Name: Kamariah bte Abu Hassan

R/N: 35642
Para 5
Age: 52
Sex: Female
Race: Malay
Religion: Islam
Occupation: Housewife
Educational level: Form 1
Address: Kuala Balah
Last Normal Menstrual Period: 4th November 2015
Last Child Birth: 21 years ago
Date of Admission: 22nd November 2015
Date of Clerking: 22nd November 2015
Chief Complaint
Patient is admitted electively from the O&G clinic due to presence of abdominal mass
at her lower part of the abdomen.
History of Presenting Illness
She first noted the mass was at her left iliac fossa. She noticed it since last January and
claims that it increases in size. She feels that the mass is hard in consistency and is
mobile.
She also claimed that she felt pain at her left iliac fossa. She feels the pain especially
in the evening, but she is able to tolerate the pain in the morning as it is not that painful.
She can carry on with her work in the morning. She described the pain as a dull pain and
it doesn't radiate to anywhere else. One of the associated symptoms was constipation. Her
constipation started since 2013. Other associated symptoms are tightness at chest and
back, nausea, dysuria, abdominal discomfort and palpitation while doing work. The
abdominal pain is an intermittent pain, aggravated by walking or doing work and relieved
by resting and bending down. The pain score was 6/10 and is bearable.
Besides that, she claimed that she had lost weight but doesn't remember since when
and for how long. She is able to notice the weight loss due to her clothes being lose. She
has no fever or shortness of breathe.
Gynaecological history
Recently, she had whitish vaginal discharge and it is foul smelling. There is no
presence of blood and itching. She has done pap smear once and it is a normal result. She
is currently not sexually active due to her husband is also in a sick condition. She never
took any hormonal contraception before. She has no history of sexually transmitted
diseases (STDs).
Menstrual history
Her menarche was at the age of 17. She has regular period and usually lasts for 8 days.
She has menorrhagia for the first 3 days and the subsequent days are not as heavy as the

first 3 days. She has no dysmenorrhea. The cycle is usually 28-32 days.
Past Medical History
Past medical and surgical history is not significant.
Obstetric History
She had 5 children previously. All of them were delivered through spontaneous
vaginal delivery and at term. They breastfed for 2 years.
Drug history
She takes Panadol for her headache and natural honey for her overall health. She
doesn't take any other supplements. She has no drug allergies.
Family history
Her parents are deceased but she is unsure of the cause of death. Her siblings are well.
No malignancy and twin history in the family.
Social history
She doesn't smoke and eats a well-balanced diet. She has no loss of appetite. Currently
living with husband and daughter.
Her husband doesn't smoke too and is in an ill-condition.
Physical Examination
On general examination, the patient is alert, conscious and no pallor. She is lying in a
supine position. She is supported by one pillow and is well-aware of the time, place,
person and responsive to questions.
Vital signs
1) BP: 150/70
2) Pulse Rate: 63
3) Temperature: 37 degree Celcius
4) Respiratory Rate: 27/min
There is no evidence of clubbing and peripheral cyanosis seen in this patient. Her facial
appearance was pink (well-perfused). The conjunctiva was pink and sclera was white.
There was no discharge from the ear, eye, and nose. Oral hygiene is good and the tongue
was pink, moist and has a normal contour. There is no pre-tibial, sacral and periorbital
edema seen. Besides that, the lymph nodes at the cervical and supraclavicular are not
enlarged or swollen. The thyroid was palpated and there is no swelling noted.
On Inspection:
Patient's abdomen is distended due to presence of abdominal mass. There are no
surgical and Pfannenstiel scar seen. Dilated veins are not present but striae albicans can
be seen indicating previous pregnancy. During examination, I asked the patient to cough

and there are no hernias noted.

On Palpation:
Before doing the examination, I asked the patient if there is any abdominal pain. She
claimed that there is no pain currently on-going at the time of examination.
On superficial palpation, the abdomen is soft and non-tender. There is no pain noted.
As for deep palpation, the abdomen is soft, non-tender and the uterus is non-palpable. A
huge mass is noted and I was able to palpate below it. The mass was mobile as I am able
to move the mass up and down and also left to right, hard in consistency and
approximately 22cm x 23cm in size. There is no hepatomegaly and splenomegaly noted.
There are no signs of peritonitis.
On Percussion:
Examination for shifting dullness was performed with patient lying on supine position.
There is no shifting dullness noted.
On Auscultation:
Bowel sounds are present.
Differential Diagnosis
Differential diagnosis that may present with abdominal mass based on the regoins of
the abdomen are;
- Uterine mass (fibroids)
- Pregnant uterus
- Ovarian mass (cyst)
Investigations
1. FBC, BUSE+creatinine
2. Liver function test
3. Ultrasonography of pelvis and abdomen
4. Test for tumor markers
- CA-125: epithelial type
- alpha-fetoprotein: yolk sac tumor
- beta-hCG: choriocarcinoma
- LDH: dysgerminoma
- CEA: any advanced adenocarcinoma (CRC, breast CA, gastric CA), mucinous
cystadenoma
5. CXR
6. CT scan for abdomen and pelvis
7. Laparoscopy, laparotomy, cytology
Management
1. Laparotomy

- Ascetic fluid is colleted and sent for cytologic examination

- A frozen section histologic diagnosis should be obtained intra-operatively to exclude
malignancy
- The definitive treatment depends on the type of neoplasm, patient's age and her desire
for future childbearing.
- Benign epithelial ovarian neoplasms are usually treated by unilateral salpingooophorectomy
- The contralateral ovary must be inspected and checked to exclude bilateral lesion.
2. In the case of the patient is young and nulliparous
Ovarian cystectomy with preservation of the ovary is performed if the ovarian
neoplasm is unilocular and there are no excrescences within the cyst. If the case is
stromal cell neoplasms of the ovary, it is treated by performing unilateral salpingooophorectomy(if patient still wants to conceive in the future). Cystic teratomas ( Dermoid
cyst ) can be treated by ovarian cystectomy.
3. In older woman
Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TABHSO) done,
especially if there is any suspicion of malignancy.
Discussion
The differential diagnosis that were made are Uterine Mass (Fibroid), pregnant uterus
and Ovarian Mass(Cyst).
Based on the table below, the final diagnosis that was made is Ovarian Cyst. This
diagnosis can be confirmed by pelvic ultrasound, laparoscopy and CA 125 blood test.
Pelvic ultrasound can confirm the presence of the cyst, help identify its location and
determine whether it's solid, filled with fluid or mixed. By doing laparoscopy, doctors
can see the ovaries and if it appears to be ovarian cyst, it can be removed. This procedure
requires the patient to be under anaesthesia. As for the CA125 test, if the ovarian cyst is
partially solid and the patient is at high risk of developing ovarian cancer, level of CA125
levels should be tested. CA125 can also be elevated in noncancerous conditions such as
endometriosis, uterine fibroids and pelvic inflammatory disease.
The final management of the patient is to go for definitive surgery; Total Abdominal
Hysterectomy and Bilateral Salpingo-oophorectomy. Since she is of older age, not
planning to conceive anymore and the cyst is growing, she agreed to undergo the
management that was recommended for her. During the surgery, the fallopian tubes,
ovaries, cervix and uterus are removed.
The possible complications of this surgery are nerve damage, allergic reaction,
haemorrhage and possibly death. Post-operative complication can be hypostension, acute
renal failure and hypokalemia.

On abdominal
examination

On bimanual
examination

Uterine Mass
(Fibroid)
Located in
midline
Lobulated
surface
Mobility:
usually side to
side, restricted
up and down
Unable to get
below it
Uterus not felt
separated from
the swelling as
such a groove is
not felt between
the uterus and
the mass
Cervix moves
witht he
movement of
the tumor felt
per abdomen.

Pregnant Uterus

Ovarian Mass (Cyst)

Palpable fetus
Head and
buttocks can be
palpated
Fetal back and
limbs can be
located and
palpated

Located
towards iliac
fossa
Soft cystic
consistency
Smooth surface
Freely mobile
Able to get
below it

Womb feels
firm, smooth
and the size
depends in the
period of
gestation.

Uterus is
separated from
mass
Groove felt
between mass
and uterus
On elevation of
mass from
abdomen,
cervix remains
stationary in
position.
Lower pole of
the cyst can be
felt through the
fornix
Absence of
pulsation of
uterine vessels
through the
fornices