Personal
Details
Name: Miss S
Age: 25 years old
Sex: Female
Address: Taman Melawati, KL
Occupation: Telemarketer
Marital status: Unmarried, nulliparous
Chief
complaint
She came to the hospital after being
referred from private hospital due to lower abdominal pain for 7 days.
Menstrual
History
She attains menarche at the age of 13 years
old. Her period is irregular, more than 30 days. Her flow lasted for 5 – 7 days
She has dysmenorrhea before the menses but
does not require any medication. Other than that, she has no menorrhagia, 4 – 5
pads per day, no intermenstrual bleeding, no dyspareunia or post-coital
bleeding. Her last menstrual period is at 19 May 2018.
History
of presenting illness
She is a known case of bilateral pyosalpinx
and was operated on 2017 whereby drainage was done through laparotomy at
Hospital Pantai Cheras. Her last follow up was on July 2017.
She was apparently well until 1 week ago
when she experiences pain over her lower abdomen. The onset was insidious. The
pain was sharp and throbbing in nature. She rates it 7/10 on the pain score. It
radiates to left of her abdomen. The pain aggravates from walking and she
relieves it by lying down, does not take any medication for the pain. The pain
is on and off. The pain associated with fever for 1 day and nausea for 7 days. The
fever is low grade, no chills and rigor. She takes paracetamol to relieve her
fever.
She is not sexually active. Her last sexual
intercourse is in January 2018.
Other than that, she had no per-vaginal
bleeding as well as abnormal, foul smelling discharge from the vagina. She also
has no vomiting, no flu or cough as well as painful urination.
Past
Obstetrics History
Nil – Nulliparous
Past
Gynaecological History
She had no previous gynecological history
such as fibroid or cyst.
She had bilateral pyosalpinx at 2017 and
laparotomy drainage was done at Hospital Pantai Cheras.
She never takes any contraception. She had
never done pap smear or mammogram.
Past
Medical History
She has asthma since childhood and
currently on Ventolin and steroid inhaler. She has history of admission to
hospital due to bronchial asthma and had been intubated during childhood due to
asthma.
Other than that, she has no hypertension or
diabetes mellitus.
Surgical
History
She had no other surgery other than the
laparotomy drainage.
Allergic
History
She has allergy to walnut and ‘kacang
parang’ and seafood as it causes shortness of breath.
Family
History
Both her parents are still alive. The father
is 63 years old and is healthy. The mother is 55 years old and she has
hypertension.
She is the third children out of 6
siblings. 3 of them are female. They have no history of gynaecological problem
such as fibroid or cyst or same as her.
There is no history of cancer in the
family.
Social
History
She lives in Taman Melawati, KL and works
as a telemarketer. She does not smoke, drink alcohol or take illicit drugs. Her
total income is about RM 1000. She takes normal diet, not a vegetarian.
Summary
Miss Sheera, 25 years old Malay female,
unmarried and nulliparous, a known case of bilateral pyosalpinx, operated on
2017 came due to left iliac fossa pain for 7 days.
General
Examination
The patient is conscious and alert. She is
in average build and height. She is responding well and well orientated to time
and place. She does not appear distress and not ill or toxic looking.
Vitals
signs:
Blood pressure: 115/74 mmHg
Pulse rate: 99 beats/minute (regular, good
volume)
Respiratory rate: 18 /minute
Temperature: 37 ⁰C
Hand
Her hands are warm and pink. There is no
swelling, no wasting of muscles, no redness or erythema. There are both
symmetrical, there are no deformity such as swan neck. The capillary filling
time (CRT) is less than 2 seconds. The fingers are not clubbed. There are no
flapping tremors as well as fine tremors.
Eyes
There is jaundice but no conjunctival
pallor.
Nose
No nasal polyps, no flaring and no
discharge.
Mouth
There is no discoloration on her mucosa.
There is no central cyanosis. The oral hygiene is good, no bleeding gums, no
ulcers and no angular stomatitis. It is also well hydrated.
Neck
There are no swellings, scars, rashes or
deformities seen. The thyroid is not enlarged, and cervical lymph nodes are not
palpable.
Legs
No pedal edema, no varicose veins, no
muscle wasting and no joint deformities. The dorsalis pedis and posterior
tibial pulses are felt.
Lymph
nodes
The lymph nodes are not enlarged and
palpable.
Systemic
Examination
Cardiovascular
Upon palpation, the apex beat is located at
the left 5th intercostal space, medial to the mid clavicular line.
There is no heave or thrill felt on all four areas of the heart.
Upon auscultation, both first (S1) and
second (S2) heart sounds are heard on all four areas. No additional sound and
murmurs were heard.
Respiratory
Upon auscultation, the air entry is good
and equal on both lungs. There are no rhonchi and crepitation on both lungs.
Abdominal
Upon inspection, the abdomen is flat. There
is surgical scar, midline with length of 15 cm with good healing and no keloid
formation, no caput medusa, no visible veins or visible peristalsis. The
umbilicus is inverted, and the flank are not full.
Upon palpation, there are no superficial
tenderness as well as rebound tenderness. On deep palpation, there is mild
tenderness at the left iliac fossa. No mass was felt on all nine regions. The
liver and spleen are not palpable. There is no shifting dullness as well as
fluid thrill. The kidneys are not ballotable.
Upon percussion, the liver span is normal.
Upon auscultation, the bowel sounds were
heard. No renal bruits.
Differential
diagnosis
-
Twisted ovarian cyst
-
Pyosalpinx
-
Tubo-ovarian abscess
-
Ovarian cyst
-
Ectopic pregnancy
Investigations
-
Full blood count
-
Urine microscopic analysis
(UFEME)
-
Ultrasound of the abdomen
Lab
investigation
Full blood count:
Result
|
Unit
|
Normal Range
|
|
Haemoglobin
|
126
|
g/L
|
130 – 180
|
Red blood cells
|
4.54
|
1013/L
|
4.50 – 6.50
|
Pack cell volume
|
0.38
|
L/L
|
0.40 – 0.55
|
Mean corpuscular volume
|
83
|
fL
|
78 – 99
|
Mean corpuscular haemoglobin
|
28
|
pg
|
27 - 32
|
Red cell distribution width
|
13.0
|
%
|
11.0 - 15.0
|
White cell count
|
7.7
|
109/L
|
4.0 – 11.0
|
Neutrophils
|
10
|
109/L
|
2.0 – 8.0
|
Leucocytes
|
3.0
|
109/L
|
1.0 – 4.0
|
Platelets
|
254
|
109/L
|
150 - 400
|
Impression: The neutrophils are raised.
Test
|
Result
|
Reference
|
Glucose
|
Negative
|
< Trace
|
Protein
|
Negative
|
< Trace
|
Bilirubin
|
Negative
|
< 1+
|
Urobilinogen
|
Normal
|
< 1+
|
pH
|
6.0
|
|
Blood
|
2+
|
< Trace
|
Ketone
|
Negative
|
< Trace
|
Nitrite
|
Negative
|
< 1+
|
Leukocytes
|
Negative
|
< Trace
|
Clarity
|
Clear
|
|
Specific gravity
|
1.002
|
|
Color
|
Colourless
|
|
Ascorbic acid
|
Negative
|
Urine for examination and microscopic
examination (UFEME):
Impressions:
There is blood in the urine. Other than that, its normal
Ultrasound
findings (TAS):
-
Uterus anteverted 6 cm X 3.6 cm
-
Elongated hypoechoic 6 cm X 2.2
cm, multiseptated, thickened wall
-
Left ovarian cyst 4 cm X 3 cm
Provisional
Diagnosis
Tubo-ovarian abscess with left ovarian cyst
The patient presented with left iliac fossa
pain. It is also associated with fever and nausea. From the examination, there
is tenderness on deep palpation, but no mass felt. From the investigations
done, the neutrophils are raised and from the ultrasound scan, findings show
that there is ovarian cyst as well as hypoechoic mass with thickened wall.
Management
-
IV Rocephine 2g stat
-
IV Flagyl 500mg TDS for 1 day,
then change to oral for 2 weeks
-
T. Doxycycline 200mg BD 2 weeks
Discussions
Miss S, 25 years old Malay lady from
Melawati, unmarried and nulliparous came to the hospital due to left iliac
fossa pain with previous history of bilateral pyosalpinx that was operated on
at 2017.
She came with symptoms of left iliac fossa
pain that is sharp and throbbing in nature that associated with fever and
nausea. However, there are no symptoms of upper respiratory tract infection
(URTI) or urinary tract infection (UTI) or even per-vaginal bleeding or
discharge. Her symptoms are not typical of patient with pelvic inflammatory
disease (PID) with sequelae of tubo-ovarian abscess. Patients come with
symptoms of abdominal pain, abnormal uterine bleeding, vaginal discharge and painful
urination.
Upon physical examination, the findings are
not very definitive of tubo-ovarian abscess except that there is tenderness at
the left iliac fossa region on deep palpation. Investigations findings shows
that the neutrophils are raised indicating that there is bacterial infection. On
ultrasound scan, it is found that there is left ovarian cyst as well as abscess
formation at the ovary.
Based on the history and the findings from
the investigations, it is suggestive that the tubo-ovarian abscess may be due
to the previous pyosalpinx being not fully drained which causes recurrent pus
formation in this admission. This is because the history is not suggestive of
ascending infection from sexual transmission as she is not sexually active, and
she does not have symptoms such as per-vaginal discharge or bleeding as well as
dysuria. She also does not experience dyspareunia. She only came with symptom
of lower abdominal pain, nausea and mild fever.
She is treated with Rocephine
(ceftriaxone), Flagyl (metronidazole) and Doxycycline whixh is appropriate
because it is used to cover for bacteria that causes PID such as gonorrhea and
chlamydia. Surgical management also can be done which is drainage of the pus
through laparotomy to ensure all pus have been drain.
References
No comments:
Post a Comment