History of present illness:
At birth, the patient’s mother noticed the patient’s enlarged abdomen but
there were no associated signs and symptoms like change in bladder and bowel
patterns, thus there was no consult done and no medications given.
Gradual abdominal enlargement was noted, but still no consult was done.
A month prior to admission, mother noted bilateral breast budding, with no
other associated signs like presence of axillary or pubic hair nor vaginal
bleeding. However, a mass was noted on the left inguinal area, which was more
prominent when patient would cry or strain. Thus mother decided to seek
consultation at Negros Oriental Provincial Hospital, ultrasound of the whole
abdomen was done which showed cystic mass on the left hemiabdomen with
septation and loculations to consider an ovarian cyst, reducible hernia on the
left inguinal region possibly the result from the pressure exerted by the cystic
mass, with negative ultrasound of the liver, gallbladder, pancreas, spleen,
kidneys and urinary bladder. Her working diagnosis then was inguinal hernia
and ovarian new growth. So additional work up were requested like CA-125,
CEA and AFP and referred to this institution for further management.
She was seen at the outpatient department and was requested with BHCG,
LDH and CT scan of the whole abdomen with contrast which revealed a large
septated cystic mass extending from the pelvis to the abdominal cavity,
measuring 8.4 x 15.5 x 13.4 cm, representing an ovarian pathology, thus
advised admission.
Prenatal history:
The patient was born, full term, without any complications except for
abdominal distension, by normal spontaneous delivery to a 20 year old mother
at their Local Health Center assisted by a midwife. Regular prenatal check-up
was done at their local health center and mother had no known maternal
illnesses, no medications were taken during her pregnancy.
Past Medical history
The patient was exclusively breastfed from birth until 6 months of age,
started with mixed feeding at 7 months. She is still breastfeeding at this age.
She had no previous hospitalizations and surgery.
Family history:
She has a positive family history of hypertension on both sides.
Personal and psychosocial history:
The patient is living with her parents and 1 sibling.The primary care giver is
the mother. For her developmental milestone, she sits without support, stands
with support but still unable to walk.
Physical examination:
V/S: HR: 140 RR:42 Temp:37.7 Wt: 9.7 ht/length:76 BMI:16.79
HC: 44 CC:42 MUAC:13
Skin: brown, no lesions, warm, good turgor
HEENT: normocephalic, closed anterior and posterior fontanels, anicteric
sclerae, pinkish palpebral conjuctivae, pupils equally brisk and reactive to light,
no nasoaural discharges
Neck: no masses, no lymphadenopathies, no neck vein engorgement
Chest and lungs: symmetrical chest expansion, clear breath sounds
Breast: Tanner stage II, the breast bud was formed, with small area of
surrounding glandular tissue; areola begins to widen
Cardiovascular: adynamic precordium, distinct heart sounds, regular rate and
rhythm, no murmurs
Abdomen: distended, abdominal girth is 55 cm, normoactive bowel sounds,
with palpable cystic mass with superior pole of the mass 2 fingerbreadth below
the xiphoid process, more on the right, movable, nontender
Genito-urinary: Pubic hair Tanner stage 1, grossly female, swelling at the left
labia majora was noted, erythematous labia majora and surrounding areas,
annular estrogenized hymen, whitish mucoid vaginal discharge
Extremities: no deformities, no limitation of movements
CNS: awake, non-irritable, no motor and sensory deficits, cranial nerves intact
Admitting Diagnosis:
1.Estrogen secreting ovarian new growth
2.Precocious puberty secondary to # 1
3.Inguinal hernia, Left
Course in the ward:
The patient was admitted under pediatrics department, diet for age was
ordered, heplock was inserted. Laboratory requests include: CBC, urinalysis,
serum electrolytes, random blood sugar, BUN, creatinine, luteinizing hormone,
FSH, TSH, FTU, 8 am serum cortisol, CT scan brain plain and estradiol.
Medication requested Diazepam 3 mg IVTT to be given prior to CT scan and
was referred to GYNE department for co-management. The patient was seen
and examined by Gyne, with additional imaging requested: Bone aging by X-
ray of the left wrist, APL and to refer to pediatric surgery. The patient was seen
by Pedia GS with additional laboratories requested: CA 125, AFP, HCG, inhibin
and LDH.
Laboratories and Imaging studies
Clinical Chemistry
LDH 371.9 (1.3x elevated)
Creatinine 0.46 (normal)
CEA 15.49 (3x elevated)
CA125 157.30 (4.5x elevated)
Alpha Feto Protein 7.75 (normal)
Random blood sugar 78 (normal)
BUN 5.89 (normal)
Estradiol 687.2 (elevated for age)
B-hcg - <0.100 (normal)
Electrolytes
Sodium 144.0 (normal)
Potassium 4.03(normal)
Chloride 111.8 (elevated)
Ionized Calcium 1.32 (normal)
Clinical Microscopy
Urinalysis 11/22/2017
Color - Light Yellow
Transparency - Clear
Specific Gravity - 1.005
PH - 6.0
Glucose - Negative
Protein - Negative
RBC - 0-1
WBC - 0-1
CAST
Crytals
Miscellaneous Structures
Bacteria - Rare
Mucus Threads - Rare
Urinalysis 11/24/2017
Color - Yellow
Transparency - Turbid
Specific Gravity - 1.030
PH - 5.5
Glucose - Negative
Protein - Negative
RBC - 0-1
WBC - 2-4
CAST
Crytals
A. Urates - Loaded
Miscellaneous Structures
Squamous E. Cells - Loaded
Bacteria - Rare
Mucus Threads - Loaded
Hematology Section
Complete Blood Count
WBC Count - 8.87
Hemoglobin - 113
Hematocrit - 0.33
MCV - 71.8
MCH - 24.5
RBC Count - 4.61
MCHC - 341
RDW - 16.4
MPV - 9.6
Platelet Count - 465
Differential Count
Neutrophil - 38.9
Lymphocyte - 43.5
Monocyte - 10.3
Eosinophil - 7.1
Basophil - 0.2
Stab - 0
Atypical Lymphocyte - 0
Metamyelocytes - 0
Myelocytes - 0
Blast - 0
X-Ray Report 11/23/2017
Procedure: Wrist-Left AP/L
The bones are normal in density, texture and modeling. There is no
evidence of fracture, bone erosion nor bone destruction. The joint
spaces are within normal limits. The epiphyses are not fused yet.
Impression:
Normal bones and joints of the left wrist
Ultrasound Report 11/14/2017
Ultrasound Finding:
The liver is not enlarged measuring approximately 9.2 cm. and exhibits
a homogenous echo pattern. There are neither parenchymal masses nor
cystic lesions noted. The intrahepatic ducts are not dilated.
The gallbladder is contracted measuring approximately 4.1 x 1.1 cm with
a wall thickness of 0.1 cm. There is no lithiasis or masses noted within
the gallbladder lumen.
The pancreas is obscured by overlying bowel gas. The spleen is not
enlarged measuring approximately 5.7 x 3.1 cm. and exhibits a
homogenous echo pattern.
The right kidney measures approximately 7.0 x 3.1 cm. with a cortical
thickness of 0.5 cm. while the left kidney measures approximately 6.9 x
2.7 cm. with a cortical thickness of 0.4 cm. Both central parenchymal
echoes are intact. There is no lithiasis or hydronephrosis noted.
The urinary bladder is unfilled with urine.
There is a multiloculated cystic mass seen in the abdomenopelvic region
with no vascular flow seen in the abdominopelvic region measuring
approximately 9.2 x 13.0 x 11.5 cm.
Conclusion:
Contracted Gallbladder
9.2 x 13.0 x 11.5 cm. multiloculated abdomenopelvic cystic mass as
described. Suggest clinical correlation and other imaging studies for
better evaluation.
Normal sonographic evaluation of the liver, spleen and both kidneys
Unfilled urinary bladder.
Ultrasound/X-Ray Report 10/17/2017
U/S of the Abdomen
U/S of the (L) hemiabdomen shows a huge anechoic mass with several
sentation and laculations measuring 9.9 cm x 9.2 cm with a complex
mas on (L) ingul area apparently increased and reduce its size when the
patients exerts effort or cries. The liver shows a homogenous echo
pattern and texture. Negative for mass per ascites. The gallbladder is
echo free with a normal thickness. The pancreas and spleen are normal.
The ® kidney measures 6.0 cm x 2.9cm while the (L) 6.1 cm x 2.6 cm
both show no stones nor collects. The urinary bladder is echo free. The
uterus is not visualized.
Remarks:
Cystics mass on (L) heptabdomen with septation and loculations to
consider and ovarian cyst.
-Reducible hernia on (L) inguinal region a possible result from the
pressure exerted by cystic mass.
-Negative U/S of the liver, gallbladder, pancreas, spleen, kidneys and
urinary bladder
Radiology Report 10/22/2017
Chest PA:
Clear lungs.
Heart is within normal in size and configuration.
Costophrenic angles are sharp.
Trachea is at midline.
Bony thorax is unremarkable.
Remark: Negative Chest
Plain and upright abdomen
Distended abdomen.
Dilated bowel loops.
No significant air fluid levels.
Negative in air rectal vault
Osseous structures unremarkable.
Remark: Ileus Pattern
CT-Scan Report 11/20/2017
Reports:
Fine axial slices of the abdomen and pelvis were done before and after
administration of intravenous contrast.
There are faint ground-glass opacities in the visualized lung bases,
posteriorly on both sides. There is no intrapulmonary nodule or mass
lesion. There is no pleural effusion.
The heart is only partly demonstrated. The visualized pericardium is not
thick. There is no pericardial effusion.
The distal esophagus and descending thoracic aorta are normal in
caliber.
The liver is normal in size and density. The hepatic contours are smooth.
The visualized intrahepatic and extrahepatic bile ducts are not dilated.
The gallbladder is distended with fluid. There is no calcified stone. The
gallbladder wall is not thick. The hepatic, portal, splenic and superior
mesenteric veins display homogeneous enhancement.
The pancreas is only partly demonstrated. The pancreatic duct is not
grossly dilated. There is no calcification within the visualized pancreatic
parenchyma.
The spleen is normal in size and density. There is homogeneous
enhancement on the contrast study.
The adrenal glands are not enlarged and normal in configuration.
The kidneys are normal in position. The renal outlines are fairly smooth.
The perinephric fat are preserved. The Gerota’s fasciae are not thick.
The renal cortices are of normal thickness. The calyces, infundibulum,
renal pelves and ureters on both sides are not dilated. There are no
calcified stones within both kidneys nor within the visualized ureters.
The urinary bladder is distended with fluid. The walls are of uniform
thickness. There is no intraluminal mass. There are no calcifications with
the urinary bladder. The perivesical fat planes are normal.
The uterus is quite prominent for her age. There is fluid within the uterine
cavity. The cervix is not enlarged. There is a huge sepatated mass
extended from the pelvis to the abdominal cavity, measuring 8.4 x 15.5
x 13.4 cm. There is no abnormal fluid accumulation within the pouch of
Douglas. There is a small left inguinal hernia.
The stomach filled with fluid and gas. The gastric walls are distensible.
The duodenum is normal in shape. The rest of the visualized small and
large bowel loops are normal in caliber. The small bowel loops are
displaced to the left.
The rectum is filled with feces and gas. The mesorectal fat is not well
delineated. There is no gross rectal mass lesion demonstrated.
The abdominal aorta is unremarkable. The celiac, superior and inferior
mesenteric and both renal arteries are patent.
There are no grossly enlarged periaortic, interaortocaval, mesenteric,
iliac nor inguinal lymph nodes.
The lumbar lordosis is not fully developed yet. The pedicles are intact.
The apophyseal joints are preserved. The intervertebral discs are of
normal height. The bony pelvis is also intact. The sacroiliac joints,
symphysis pubis and both hip joints are not widened. The epiphyses and
apophyses are not fused yet. There is no evidence of lytic bone
destruction.
Impression:
The uterus is quite prominent for her age with a small amount of fluid
within the uterine cavity. There is a large sepatated cystic mass
extending from the pelvis to the abdominal cavity, measuring 8.4 x 15.5
x 13.4 cm. the finding may represent an ovarian pathology. Suggest
clinical correlation.
C.T. Scan Section 11/28/2017
Brain Plain (SPC)
There are no hypodense or hyperdense parenchymal lesions seen.
There is no evidence of hemorrhage. The cordical sulci and gyri are
preserved. The ventricles and basal cisterns are within normal limits.
Note the presence of a cavum septum pellucidum (anatomical variant).
The midline structures are not displaced. There are no intra or extra axial
fluid collections seen. There are no abnormal calcifications noted. The
orbital structures are unremarkable. The mastoid air cells are well
aerated. The cranial sutures. Are not yet fused.
Impression:
Presence of a cavum septum pellucidum (anatomical variant).
Otherwise, unremarkable non-enhanced CT scan of the brain.
