Preoperative
Conference
By: Jessica de dios
year level IV resident
GENERAL INFORMATION
R.T.
59 years old
Married
G6P6 (6006)
2
CHIEF
COMPLAINT
Abdominal Enlargement
3
HISTORY OF PRESENT
ILLNESS
1 year prior to consult
• Note of progressive abdominal enlargement
• No other associated symptoms
• No consult done
4
HISTORY OF PRESENT
ILLNESS
2 months prior to consult
• Progressive enlargement of the abdomen with right
lower quadrant discomfort
• Pain scale 4/10
• Prompted to seek ought consult
• ROS: early satiety, abdominal bloatedness, (-) bladder
and bowel symptoms
5
TRANSVAGINAL ULTRASOUND
Uterus is anteverted deviated to the left with smooth contour and homogeneous
echopattern measuring 5.6 x 3.7 x 2.2 cm
Cervix is 2.0 x 2.2 x 2.3 cm with several cystic spaces ranging from 0.2 – 0.6 cm in
diameter (Nabothian cysts).
Endometrium measures 0.3 cm thin, hyperechoic
6
TRANSVAGINAL ULTRASOUND
Right ovary not visualized
Left ovary not visualized
There is a huge abdominopelvic multiloculated cyst containing low level echoes noted
anterosuperior to the uterus measuring 38.2 x 30.0 x 19.5 cm. Color mapping shows
minimal vascular flow (Color score:2). Chance of Benign Tumor is 96.4% by IOTA
Adnex Model.
Cul de sac: minimal fluid
COMMENTS: Normal sized postmenopausal uterus
Consider Ovarian Newgrowth Probably Benign by IOTA adnex model
7
HISTORY OF PRESENT
ILLNESS
Referred to housecase service for further management
8
Past medical, family,
personal/social history
Past Medical History Personal/Social
(+) DM Type 2 –
Non smoker
(+) PTB -2002 – completed
treatment Non alcoholic beverage
drinker
Family History Homemaker
(+) Bronchial Asthma - sibling
(-) Covid vaccination
9
OBGYNE History
• G6P6 (6006) Menarche at 12yo • Coitarche: 24yo
Regular intervals
• All NSVD • Menopause at 45 yo
6-7 days
• No complications 3-5 ppd • Papsmear July 2022
(+) symptoms - NILM
10
Physical examination
General Survey and Vital Signs
• Awake, coherent, not in distress
• BP= 120/80 mmHg HR= 72 bpm RR= 17 cpm Temp= 36.3 C
• Wt = 56 kg Ht = 5’1” cm BMI = 23.2 kg/m2
HEENT
• Anicteric sclerae, pale conjunctivae, no neck masses, no cervical
lymphadenopathy
Chest and Thorax, Breast
• Symmetric Chest Expansion, Clear breath sounds
• Breasts symmetric, without masses, no nipple retractions or discharges
Cardiovascular System
• Adynamic precordium, regular cardiac rhythym, (-) murmurs
11
PHYSICAL EXAMINATION
Abdomen
• Palpable fluctuant mass, non-tender, non-movable
• FH 36cm
Pelvic exam
Grossly normal external genitalia appropriate for age
Smooth vaginal walls
Cervix delineated, measuring 2 x 2 cm, smooth and no lesions
Hypogastric mass extending up to the level of the xiphoid process, with Fundic height of 36
cm, soft, non-tender
Grossly normal anal sphincter, smooth rectal walls, intact rectovaginal septum, no
intraluminal masses, bilateral parametria smooth and pliable
12
COMPLETE BLOOD COUNT Blood typing O+
Urinalysis Normal
Hemoglobin 130
ALT/SGPT 13
Hematocrit 0.40 Fasting Blood Sugar 132
RBC 4.60 Creatinine 0.65
Sodium 138.50
WBC 8.3
Potassium 4.56
Segmenters .63 HBS Antigen Nonreactive
CA 125 440.9
Platelet 311
Protime
Patient 11 seconds
% activity 120.8 %
INR 0.96
13
INITIAL
1 IMPRESSION
G6P6 (6006), Abdominopelvic Mass, probably
ovarian in origin, laterality unknown, rule out
malignancy, DM Type 2
Plan:
For PFC, TAHBSO, BLND, IO, AP
Cleared by HCIM
OR: August 19
Preoperative
Conference
By: Jessica de dios
year level IV resident
GENERAL INFORMATION
C.A
45 YEARS OLD
G1P1 (1001)
16
A case of
PROLAPSING INTROITAL MASS
17
HISTORY OF PRESENT
ILLNESS
10 years prior to consult,
• Noted introital mass within the vaginal canal
• No other associated symptoms
• During the interim, there was progressive prolapsing of the mass
2 years prior to consult,
• The mass was noted to be prolapsing from the introitus, approximately 5 cm, this
was aggravated by coughing, prolonged walking and during straining
• and there was erythema on the distal area of the prolapsed mass
• Advised surgery but patient was lost to ff-up
18
HISTORY OF PRESENT
ILLNESS
1 month prior to consult,
• Sought consult due to difficulty voiding
• Patient described it that she needs to reduced the prolapsed
introital mass in order to pass urine
• She was advised vaginal hysterectomy
• Was referred under housecase financial constraints and for
further management
19
Transvaginal Ultrasound
Uterus is anteverted deviated to the left with smooth contour, heterogeneous echopattern measuring 8.3 x 5.1 x 4.5 cm
There are multiple hypoechoic masses with definite border noted:
M1: at the anterior myometrium measuring 0.7 x 0.6 x 0.7 cm
M2: at the posterior myometrium measuring 1.7 x 1.3 x 1.2 cm
M3: at the left lateral portion of the uterus measuring 0.3 x 0.6 x 0.5 cm
Cervix measures 2.9 x 2.8 x 3.1 cm with homogeneous stroma and distinct endocervical canal
Endometrium measures 0.9 cm thick, trilaminar and smooth. The subendometrial halo is intact.
Left ovary measures 2.8 x 1.6 x 1.6 cm with several follicles ranging from 0.2 – 0.6 cm in diameter. It is lateral to the uterus.
Right ovary measured 2.8 x 2.0 x 1.9 cm with largest follicle measuring 1.4 x 1.3 x 1.3 cm. it is lateral to the uterus
No fluid in the cul de sac
COMMENTS: Multiple small intramural Myoma
Proliferative Phase Endometrium
Normal Ovaries with Dominant Follicle- Right
20
Past medical, family,
personal/social history
Past Medical History
Personal/Social
(+) Hypertension – Amlodipine 5mg/tab 1
tab OD Non smoker
Previous Surgery – VA 2000, skin grafting
Non alcoholic beverage
right leg
drinker
Allergies – Co-amoxiclav, cefuroxime Home maker
Family History –
(+) HPN – Paternal
(+) DM - Maternal
Partially vaccinated – 1st and 2nd dose – 21
OBGYNE History
• G1P1 (1001) - 2005 • Coitarche – 27yo
• delivered via NSVD with
no postpartum • LMP: 7/5/22
complIcations • PMP 6/11/22
M – 12 yo • OCP (-)
I – Regular • Pap Smear 7/19/22 - NILM
D – 3 days
A – 4-5 ppd
S – (-) dysmenorrhea
22
Physical examination
General Survey and Vital Signs
• Awake, coherent, not in distress
• BP= 130/90 mmHg HR= 81 bpm RR= 18 cpm Temp= 36 C
• Wt = 60 kg Ht = 5’1” cm BMI = 24.9 kg/m2
HEENT
• Anicteric sclerae, pale conjunctivae, no neck masses, no cervical
lymphadenopathy
Chest and Thorax, Breast
• Symmetric Chest Expansion, Clear breath sounds
• Breasts symmetric, without masses, no nipple retractions or discharges
Cardiovascular System
• Adynamic precordium, regular cardiac rhythym, (-) murmurs
23
PHYSICAL EXAMINATION
Abdomen
• Soft, flat non-tender, no palpable masses
Upon pelvic examination, the cervix has erosions
No adnexal masses/tenderness noted
RVE: bilateral parametria smooth and pliable
24
LABORATORY RESULTS
Complete Blood Other Labs
Count Blood type O+
Hgb 136 FBS 95 ECG 12L Sinus Rhythm
Hct 0.41 Crea 0.61 CXR Normal chest
SGPT 18 findings
RBC 4.33
Na 140.50
WBC 5.4
K 3.9
Neut .62 U/A Normal
Lymph 0.29 Protime % activity 123%
INR 0.95
Plt 182
25
1 Admitting diagnosis
G1P1 (1001) PELVIC ORGAN PROLAPSE
(Apical, Anterior, Posterior Compartment)
STAGE 3, HCVD
PLAN:
Vaginal Hysterectomy, Anterior and Posterior
colporrhaphy, SSF
CP cleared by HCIM
OR: August 3
The risk of developing ovarian cancer after hysterectomy with ovarian
conservation performed for benign disease is 40% lower than with
women who do not undergo hysterectomy.
However, performing Elective Oophorectomy to reduce cancer risk at
the time of hysterectomy may unintentionally cause more deaths from
all causes by age 80 than the number of lives saved from ovarian
cancer.
27
The current recommendation by the American College of
Obstetricians and Gynecologists (ACOG) on Elective Oophorectomy
is that “strong consideration should be made for retaining normal
ovaries in women who are not at increased genetic risk of ovarian
cancer.
“the decision to perform prophylactic oophorectomy should be
based not only on the patient’s age but also on other factors that
weigh individual risk for developing ovarian cancer against loss of
ovarian function”
28
Benefits of the Postmenopausal Ovary
Following menopause, the ovary continues to produce
androstenedione and testosterone in significant amounts until
age 80 and these androgens are converted in fat, muscle and skin
into estrone
Oophorectomy after age 50 increases the risk of developing
cardiovascular disease
29
