. Mother claimed that the child
received immunizations given at the health center. No known food and drug allergy.
OB/GYN History: Patient had her menarche seven (7) months ago lasting for about four (4) days. Her LMP was two (2) months prior to
admission. It was only her second time to menstruate. It lasted for five (5) days and was associated with mild crampy pain on the 1 st and 2nd day.
D PERSONAL AND SOCIAL HISTORY: Patient is the 3rd child in the family of 4. She is presently a Grade 6 pupil in a local elementary school.
E FAMILY HISTORY: (+) history of hypertension Father. Denies history of cancer in the family.
PHYSICAL EXAMINATION
Examined a fairly nourished girl in severe pain with the following vital signs:
BP: 90/60 mmHg CR: 105 beats/min Temp: 37.5 oC RR: 24/min
HEENT: pinkish palpebral conjunctivae (patient was crying)
C/L: tachycardic, regular cardiac rhythm
Abdomen: difficult to assess as patient was uncooperative; a palpable exquisitely tender mass about 10 x 10 cm was noted in the hypogastric
area/RLQ, (+) direct and rebound tenderness.
Extremities: cold clammy
III. APPROACH TO THE PATIENT
Case Summary: A case of a 12 year old girl with a history of a hypogastric mass for a few months who came in for acute RLQ pain which was
continuous and intense which was noted while playing. Menarche was 7 months ago and LMP was 2 months PTA. On examination the patient was
tachycardic and tachypneic with a hard, palpable, exquisitely tender mass about 10 x 10 cm in the hypogastric / RLQ area with direct and rebound
tenderness. Extremities were cold and clammy.
Upon presentation we immediately think about diseases affecting the organs overlying the RLQ and sourrounding areas that may radiate pain to it
as possible sources of the patients complaint, including appendicitis, urinary tract infection, bowel obstruction and pelvic pain. Upon history
extraction and physical examination, the most notable finding was a RLQ / hypogastric mass. Possible causes of the mass includes adnexal
masses, intra-abdominal abscesses, particularly a peri-appendiceal abscess, and uterine masses. There was no health history or PE finding that
would support a possible source of an abscess since it would probably first present with signs and symptoms of an infection like fever, and uterine
masses are rare in this age group especially in our patients case since she just had her menarche 7 months ago. This leaves us with adnexal
masses which may involve the ovary or the oviduct. In the ovarys case, we considered functional cysts, neoplasms, torsion, and endometrioma.
For the oviduct, we considered an ectopic pregnancy, hydro or pyosalpinx and a tubo-ovarian abscess.
Considering the acuteness and the severity of the patients pain, rupture or torsion of a functional ovarian cyst, torsion of a neoplasm, ectopic
pregnancy, pyosalpinx, and TOA are all possible. Although there were no signs of an infection like fever or vaginal discharge making pyosalpinx,
and TOA unlikely, and the patient just had her LMP 2 weeks ago making an ectopic pregnancy unlikely too since the mass is already 10 x 10cm in
size. Guided by epidemiological trends in this age group and the patients history and PE, we then narrowed our diagnoses to a rupture or torsion
of a functional ovarian cyst, the follicular variant being more common, and to a twisted neoplastic tumor, particularly germ cell tumors, with the
mature cystic teratoma and immature cystic teratoma being the most common benign and malignant variant respectively, beacause of its relatively
high incidence in this particlular age group.
Ovarian follicular cysts are the most common cause of a mass in the adolescent age group and although a single episode of an ovarian follicular
cyst cannot explain the mass that was already noted months ago, it is possible that the follicular cyst produced during menarche resolved and this
is a new cyst produced during the current cycle. And yet, even though follicular cysts can reach up to 10 cm and more in size, its occurrence is an
exception rather than the rule. That being said, the size and hard conistency of the mass, and the timing of its discovery a few months ago points
us to a neoplastic etiology.
Regardless of the etiology, the patient presents with an acute abdomen making timely intervention imperative. Ultrasonography can help us
delineate the anatomical structures involved and the composition of the mass, helping in both the diagnosis and planning the management.
Surgery will most probably be needed, affording direct visualization and retrieval of tissue for biopsy helping us clinch the final diagnosis.

IV. PRIMARY WORKING IMP

Torsion of Mature Cystic Teratoma
These tumors, otherwise known as dermoid cysts, contain elements from all three germ cell layers whith preponderance for ectodermal tissue.
These slow growing tumors are among the most common ovarian neoplasms and account for more than 90% of germ cell tumors of the ovary. It is
also the most common ovarian neoplasm in prepubertal females and are also common in teenagers, hence it being chosen as our primary working
disagnosis.
The mass being noted by the patient a few months ago, itss consistency and size on palpation, and the patients age corroborates our diagnosis.
These tumors usually dont present with acute abdominal pain unless a complication is present. Torsion is the most frequent complication of
dermoid cysts which presents in up to 11% of cases with a directly proportional risk to the size of the tumor, hence our suspison of torsion of a
neoplasm which is also supported by the onset of pain while playing. This diagnosis is the most likely and cannot be ruled out as of the moment.
V. DIFFERENTIAL Dx
Torsion of Immature Cystic Teratoma
Ruptured Ovarian Follicular Cyst
Immature cystic teratomas are fast growing malignant neoplasms which account for up to 20% of germ cell tumors and although rare in general,
they are relatively common in younger females hence its inclusion in the differentials. Points for and against functional ovarian cysts have already
been discussed above and still remain one of our differentials. These masses usually dont present as an acute abdomen that is why we are
entertaining complications like rupture or torsion.
VI. LABORATORY and DIAGNOSTIC TEST/S to order
TEST
NO VALUES
RATIONALE
COST
Hct and Hb concentration measurement are the most commonly
Hemglobin 12-16mg/dl
performed blood tests, usually as part of CBC. It is primarily taken to
Complete Blood Count
Php 60.00
Hematocrit 37-48%
determine the O2-carrying capacity of the blood and to assess the
hemodynamic stability of the patient.
A highly elevated serum CA 19-9 and CA 125 level may be an adjunct
serum marker for the diagnosis of ovarian teratoma and could also provide
useful information on the presence of torsion. The simultaneous elevations
of CA19-9 and CA125 are not always associated with malignancy and may
Tumor Markers
improve the detection of torsion and the prediction of the extent of
Cancer antigen 19-9
CA 19-9 <37U/mL
Php
necrosis.
and Cancer antigen
CA 125 <35 U/mL
1500.00
CA 19-9 has been immunohistochemically demonstrated in the glands of
125
mature cystic teratoma and it has been shown to be secreted into the
cystic cavity of the lesion. CA 19-9 is more frequently elevated than CA
125 and hence a more useful marker but has a limited diagnostic value
when used alone.
Dermoid cysts present various and complex ultrasonographic aspects. But, a thorough analysis of all
ultrasound features that characterize dermoid cysts can lead in the vast majority of the cases to an exact
diagnosis. The most typical ultrasonographic aspects of dermoid cysts are:
1. Dermoid plug (Rokitanski nodule) is the most characteristic aspect of the dermoid cysts. It
consists of nodular, pediculate, dense, parietal structure that forms on the cysts interior surface and
which bulges inside it. The dermoid plug may contain bones, teeth, but also hair that can extend into
the cysts cavity. The ultrasound appearance is that of an hyperechoic nodular structure with distal
acoustic shadow which is situated near a cyst wall.
2. Dermoid mesh corresponds to the presence of hair inside the cyst. The ultrasonograhic appearance
may be that of long, echoic lines or that of point-like echoic images inside the lesion.
Php
Abdominal Ultrasound
3. Tip of the iceberg sign the contour of the cyst may be seen because of the distal acoustic
450.00
shadow. There are three types of tissues that can produce acoustic shadowing: calcified structures
(bones, teeth), hair conglomerates inside the cyst cavity and the fat within the Rokitanski nodule.
4. Echoic white ball aspect may occupy sometimes the entire cystic cavity. The histopathologic
exam of the entirely echoic dermoid cysts shows a content containing mainly hair, fat and sebaceous
material. Other times an echoic, relatively homogenous and lobulated mass that fills a part of the
cyst cavity is visualized.
5. Tendency towards sedimentation occurs within the serous components of the dermoid cyst and the
sebum, producing an ultrasound visible interface that changes position with gravity - presence of a
fluid-fluid level.
VII. FINAL DIAGNOSIS: Torsion of Dermoid Cyst
VIII. PATHOPHYSIOLOGY: please see attached document

IX. THERAPEUTIC OBJECTIVES

Removal of an exquisitely, palpable, and tender mass about 10 x 10 cm on the hypogastric area/RLQ
A NON-PHARMACOLOGIC MANAGEMENT
Pre-Operative Management:
1. Admit patient for surgical management.
2. Secure patients/parents consent.
3. Start venoclysis Plain LR 1L @ 10gtts/min.
4. Monitor vital signs every 4 hours.
5. Diet: NPO initially until cleared by Surgery and OB-Gynecology.
Intra-Operative (Surgical Management):
Due to the low frequency of malignancy in the pubertal age group, OVARIAN SPARING SURGERY is the
goal. The treatment consists of OPEN LAPAROTOMY and CYSTECTOMY since the patient presented with
10cmx10cm mass and pain which may indicate torsion.
1. Open Laparotomy
- Inspect the contralateral ovary. The current treatment involves preservation of the
contralateral overy without biopsy if it grossly appears normal.
2. Cystectomy is the operative treatment of choice, with preservation of the remaining portion of the
ovary.
- Scalpel incision is made in ovary at intersection of dermoid and normal ovary.
- Dermoid will be separated from the ovary.
Reconstruction of the normal ovary.
B PHARMACOLOGIC MANAGEMENT
DRUG
EFFICACY
SAFETY
SUITABILITY
COST
NONSTEROIDAL ANTI-INFLAMMATORY DRUG
Ketorolac
Ketorolac
inhibits Administration:
Inject For short-term
(KETERO)
prostaglandin
over 15 seconds.
management of
1mg/kg IV every synthesis
by
mild to moderate
6 hours for 2
decreasing the activity Contraindications:
post-op pain.
days
of
the
enzyme Hypersensitivity
to
cyclooxygenase,
NSAIDS, history of asthma
Preparation:
which
results
in and GI bleeding.
Ketero in
decreased formation
30mg/ml vial
of
prostaglandin
precursors.
NARCOTIC ANALGESICS
Morphine (MST
Narcotic
agonist- Administration: May be
Prolonged relief
CONTINUS)
analgesic of opiate taken with or without
moderate to
20mg every
receptors;
inhibits food. Swallow whole, do
severe post-op
12hrs
ascending
pain not break/chew/crush.
pain.
pathways,
thus
Preparation:
altering response to Contraindications:
MST Continus
pain;
produces Hypersensitivity, paralytic
MR tab 10mg
analgesia, respiratory ileus.
depression,
and
sedation; suppresses
cough
by
acting
centrally in medulla
P DRUGS
Ketorolac (KETERO) 1mg/kg IV every 6 hours for 2 days
X.

MONITORING & FOLLOW-UP

1. OPD Follow-up:7 days after the patient was discharge, patient should have hER follow up check
up on the nearest health center or hospital.
2. Exercise
- Relaxation exercise (Deep breathing exercises, ambulation)
- Turning to sides every 2 hours if lying in bed for long hours
- do light activities such as walking, or sitting down
- Exercise social interaction with the family

3. Proper hygiene.
4. Diet: Proper diet such as eating nutritional foods that are rich in protein, fiber and Vit. C to
promote well-being. Increase oral fluid intake.

XIII. PRESCRIPTION WRITING

R o s h e i l D e l o s S a n t o s, M . D .
SILLIMAN UNIVERSITY MEDICAL CENTER
(035) 000 0000

Patient:
X,Y
07/23/2015
Address: Mabinay, Neg. Or.
12y.o./Female

Date:
Age/Sex:

Ketorolac (KETERO)
30mg/ml vial
#12
Sig:
Administer 40mg IV every 6 hours for 2
days