Case Write Up Gynae (Ovarian Cyst)

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 5^th 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

1. http://antibiotics.emedtv.com/rocephin/rocephine.html

2. https://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Case Write Up Paediatric (Pneumonia)

Patient ID

Name                             : Muhammad                                            

Date of Birth                : 10 April 2017                          

Age                                 : 14 months                         

Gender                          : Male                                           

Race                               : Malay                                  

Religion                         : Muslim                               

Address                          : Setapak, Kuala Lumpur

Informant                     : Siti Sarah (mother)

Chief Complaint

Patient was presented to emergency department at 8am on 20 May 2018 with chief complaint of difficulty in breathing for 5hours.

History of Presenting Illness

Patient was known case of bronchitis. He was hospitalized when he was 9months old at Hospital Kuala Lumpur due to difficulty in breathing. This is the 2^nd hospitalization due to difficulty in breathing.

Patient was previously well, until 17 May 2018 on Thursday night, patient developed rised in body temperature. It was sudden and resolved with medication. The mother had measured the temperature, it was 38.8°C. The fever was continuous and did not fluctuate, unless decreases with medication.  The medication resolved the fever to 37°C. No night peak. The medication was given in 6hours interval. Before the fever, the mother said that she was having fever. The fever did not associate with vomiting and rash. The fever lasted for 4days.

One day after that, on Friday, he started to developed runny nose. It started on onset of sudden and the patient is still having runny nose until clerking day. It is always there and continuous. It became worsen since the discharge was clear in the beginning but started to turn greenish. The flow was subtle on Friday but started to become heavy flow the next day. It got worse when he cries.

On Saturday the next day after the patient started to have runny nose, cough had developed. It was sudden, and on and off. The cough was same since first event until today. It is a wet cough and become worse at night. There is no post tussive vomiting.

On Sunday, at 2am, he developed difficulty in breathing when he was sleeping. Mother commented that the breathing become more rapid than usual. The event lasted or 5hours, prior to admission. The progression was same. The difficulty in breathing has no relieving factor. No noisy breathing was noted upon patient.

Then, the mother brought him to Emergency Department(ED) in HKL at 8am and was advised to go back. Patient was given antipyretic and nasal normal saline, but the symptoms did not subside. The difficulty in breathing came back and got worse. The mother brought him to ED again, at 11pm and he was given nebulizer, but did not respond. 3 nebulizers were repeated but patient had no response towards treatment. Then he was referred to paediatrician and admitted into the ward KK2 at 11.30pm.

System Review

No vomiting

No rash

No abnormal movement

Decreased bowel movement, no loose stool or straining.

Decreased urine output

Appetite was reduced, he refused any meal intake

Weight reduced

Sleep was disturbed

Past Medical History

Patient was diagnosed to have bronchitis on December 2015. He also was diagnosed as Iron Dificiency Anemia.

Birth history

For perinatal history, during pregnancy of the mother, or prenatal, the mother had low hemoglobin level and fever. For antenatal, he was delivered mature, normal without any complication or problem. The weight was 3.01 kilogram. For postnatal, patient had attack of jaundice 2days after delivery for 1week. No admission due to jaundice.

Past Admission History and Surgical History

Patient had admission due to acute bronchitis on December 2015 in Hospital Kuala Lumpur. No significant surgical history.

Immunization History

Completed all vaccination and never missed any.

Feeding History

The child is still breastfeeding. The child was purely breastfeeding until age of 6months. Then, he started to have mix meals which are breastfeed and solid food. No cow’s milk or formula milk was given. After delivery, the child was breastfed immediately within 2hours. The bottle hygiene is good. The mother sterilized the bottle after usage.

Developmental History

Gross motor : walking without support at 1year and practicing to run. He sits without support

Fine motor : able to scribble, mature pincing

Social : strangers anxiety

Speech : understands many phrases, able to call the father and mother

Drugs and Allergy History

Antipyretics, nasal normal saline. No cough syrup was given during illness. No food allergy. There is iron syrup given for IDA.

Family history

Patient is 3^rd among 3siblings. The first brother is 5years old, healthy and second brother is 3years old, known asthmatic. The has history of asthma during childhood. The father has allergy rhinitis and a smoker. No eczema runs in the family.

Social History

The child is living with his family in a flat house Setapak, Kuala Lumpur. The mother is a housewife, and take care of the child herself. The father is a technician, a smoker, but smokes outside the house. Patient is a non-passive smoker. No travel history was noted. The area was known as hotspot area of dengue. The drainage is good. And water supply is clean. They did not use filter but they boil water for drinking. No contact with person with same illness. But before the illness, they did take meal from outside.

Summary

A 14months old child presented with difficulty in breathing for 5hours on Sunday (20/5/2018). He had fever, cough and runny nose 2-3days prior to admission. Fever was sudden and low grade. It resolved by medication. The runny nose was sudden and continuous. It becomes increase of flow and mucous turns from clear to greenish. The cough was sudden and dry cough. It was on and off, and wet cough. It peaks at night with same progression. The rapid breathing was sudden. The progression is same. No aggravating and relieving factor. The patient was brought to ED for treatment and admitted in KK2.

PHYSICAL EXAMINATION

General Examination

On inspection, the patient was alert, conscious, communicative and active. Patient appeared well nourished and well hydrated. The child appeared pink. There was a sign of breathlessness and he was tachypneic. There was no accessory muscles were used during respiration. The subcostal recession and Harrison sulcus can be seen.

Vital signs-

Blood pressure                   :           98/54 mmHg (normal 90-105/55-70)

Pulse rate                             :           146bpm (normal 80-140), good volume and

                                                            regular rhythm

Respiratory rate                 :           35/min (normal 25-30)

Temperature                       :           38.2C

Face-

Patient’s conjunctiva were pink on both sides,  and there were no sign of jaundice at the sclera of both eyes. There was no nasal flaring but positive nasal discharge. There was no central cyanosis at the tongue, no ulcers and the lips were moist. There were no rashes or any deformities on the face. The face shows toxic-ill look.

Neck-

There were no sign of enlarged lymph nodes and no raised jugular venous pressure. Trachea cannot be assessed because patient was not cooperative.

Hands-

There were no signs of pallor at the palmar crease, no peripheral cyanosis, no nail clubbing and no palmar erythema. The capillary filling was normal (less than 2 seconds). There was no scars on the hand.

Legs-

No pitting edema was seen in both legs. The pulses of the dorsalis pedis artery were felt in both legs.

Weight                                  :           8.5kg (below 5^th percentile)

Height                                   :           85cm (below 5^th percentile)

Head circumference         :           47.5cm (at 25^th percentile)

SYSTEMIC EXAMINATION

Respiratory system-

On inspection, there were no scars, no deformitites and no masses can be seen on the anterior and posterior chest. There were no hyperpigmentation, no rashes seen. The chest was symmetrical. The subcostal recession and Harrison sulci were seen. Percussion of the chest was not done since the child is still under 5 years old. Upon auscultation, normal vesicular breath sounds were heard. There was generalized rhonchi heard in both lungs during expiration with prolonged expiratory phase with bilateral crepitation.

Cardiovascular system-

On inspection of the chest, there were no surgical scars or any deformities. No dilated veins and no visible pulsations were seen. Upon auscultation, both first and second heart sounds were heard. No abnormal murmur sound was heard.

Gastrointestinal system-

On inspection, the abdomen was symmetrical and there was no distention. The umbilicus was inverted and centrally located. No smilling umbilicus (denoting ascites) was seen. There was no dilated veins and no caput medusa. No visible peristalsis or pulsations were seen. There were no scars, no hyperpigmentation and no spider naevi seen. Upon palpation, there was no tenderness. On percussion, there were no shifting dullness and no fluid thrills.

PROVISIONAL DIAGNOSIS

Left lobar pneumonia with bronchospasm, due to chest x-ray shows left lower consolidation of the lung. Lobar pneumonia usually caused by Streptococcus Pnuemonia. The bronchospasms was diagnosed due to rhonchi at end expiration, and prolonged expiration in the child.

DIFFERENTIAL DIAGNOSIS

Asthma

Patient has positive family history of atopy. Family history of atopy give strong diagnosis to asthma. But the patient developed toxic-ill look and basal crepitation which shows fluid accumulation.

Acute bronchitis

The child developed cough before he had rapid breathing. The cough lasted for  about 2 weeks or longer in acute bronchitis. But the patient did not yet reach 2weeks cough. The patient also has rise in body temperature. The child was having wet cough since the beginning.

INVESTIGATIONS

Based on the history and physical examination, a provisional diagnosis was made. In order to confirm the diagnosis, a few laboratory investigations were requested. A full blood count to look for infection (raised white blood cell) and chest X-ray was ordered.

Full blood count-

Test	Patient’s value	Normal range	Interpretation
White blood cell (x10^9/L)	11.0	4.0-9.0	High
Red blood cell (x10^12/L)	5.31	3.8-6.0	Normal
Haemoglobin (g/dL)	11.6	10.5-14.0	Normal
Haematocrit )%)	37.5	29-59	Normal

Chest X-Ray

Left lower consolidation of lung.

MANAGEMENT

1.    Antibiotic therapy

2.    Give inhaled bronchodilators

3.    Supplemental oxygen through nasal canula

4.    Fluid resuscitation

5.    Empiric antibiotic therapy

6.    Corticosteroids

DISCUSSION

            The incidence of pneumonia peaks in infancy and old age, but is relatively high in childhood. Pneumonia is a major cause of childhood mortality in resource-poor countries. It is caused by variety of viruses and bacteria, although in over 50% no causative pathogen is identified. Viruses is more common is young children, while bacteria are more common in older children. In clinical practice, sometimes it is difficult to distinguish between viral and bacterial pneumonia.

            The pathogen causing pneumonia vary according to the child’s age. In this patient, he is 14months old which is considered young child. In this age, respiratory viruses, particularly RSV(respiratory syncytial virus) are more common, but bacterial infections include Streptococcus pneumonia or Haemophilus influenza. Bordetella pertussis and Chlamydia trachomatis can also cause pneumonia at this age. In an infrequent but serious cause, is Staphylococcus aureus.

            Usually, for pneumonia, the clinical features of fever and difficulty in breathing are the commonest symptoms, usually preceded by an upper respiratory tract infection. Other symptoms include cough, lethargy, poor feeding and an ‘unwell’ child. Localized chest, abdominal, or neck pain is a feature of of pleural irritation and suggests bacterial infection. Examination reveals tachypnea, nasal flaring and chest indrawing – the best clinical sign of pneumonia in children is increased respiratory rate, which in this patient, the respiratory was a bit higher than normal border. To confirm the diagnosis of pneumonia is by using chest X-ray, but in exception of lobar pneumonia.

           

Lobar pneumonia is an acute exudative inflammation of an entire pulmonary lobe, produced in 95 % of cases by Streptococcus pneumoniae (pneumococci).

If not treated, lobar pneumonia evolves in four stages. Common to all stages is the enlargement of the affected lobe with loss of it's spongy appearance.

In the first stage, congestion (day 1 - 2), the affected lung parenchyma is partially consolidated, and red-purple, partially aerated. Microscopy: alveolar lumen contains serous exudate, bacteria and rare leucocytes.

In the second stage, red hepatization (day 3 - 4), the pulmonary lobe appears consolidate, red-brown, dry, firm, with a liver-like consistenc. The cut surface is dry, rough. Microscopy : the characteristic aspect of this stage is determined by the accumulation in the alveolar spaces of an exudate rich in fibrin (mainly), with bacteria, leucocytes, and erythrocytes. Alveolar walls are thickened due to capillary congestion and edema.

The third stage, gray hepatization (day 5 - 7), the affected lobe has a liver-like consistency, with uniform gray colour. On the cut surface, a grayish purulent liquid drains. It is because alveolar lumens are filled with leukocytic (suppurative) exudate (neutrophils and macrophages, in order to remove the fibrin). Capillary congestion and edema are still present, therefore alveolar walls are thick.

The resolution stage begins on day 8 and continues for 3 weeks (uncomplicated cases), while the exudate within the alveolar spaces will be drained through lymphatics and airways ("productive" cough) with gradually aeration of the affected segment.

The management of pneumonia usually is antibiotic which determined by the child age, severity of illness and appearance on chest Xray. Most older infants can be managed by oral amoxicillin, with broad spectrum antibiotics.

REFERENCES

•                Kleigman, R.M., et al. Nelson Textbook of Pediatrics, 19th ed. Philadelphia: Saunders, 2011.

•                Illustrated textbook of paediatrics 4th ed. :Lissauer and Clayden

•                Paediatrics protocol for Malaysian Hospitals 3rd edition

•                http://www.pathologyatlas.ro/lobar-pneumonia-leukocytic-alveolitis.php

Perbandingan Pelan Internet Prabayar (*sehingga 15/06/2017)

Aku pengguna hotlink plan #Hotlink. Sekarang tangah buat perbandingan antara telco-telco lain. Baru aku tahu yang plan aku pakai sekarang yang paling mahal T_T

Aku bandingkan dengan harga RM 50 untuk langganan selama sebulan sebab bila dah topup rm 50 sebulan takyah fikir pasal internet dah. Guna sampai habis atau datang bulan baru. Tak payah susah-susah fikir pasal nak renew setiap hari atau setiap minggu.

Jadi, dari segi harga kesemua telco meletakkan harga bawah rm 50 yang mana 'affordable' la untuk berstatus pelajar macam aku ni.

Kalau dari segi data (ikut 'ranking') :
1. Umobile
2. Digi = Xpax
3. Hotlink
Bermakna Umobile menyediakan data paling banyak.
'Loser' adalah Hotlink. haha

Kalau dari segi ekstra, kita dapat lihat yang Umobile ada banyak kelebihan daripada telco-telco lain.

So, nak pilih yang mana satu ni?

Rujukan :
1. https://www.hotlink.com.my/en/internet/mobile-internet-plans.html
2. https://www.xpax.com.my/internet
3. http://new.digi.com.my/prepaid-addons#Internet-Plans
4. http://www.u.com.my/prepaid/umi