Ministry of Health of Ukraine
Lugansk State Medical University
Department of Obstetrics, Gynecology and Dermatovenereology
Department head Doctor of Medical Sciences, Professor Simrok V.V.
Teacher Candidate of Medical Sciences, Associate Professor Gordienko E.V.
DISEASE HISTORY
Dzhioeva Svetlana Igorevna , 29 years
Clinical diagnosis: Pyosalpinx on the left. Endometrial cyst of the right ovary.
Curator: student of the 1st group of the 5th year
Faculty of Medicine
Nikolaeva Olga Andreevna
Curation date: 10.09.09. - 17.09.09.
Lugansk, 2009
^ PASSPORT PART
1. Dzhioeva Svetlana Igorevna
2. Age: 29 years old
3. Profession: cashier
4. Place of work: PE "Demenkov"
5. Home address: Lugansk, apt. Gaevogo, d. 1, apt. 7
7. Marital status: married
8. Delivered to the gynecological department by ambulance.
COMPLAINTS
At the time of hospitalization, complaints about intense sharp pains in the lower part of the abdomen on the left with irradiation from the left side; bloody discharge from the genital tract; increase in body temperature up to 37.5 ° C; dizziness; weakness.
^ HISTORY OF DISEASE
The patient considers herself ill since August 29, 2009, when she first felt moderate pain in the lower abdomen on the left; at the same time, scanty bloody discharge from the genital tract appeared. The body temperature rose to 37.5°C. The patient did not seek medical help and did not carry out drug therapy, she performed warming of the left iliac region in order to relieve the pain symptom. Positive dynamics was not observed. The intensity of pain progressively increased.
On September 1, 2009, the pains became acute, unbearable. The patient called an ambulance medical care and was delivered by her to the gynecological department of the Lugansk city maternity hospital.
^ ANAMNESIS OF LIFE
The patient is the second child in the family. She was born on June 20, 1980 in Lugansk with a weight of 3200 g. Physically and mental development did not lag behind peers.
In 2004 she graduated from vocational school with a degree in Accounting and audit. She began her career after graduating from vocational school as a cashier at the state of emergency "Demenkov", where she works to this day. Occupational and environmental hazards associated with labor activity, denies.
Past illnesses: at the age of 8 she had chickenpox, at the age of 10 - rubella. He rarely suffers from colds (ARVI 1-2 times a year). Until the age of 10 she suffered from bronchial asthma mild degree. After ten years of seizures bronchial asthma did not have.
Blood transfusion in 2005
Venereal diseases, viral hepatitis denies.
History of acute intestinal infections, malaria, helminthic invasions, teniorrhinhoza is not burdened.
Allergological anamnesis is not burdened. Bad habits denies.
The family history of diabetes mellitus, tuberculosis and oncological diseases on the part of the mother of the patient is not burdened, on the part of the father is unknown.
Married. Has been married since 1998.
Financial and living conditions are satisfactory.
^ SPECIAL HISTORY
MENSTRUAL FUNCTION
^ SEXUAL FUNCTION
First marriage, married for 11 years. No pain during intercourse. Sexual relations are regular.
^ GENERAL FUNCTION
I pregnancy (1998) - multiple (twin), ended in spontaneous abortion at 16 weeks. Curettage of the uterine cavity was performed and conservative therapy was carried out.
II pregnancy (2005) - ectopic pregnancy (tubal), interrupted in a period of 8 weeks. There was a break in the right fallopian tube. Operation - tubectomy on the left.
^ DATA OF OBJECTIVE EXAMINATION
General state at the time of admission, severe, the severity is due to pain.
At the time of curation - satisfactory.
Body temperature - 37.2 ° C.
Pulse - 74 beats per minute.
Blood pressure - 130/80 mm Hg.
Height - 167 cm.
Weight - 62 kg.
The constitution is normosthenic.
The physique is correct.
Body type - female.
Skin covers. The color of the skin and visible mucous membranes is pink. The skin is hyperemic. There is no rash. The skin is elastic, moderate moisture. Skin turgor is preserved. There is a postoperative scar from laparotomy according to Pschannenshtil. Hair on the female type.
Subcutaneous adipose tissue. Moderately developed. The thickness of the fold on the abdomen is 4 cm. The subcutaneous fat layer is evenly distributed. At the time of curation, pastosity and edema were not observed. The saphenous veins are inconspicuous. Subcutaneous adipose tissue is painless under pressure.
Mammary gland. ABOUT round shape, symmetrical, nipples developed, moderately pigmented.
The lymph nodes. Palpation available submandibular, axillary and inguinal lymph nodes. They are solitary, up to 5 mm in diameter, rounded, soft, painless on palpation, mobile, not soldered to the skin and surrounding tissues.
muscles moderately developed, toned, painless on examination.
Bones painless on examination, no bone deformities.
joints painless on palpation, active and passive movements are fully preserved, the configuration of the joints is without features.
Respiratory system. The chest is normosthenic, without deformities. Breathing through the nose is not difficult, the type of breathing is chest. Both halves of the chest are equally involved in the act of breathing. Respiratory rate - 14 times per minute, the rhythm of breathing is correct. There is no shortness of breath at rest.
Percussion: a clear pulmonary sound is heard over the entire surface of the lungs.
Auscultation: vesicular breathing. There are no breath sounds, wheezing, or pleural friction noise.
circulatory system. The area of the heart is not changed. Pathological pulsation of the carotid arteries, swelling and pulsation of the jugular veins were not detected. There is no pulsation in the region of the heart and epigastrium. The apical impulse is not visually determined.
Systolic and diastolic trembling is not determined.
The pulse is synchronous, 74 beats per minute, rhythmic, moderate tension and filling, fast.
Percussion: the boundaries of relative and absolute cardiac dullness correspond to physiological norms.
Auscultation of the heart: heart rate - 74 beats per minute, rhythmic heart contractions.
Heart sounds are clear, rhythmic.
Noises are not heard.
Arterial pressure - 130/80 mm. rt. Art.
System of the gastrointestinal tract. Lips Pink colour, moderately moist, without rashes, cracks and erosion. The mucous membrane of the oral cavity is pink, moderately moist. Hyperemia, ulceration, aft, not found. The gums are not loosened and do not bleed. Tongue pink, moist, lined with white coating. Tonsils without features.
The salivary glands (parotid, salivary and sublingual) are not enlarged, painless, there is no change in skin color over the region of the glands, there is no pain when chewing and opening the mouth.
The abdomen is sharply painful on palpation in the left iliac region (in the region of the postoperative scar). The abdomen is symmetrical, visible to the eye peristalsis of the intestines and stomach is not observed.
Divergence of the rectus abdominis muscles, hernias, pronounced enlargement of internal organs, volumetric formations, dilated saphenous veins are not observed.
Liver on the edge of the costal arch, the edge is smooth, soft, painless. The gallbladder is not palpable.
There are pelvic peritoneal symptoms.
^ Characteristics of bowel movements: stool 1 - 2 times a day, Brown, decorated consistency.
Urinary system. On examination, the lumbar region was not changed. With bimanual deep palpation, the kidneys are not palpable. Bladder palpation is not available. Palpation in the upper and lower ureteral points is painless. The ″tapping″ symptom is negative. The frequency of urination is 5-7 times a day, urination is painless. Diuresis - up to 1000 ml of urine per day.
^ SPECIAL GYNECOLOGICAL EXAMINATION
INSPECTION. The external genital organs are developed correctly. Female hair growth. Pathological changes in the vulva, examination of the ureter, paraurethral passages, excretory ducts of the Bartholin glands, perineum, vestibule of the vagina were not found.
^ LOOKING IN THE MIRRORS. Vagina nulliparous, no partitions. The mucous membrane of the vagina is pink, folded, not edematous. The cervix is cylindrical. There are no erosions, exocervicitis, endocervicitis, polyps, warts, ruptures. The external os is closed. Allocations - "chocolate".
^ BIMANUAL VAGINAL EXAMINATION. Palpation of the labia majora, Bartholin's glands, vaginal vaults, and cervix is painless; no pathological formations were found.
The body of the uterus is not enlarged, deviated anteriorly, dense, mobile, painless on palpation. Adnexa of the uterus on the right without features. On the left, a rounded formation 4 x 5 cm in diameter, soft-elastic consistency, almost immovable, is palpable. The sacro-uterine ligaments are not changed.
The rectal ampulla is free.
^ PRELIMINARY DIAGNOSIS
Based:
● complaints- intense acute pain in the lower abdomen on the left with irradiation from the left side; bloody discharge from the genital tract; increase in body temperature up to 37.5 ° C; dizziness; weakness.
● medical history- progressive increase in pain in the lower abdomen with irradiation to the left side;
● life history- prolonged bloody menstruation, spontaneous abortion (1998), tubal pregnancy (2005), rupture of the right fallopian tube followed by tubectomy;
● objective data- detection during bimanual examination of the uterine appendages on the left of a rounded formation 4 x 5 cm in diameter, soft elastic consistency, low displacement
You can guess!!! provisional diagnosis:
Basic: tubo-ovarian formation on the left.
^ SURVEY PLAN
Laboratory research
Clinical blood test
General analysis urine
Blood sugar test
Serological blood test for syphilis MCI
Examination of feces for helminth eggs
Determination of blood group and Rh factor
Coagulogram
Biochemical blood test (liver tests, proteins, electrolytes)
Extraction analysis cervical canal, urethra
Sowing from the vagina on the flora
II. Gynecological examination - puncture abdominal cavity through the posterior fornix of the vagina
III. Instrumental research methods
Ultrasound of OBP and OMT
Consultations of related specialists
^ RESULTS OF RESEARCH
RESULTS OF LABORATORY STUDIES
Clinical blood test (01.09.09):
Erythrocytes: 4.83×10 12 /l;
Leukocytes: 9.0×10 9 /l
Band: 4%;
Segmented: 63%;
ESR: 15 mm/h.
General urine analysis (01.09.09):
Specific Gravity: 1013
The reaction is slightly alkaline;
Protein: no;
Erythrocytes: 2 - 4 in p / s;
Leukocytes: 7 - 9 in p / s;
Slime: no.
Blood sugar test(01.09.09):
Serological blood test for syphilis MCI(01.09.09):
Analysis of feces for helminth eggs(01.09.09):
Blood biochemistry (electrolytes, liver tests, proteins) (01.09.09):
ALT: 0.5 mmol/h/l;
Thymol test: 3 IU;
Total protein: 72 g/l;
Albumin: 41 g/l;
Urea: 5.6 mmol/l.
Blood coagulogram(01.09.09):
Recalcification time: 92"
Fibrin enzyme: 13 mg/ml;
Fibrinogen: 289mg/100ml.
Determination of blood group and Rh factor(01.09.09):
9) Analysis of secretions of the cervical canal, urethra (01.09.09):
Mucus - a moderate amount;
Epithelium - 12 - 14 in the field of view;
Flora - sticks;
GN - negative;
Tr. − negative
10) Sowing from the vagina on the flora: (01.09.09):
Pathogenic flora is not sown.
^ PUNCTION OF THE ABDOMINAL CAVITY THROUGH THE POSTERIOR FORNISH OF THE VAGINA (01.09.09)
Under aseptic conditions, after appropriate treatment of the vagina and external genital organs, the cervix is exposed in the mirrors, taken on bullet forceps by the back lip. Anesthesia - novocaine 5% - 5 ml.
Produced by puncture of the abdominal cavity through the posterior fornix of the vagina. Received 3 ml of "chocolate" content.
Conclusion: ruptured left ovarian cyst.
^ INSTRUMENTAL RESEARCH METHODS
OMT ultrasound (01.09.09):
The right ovary is determined, the dimensions are normal (22 x 18 x 17 mm).
Pathological formations in the pelvic cavity are determined: to the left and anterior to the uterus - tubo-ovarian tumor, consisting of cysts. Hydrosalpinx on the left.
The left fallopian tube is defined as a liquid formation with constrictions, size 92 x 40 mm.
Conclusion: .
ECG (01.09.09):
Sinus rhythm is correct. The electrical axis of the heart is not deviated.
^ SURGEON'S CONSULTATION
Surgical pathology was excluded.
PREOPERATIVE DIAGNOSIS
Based:
♦ complaints, anamnesis of the disease and preliminary diagnosis: tubo-ovarian formation on the left;
♦ results puncture of the abdominal cavity through the posterior fornix of the vagina: ruptured left ovarian cyst;
♦ conclusions OMT ultrasound: tubo-ovarian tumor on the left
You can make a preoperative diagnosis: ^
The patient is shown surgical treatment according to vital indications. The volume will be considered during the operation. The patient's consent to the operation was obtained. WITH possible consequences familiarized.
^ OPERATION PROTOCOL
Operation name: Pfannenstiel laparotomy. Removal of the left appendages. Resection of 1/3 of the right ovary. Resection of the greater omentum. Abdominal drainage.
^ Diagnosis before surgery : Tuboovarian formation on the left? Rupture of a left ovarian cyst?
Diagnosis after surgery:
^ Progress of the operation:
Under aseptic conditions, after appropriate treatment of the surgical field with betadine, after treatment of the surgeon's hands, after excision of the old scar, the abdominal cavity was opened in layers by a Pfannenstiel incision.
In the region of the left appendages, a conglomerate 6 × 7 cm in size was found, the walls were edematous, infiltrated, and imbibed with pus. The body of the uterus is not enlarged.
On the right - the fallopian tube is missing due to the operation in 2005. At the lower pole of the ovary, an endometrioid formation with a diameter of about 4 cm was found, which opened ("chocolate" contents).
An adnexectomy was performed on the left. The stump is sutured and ligated. Hemostasis control. Dry.
The right ovary was resected by 1/3 within healthy tissues. The stump is sutured with separate ligatures. Produced control of hemostasis. Dry.
The greater omentum was resected.
Drainage of the abdominal cavity - into the right and left iliac region through counter-openings. Hemostasis control - dry.
Counting napkins and tools (“everything is available”).
The abdominal cavity is tightly sutured in layers.
Seams on the skin according to Donati.
An aseptic bandage was applied.
Urine through the catheter is light, transparent, 150 ml.
Blood loss 250 ml.
Gross preparations:
1) On the left, an open conglomerate 6 x 7 cm in size, the walls are edematous, infiltrated.
On the right is a formation with a diameter of 4 cm.
^ DIFFERENTIAL DIAGNOSIS
The differential diagnosis is carried out with almost all tubo-ovarian formations: rupture of the tube with ectopic pregnancy, torsion and rupture of an ovarian cyst, hydrosalpinx, tumors of the ovaries and fallopian tubes, cystomas.
Rupture of the fallopian tube during tubal pregnancy occurs, as a rule, acutely, with a pronounced clinical picture of bleeding into the abdominal cavity: a sharp anemization and a decrease blood pressure, dizziness, fainting, peritoneal shock, pain attack. It usually occurs at 4 - 6 or 7 - 8 weeks of pregnancy. Confirm the diagnosis also allow signs of pregnancy.
The clinic of hydrosalpinx and pyosalpinx is similar; pyosalpinx is more severe, which is due to general intoxication of the body, fever, chills, tachycardia. The presence of pus and histological examination of the removed formation allow us to confirm the diagnosis of pyosalpinx.
Tumors of the ovary and fallopian tube at a certain stage of development can be differentiated from pyosalpinx. With them, a tumor-like formation in the tubo-ovarian region, general weakness, malaise, and possibly an increase in body temperature are also determined. Young patients sometimes experience pain up to severe symptoms of "acute abdomen" due to possible torsion of the leg or perforation of the tumor capsule.
But with tumors of the ovary and fallopian tube, there are atypical for pyosalpinx clinical symptoms: decrease and perversion of appetite, dysfunction of the gastrointestinal tract, an increase in the abdomen due to ascites, effusion in one or both pleural cavities, signs of cardiovascular and respiratory failure, edema in the lower extremities.
Torsion and rupture of a large ovarian cyst are accompanied by a pronounced clinic of an “acute” abdomen, pain appears above the pubis, which can also cover the left iliac region, radiates to the back, perineum, and spreads to the inner thighs. There is repeated vomiting, painful reflex nausea, pollakiuria, frequent urge to defecate. The patient's behavior is restless. With significant bleeding from the cyst wall, symptoms of internal bleeding also appear: general weakness, dizziness, tinnitus, pallor of the skin, tachycardia. When examining the abdomen, in rare cases it is possible to palpate the cyst, but usually with the most thorough palpation this method fails to establish the cause of acute pain in the lower abdomen, although some resistance and even a distinct protective muscle tension and positive symptoms of peritoneal irritation are noted. Body temperature is normal. The difference between the body temperature in the armpit and the rectum does not exceed 0.5-0.7 ° C. Bimanual examination in these cases reveals a rounded, smooth-surfaced, elastic, painful tumor that is quite distinctly separated from the uterus and has a stalk.
A blood test reveals a slight decrease in the level of hemoglobin and the number of red blood cells if the rupture of the cyst is accompanied by intra-abdominal bleeding. With minor bleeding and torsion of the cyst, such changes are not detected. The number of leukocytes and the leukocyte count of the blood also do not change.
^ CLINICAL DIAGNOSIS
Based
◄ preliminary preoperative diagnosis: tubo-ovarian formation on the left? Rupture of a cyst of the left ovary?;
◄ data of intraoperative revision of the pelvic organs: in the area of the left appendages - a conglomerate 6 × 7 cm in size, the walls are edematous, infiltrated, imbibed with pus, on the right at the lower pole of the ovary - an endometrioid formation with a diameter of about 4 cm, opened;
◄ results of histological examination of brand preparations obtained during the operation: an opened conglomerate on the left, on the right - a formation with a diameter of 4 cm, in the greater omentum - a thickening of adipose tissue with multiple cystic inclusions
installed clinical diagnosis : Pyosalpinx on the left. Endometrial cyst of the right ovary.
^ PRINCIPLES OF POSTOPERATIVE MANAGEMENT AND TREATMENT
Mode: strict bed - 1 day;
Bed - 2 days;
Ward - the following days.
^ Diet: Table number 0 - 1 day of the postoperative period;
Table number 15 - the following days.
Dressings postoperative wound under aseptic conditions - daily.
On the first postoperative day - an ice pack on the lower abdomen.
Medically:
Antibacterial therapy
Non-narcotic analgesics
Infusion therapy
Therapy aimed at restoring the motor-evacuation
vitamin therapy
Hormone replacement therapy (starting from the 3rd day of the postoperative period)
Absorption therapy
Appointment list:
Sol. Ringer - Locke 500.0 ml IV drip once a day N. 2.
Sol. Ceftriaxoni - 1 g, diluted in 3 ml of 0.9% Sol. NaCl and 2 ml Sol. Lidocaini
Sol. Metrogili 100.0 ml IV drip 3 times a day N. 3.
Sol. Analgini 5.0 ml IM 2 times a day N. 5.
Sol. Dinastat - dilute the contents of the vial in 5 ml of sterile 0.9% NaCl solution, inject intravenously in the first days with severe pain.
Sol. Proserini 2.0 ml s.c. 2 times a day N. 3.
Tab. "Polyvit" 1 tablet 1 time per day N. 30.
Tab. "Femoston Conti" 1 tablet 1 time per day.
Sol. "Extract Aloe" 1 ml s / c 1 time per day N. 10.
^ DIARY OF OBSERVATIONS
2.09.09 (first day of the p/o period)
Complaints:
On pain in the area of the postoperative wound.
Objectively:
The general condition corresponds to the severity of the operation.
The tongue is moist and clean. The abdomen is soft, moderately painful in the area of the postoperative wound.
The dressing is dry and clean. Removed drains. Intestinal peristalsis is auscultated.
Urine - through the catheter 750 ml, light.
Locally
Complaints:
For minor pain in the area of the postoperative wound.
Objectively:
In the lungs - vesicular breathing, no wheezing.
Heart - clear, rhythmic tones.
The tongue is moist and clean. The abdomen is soft, moderately painful in the area of the p / o wound.
The dressing is dry and clean. Peristalsis is heard.
Urine about 1000 ml, light.
The chair is not broken.
There are no discharges from the genital tract.
Locally: p / o the scar is calm, without signs of inflammation.
4.09.09 (third day of the p/o period)
Complaints:
For aching pain in the area of the postoperative wound.
Objectively:
General condition with positive dynamics
In the lungs - vesicular breathing, no wheezing.
Heart - clear, rhythmic tones.
The tongue is moist and clean. The abdomen is soft, moderately painful in the region of the wound. The dressing is dry and clean. Peristalsis is heard.
Urine about 1200 ml, light.
The chair is not broken.
There are no discharges from the genital tract.
Locally: p / o the scar is calm, without signs of inflammation.
^ EXECUTIVE SUMMARY
Patient Dzhioeva Svetlana Igorevna, born in 1980, was hospitalized in the gynecological department of the Lugansk city maternity hospital from 01.09.09 to 11.09.09, with a diagnosis of tubo-ovarian formation on the left. Right ovarian cyst.
She was hospitalized by an ambulance in an urgent manner. Upon receipt of a complaint of intense acute pain in the lower abdomen on the left with irradiation from the left side for 5 days; bloody discharge from the genital tract; dizziness; increase in body temperature up to 37.5 ° C; dizziness; weakness.
Anamnestically: spontaneous abortion (1998), tubal pregnancy (2005), tubectomy on the right.
The patient's condition is severe, the severity is due to pain syndrome.
On 09/01/09: Clinical blood test: Hb: 142 g/l; Er.: 4.83×10 12 /l; CPU: 0.87;
L.: 9.0×10 9 /l; ESR: 15 mm/h;
^ Blood Biochemistry: Bi. direct: 7 µmol/l; ALT: 0.5 mmol/h/l;
Thymol test: 3 IU;
Total protein: 72 g/l; albumin: 41 g/l;
Blood coagulogram: PTI: 105%; Recalcification time: 92"
Fibrinogen: 289mg/100ml
^ Puncture of the abdominal cavity through the posterior fornix of the vagina : gap
cysts of the left ovary.
OMT ultrasound: tubo-ovarian tumor on the left.
In an urgent order, an operation was performed in the following volume: Pfannenstiel laparotomy. Adnexectomy on the left. Resection and suturing of the right ovary. Resection of the greater omentum. Abdominal drainage.
The postoperative period was uneventful and without complications. Drains removed by 2 e day.
In the postoperative period received: infusion therapy, ceftriaxone, metrogil, dynastat, analgin, prozerin, Aloe extract, femoston Conti, Polivit.
The wound healed by first intention. Stitches removed at 7 e day. The scar is calm and wealthy.
At the time of discharge, the patient's condition was satisfactory. There are no complaints.
^ Clinical diagnosis : Pyosalpinx on the left. Endometrial cyst of the right ovary.
Expert history: sick leave for 1 month.
Compliance with diet physical activity, sleep and rest, psycho-emotional peace.
Observation at the gynecologist at the place of residence.
Additional examination for the infectious process of the endometrium.
Continue vitamin therapy ("Polivit" 1 t. 1 time per day), absorbable therapy (Aloe Extract - 1 tab. 3 times a day).
Together with a gynecologist at the place of residence, carry out a correction of hormone replacement therapy, taking into account the hormonal background.
FORECAST
^ Forecast for life - favorable.
Health prognosis- conditionally - favorable.
Employment forecast: sick leave for 1 month. Exclusion of weight lifting over 3 kg for 6 months.
^ REFERENCES
Makarov R.R., Gabelov A.A. "Operative Gynecology". - Leningrad, Medicine, 1977, 296 p.
Mashkovsky M.D. " Medicines". - M., New wave, 2007, 1206 p.
Savelyeva G.M., Breusenko V.G. "Gynecology". – Moscow, GEOTAR – MED,
Smetnik V.P., Tumilovich L.G. Operative gynecology: a guide for physicians. - M .: Medical Information Agency, 2001.
Khmil S.V., Kuchma Z.M., Romanchuk L.I. "Gynecology". – Ukrmedkniga, 1999, 538s.
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1. Complaints
At the time of hospitalization, she complained of pulling pains in the lower abdomen.
2. medical history (Anamnesismorbi)
During the last 6 months, pulling pains in the lower abdomen began to disturb. Has addressed to the gynecologist. On ultrasound from 01/26/2015 - a dermoid cyst of the left ovary. Examined. Sent for hospitalization in the gynecological department of the city clinical hospital No. 10 for planned surgical treatment.
3. The history of the life of the patient (Anamnesis vitae)
She was born in the Republic of Azerbaijan in 1984. in the mental and physical development did not lag behind peers. She grew and developed normally. The patient is the first and only child in the family. She studied well at school, graduated from 11 classes. Currently not working.
Housing conditions are currently satisfactory.
Bad habits are denied.
Heredity is not burdened.
Allergic reactions to medications, food, household allergens denies.
Past diseases: SARS
4. Gynecological history
1. Menstrual function:
First menstruation: 15 years
Periods regular after 28 days
Duration: 5 days
The first day of menstruation is accompanied by pain.
· With the onset of sexual activity, the duration and frequency of menstruation did not change.
Date of last menstrual period: 02/17/15
2. Secretory function:
The first discharge appeared at the age of 15.
Discharges in moderate amounts are liquid, transparent, odorless, do not irritate the surrounding tissues.
3. Sexual function:
· sex life from 20 years old.
· Married.
· She is currently sexually active and has a permanent sexual partner.
During sexual intercourse pain, spotting from the vagina does not mark.
· Method of contraception: condoms.
4. Childbearing function:
In 2007 urgent delivery
5. present state (Statusgifts)
The general condition is satisfactory, the patient's position is active, consciousness is clear, the face is calm, the physique is proportional, height 164 cm, weight 60 kg, normosthenic. The gait is even. Body temperature 36.6 o C
Skin of normal color.
Visible mucous membranes of the lips, mouth, nose, eyes are light pink in color. There are no rashes on the mucous membranes. There is no dryness of the mucous membranes.
Subcutaneous tissue is moderately developed, fat deposits are uniform. Edema is absent.
Lymphatic system: submandibular lymph nodes are the size of lentils, axillary nodes are palpable the size of a pea, inguinal nodes are the size of a bean. Occipital, supraclavicular, subclavian, parotid, ulnar lymph nodes are not palpable. Lymph nodes have a soft texture, are not enlarged, with surrounding tissues and are not fused with each other, are painless on palpation. The condition of the skin over the palpable nodes is unchanged.
Muscles are developed moderately, evenly. The tone is preserved, the strength is good. Soreness on palpation, compaction in the muscles, local hypertrophy, atrophy are absent.
The bones of the skull, spine, limbs without features. There is no pain on palpation and tapping of the sternum, ribs, tubular bones, and vertebrae.
Joints. Pain in all joints is absent. Movements in all joints are active, free.
Respiratory system
Lungs: No chest pain. Shortness of breath, suffocation are absent.
Examination of the chest: the shape of the chest is normosthenic, the epigastric angle is 90°. The chest is symmetrical, there is no protrusion or retraction of half of the chest. The width of the intercostal spaces and the direction of the ribs were not changed. The shoulder blades are close to the chest. NPV 16 per minute.
Palpation of the chest: no pain on palpation of the chest. Chest resistance is normal. Voice trembling is not changed.
Percussion of the chest: with comparative percussion, a clear lung sound over symmetrical areas is determined.
With topographic percussion, the standing height of the tops of the lungs in front of the clavicle is 3 cm on both sides, behind - at the level of the spinous process of the VII cervical vertebra. The width of the Krening fields is 5 cm on both sides.
Inferior border of the lungs
|
peristernal line |
Fifth intercostal space |
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|
midclavicular line |
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|
anterior axillary line |
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Middle axillary line |
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Posterior axillary line |
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scapular line |
|||
|
Paravertebral line |
Spinous process of the 11th thoracic vertebra |
Auscultation of the lungs: auscultatory over the entire surface of the lungs breathing is vesicular. There are no side breath sounds. Bronchophony is not changed.
Circulatory system
Pain in the region of the heart is absent. On palpation, the arteries are soft. The arterial pulse is the same on both radial arteries - 76 beats/min, the rhythm is correct, the same, there is no pulse deficit, the shape of the pulse wave is normal, the pulse is of normal filling, normal value.
Arterial pressure 110/70 mm. rt. Art.
Examination of the heart area: when examining the heart area, cardiac, apex beat and epigastric pulsation are not detected, the cardiac hump is not detected.
Palpation of the cardiac region: the apex beat is not defined. Cardiac impulse, trembling in the region of the heart, pulsation in the epigastric region are absent.
Auscultation: heart sounds are clear, rhythmic. There is no splitting and bifurcation of tones. Pathological tones and noises are not heard.
Digestive system
Inquiry: no complaints. Appetite saved. Swallowing is free, painless. The mucous membrane of the inner surface of the lips, cheeks, hard and soft palate is light pink in color, without damage and the presence of a rash. The tongue is light pink in color, not coated. The pharynx is of normal color, without plaque. The tonsils are not enlarged. Pharynx of normal color, smooth mucosa
According to the approximate superficial palpation of the abdomen, the tone of the abdominal muscles is normal; the abdominal wall is soft, supple. The abdomen is painless, not swollen. Shchetkin-Blumberg's symptom is negative. The state of the navel, muscles, white line of the abdomen without pathological changes. Abdominal percussion of free and encysted fluid in the abdominal cavity revealed no liver. There is no visible enlargement of the liver. The size of the liver according to Kurlov - along the right midclavicular line - 9 cm, along the midline - 8, along the left costal arch - 7 cm. On palpation, the edge of the liver is smooth, rounded, painless.
Urinary system
There are no complaints. Urination is free. The frequency of urination is 4-6 times a day. Diuresis is normal. There is no pain in the region of the kidneys. Pasternatsky's symptom is negative on both sides.
Endocrine system
There are no complaints. There is no visible enlargement of the thyroid gland. Palpation of the thyroid gland of dense consistency, painless, not enlarged.
Nervous system
Inquiry: no complaints. Memory is good. Sleep is good. Sense of smell and taste are not changed. The pupils are round, reactive to light. Hearing is not reduced. Speech is clean. Movement coordination preserved
6. Gynecological status
The external genital organs are formed correctly, the female type of hair is moderately developed. Hyperemia, edema, soreness, scars, in the perineal area are not observed. The integrity of the hymen is broken.
Inspection of the vagina and cervix in the mirrors: the mucous membrane is pink, the cervix is deformed, the pharynx is closed. Additional formations not detected.
Bimanual study:
The cervix is dense, conical.
uterus normal sizes, dense, mobile, painless, position - anteflexio.
· Adnexa of the uterus on the right are not defined. On the left, the formation d = 4.5 cm is determined. The discharge is light, liquid, odorless.
7. Preliminary diagnosis
Based:
History of the disease: observed by a gynecologist regularly. Last year noted low-intensity, dull, non-radiating pain in the lower abdomen. Didn't ask for help. Behind last week pain intensified, and therefore turned to a gynecologist at the place of residence. Was produced ultrasonography pelvic organs (26.01.15), conclusion: dermoid cyst of the left ovary.
Ultrasound (26.01.15): dermoid cyst of the right ovary
It is possible to formulate a preliminary diagnosis: dermoid cyst of the left ovary.
8. Special methods of gynecological examination
· Ultrasound of the pelvic organs from 26.01 :
7 day m / cycle
Dimensions 54x39x52 mm (normal sizes).
The structure of the myometrium is homogeneous.
Thickness of the endometrium: 6 mm. The structure is homogeneous. The walls of the cavity are even. Reflections from the endometrium correspond to physiological changes - the initial stage of proliferation.
Ovaries: left - 47x32x38 mm. Usually located. It contains a liquid cavity formation with dense contents 38x22x32 mm in size, with a hyperechoic parietal inclusion d=7 mm. The thickness of the capsule is 2 mm.
Right: dimensions - 28x12x30 mm. Located along the rib of the uterus.
Dominant follicle d=16 mm.
The volume of the ovarian stroma is not increased. The ovarian capsule is not thickened.
Fallopian tubes: not visualized.
Cervix: 28x23 mm. Endocervix cysts max d=8 mm.
Endocervix: 6 mm. Without features.
Pelvic space: no free fluid detected.
Conclusion: Dermoid cyst of the left ovary.
9. Laboratory research methods
1. Complete blood count dated 09.02. 15 G. :
Erythrocytes - 4.09 x10 12 / l
Hemoglobin - 122 g/l
Hematocrit - 38.1%
Leukocytes - 7.0x10 9 / l
Platelets - 246x10 9 / l
Eosinophils - 2.4%
Neutrophils - 65.4%
Lymphocytes - 23.8%
Monocytes - 8.1%
ESR - 59 mm/h
2. clotting time : start - 4"11" end - 4"37" duration - 1"17"
3. Definition of g ruppy blood and Rh factor from 09.02. 15 G. : B(III) Rh(+)
4. General analysis of urine from 09.02. 15 G. :
· Yellow color
Urine pH: 5.5 units
Clarity: slightly cloudy
Specific Gravity: 1.035 g/ml
Protein: 0.160 g/l
Glucose: negative
Ketones: negative
Bilirubin: negative
Erythrocytes 1-0 in p / sp
Single leukocytes
squamous epithelium 1-0
Mucus a lot
5. ODA Dividing the Wassermann reaction from 1 2.02. 15 G. : negative.
6. Blood for ELISA from 12.02. 15 G. : Abs for HIV, hepatitis B, C virus were not detected.
7. Electrocardiography from 12.02. 15 G. : sinus rhythm. Normal position of the EOS.
8. Biochemical blood test from 09.02. 15 G. :
Blood glucose - 4.72 mmol / l
AlAT - 14.6 U/l
AST - 15.6 U/l
Bilirubin total - 8.3 µmol / l
Creatinine - 60.0 µmol/l
Urea - 5.1 mmol/l
Total protein - 73.9 g/l
Biochemical blood test dated 09.02.15 :
Residual nitrogen 16.4
Urea 5.2
9. Oncomarkers from 09.02. 15 G. : SA 125 - 13.2 U/l
Oncomarkers from 09.02 . 15 G. :
Alpha-fetoprotein<0.500
SA 15-3 10.8
10. Hormonal studies about t 09.02. 15 G. :
Chorionic gonadotropin<0.100
11. Smear on flora dated 10.02. 15 G. :
Leukocytes 5-7 in p / s
Squamous epithelium unit. in p / s
Gonococci - 0
Dr. bacteria - 0
10. Consultants' opinion
Consultation of the therapist from 06/04/14:
Makes no complaints. The general condition is satisfactory. Skin of normal color. In the lungs, vesicular breathing, no wheezing. NPV 17 min. Heart sounds are clear, rhythmic. AD 110/70 mm. rt. Art. Pulse 70 beats / min. The abdomen is soft, painless. Urination, stool normal. ECG: sinus rhythm. Normal position of the EOS. FLG - no pathology was detected.
Conclusion: surgical treatment is not contraindicated.
Anesthesiologist consultation from 24.02.15 :
Makes no complaints. Allergological anamnesis is not burdened.
The general condition is satisfactory. The physique is correct, satisfactory nutrition. Height 164 cm, weight 60 kg. Skin of normal color. With percussion, a pulmonary sound is determined over the entire surface of the lungs. In the lungs, vesicular breathing, no wheezing. NPV 16 per min. Heart sounds are clear, rhythmic. AD 110/70 mm. rt. Art. Pulse 72 beats / min. The abdomen is soft, painless. Urination, stool normal.
There are no contraindications to surgical treatment.
Anesthetic risk II degree.
Consent for the operation was obtained.
Assumed: endotracheal anesthesia
11. Differential Diagnosis
Benign ovarian tumors must be differentiated from a number of diseases:
Ovarian cancer in its early stages, especially if it develops in a pre-existing benign tumor, does not give clinical signs to distinguish it from a benign neoplasm. Therefore, all tumor formations of the ovaries, which do not even cause the doctor to suspect malignancy, are subject to prompt removal and careful treatment. histological examination to rule out cancer.
· Chronic inflammatory diseases of the uterine appendages are often bilateral. Inflammatory tubo-ovarian formations have bizarre fuzzy outlines, usually soldered to the uterus, the parietal peritoneum of the small pelvis and adjacent organs, as a result of which their mobility is sharply limited, and palpation causes pain. Patients have a history of frequent exacerbations of the inflammatory process and long-term conservative treatment.
· Uterine fibroids with a subserous node present difficulties for differential diagnosis with ovarian cystadenoma. For this purpose, the technique of bringing down the cervix, captured by bullet forceps, is used, together with the uterus downwards. The transfer of movement to a tumor palpable in the small pelvis indicates its direct connection with the body of the uterus. The position of the ovarian cystadenoma does not change during this diagnostic procedure. For differential diagnosis, X-ray methods are also used: pneumoperitoneum, transuterine visceral phlebography.
A benign ovarian tumor of significant size should be differentiated from a long-term pregnancy on the basis of secondary signs of pregnancy, listening to the fetal heartbeat and abdominal fluoroscopy data. In case of an ovarian tumor that has a long stalk and is relatively freely movable when examined in the abdominal cavity, it should be differentiated from mobile tumors of the abdominal cavity. In addition to the data of an objective examination, in such cases, X-ray examination using pneumoperitoneum is of great help in the diagnosis.
12. Final Diagnosis
Based:
Complaints: pulling pains in the lower abdomen.
History of the disease: observed by a gynecologist regularly. Last year, she noted low-intensity, dull, non-radiating pain in the lower abdomen, mainly on the right. Didn't ask for help. Over the past week, the pain has intensified, in connection with which she turned to a gynecologist at the place of residence. An ultrasound examination of the pelvic organs was performed (26.02.15), the conclusion: a dermoid cyst of the left ovary.
Gynecological status: uterine appendages are not determined on the right, an elastic, rounded, mobile, painless formation measuring 4.5 cm is determined on the left.
Ultrasound (26.02.15): dermoid cyst of the left ovary
Laboratory research methods: Oncomarkers: CA 125 - 13.2 U / l, Alpha-fetoprotein<0.500, СА 15-3 - 10,8
The differential diagnosis
It is possible to formulate the final clinical diagnosis:
Main: dermoid cyst of the left ovary
Complication: no
Related: no
13. Etiology
The etiology of ovarian tumors is unknown. In the origin of tumor-like formations of the ovaries, hormonal disorders and, possibly, inflammation play a large role. However, it was not possible to reliably prove the role of certain hormonal disorders. There is a concept of increased ovulatory load on the ovary, the so-called hypothesis of continuous ovulation, confirmed by the more frequent occurrence of tumors in the only remaining gonad after unilateral adnexectomy.
It is believed that epithelial tumors arise from inclusion cysts of the integumentary epithelium that have arisen in places of frequent ovulation. However, the role of ovulation stimulants in this regard has not been conclusively proven.
The theory of the development of epithelial ovarian tumors from the integumentary epithelium is widespread.
It is suggested that sex cord tumors and germ cell tumors may develop as a result of embryonic disorders against the background of hypergonadotropinemia, which explains the age peaks in the incidence of ovarian tumors during puberty and perimenopause.
Risk factors for ovarian tumors:
early menarche
Late menopause
Reproductive disorders
A high-calorie diet high in saturated fatty acids
a genetic predisposition
infertility
smoking
Neuroendocrine disorders, thyroid diseases, obesity are not significantly associated with ovarian tumors and are not described in evidence-based models.
14. Pathogenesis
The pathogenesis of ovarian tumors is not well understood and causes a lot of controversy. It is believed that epithelial ovarian tumors develop from the surface epithelium as a result of the formation of inclusion cysts, possibly against the background of hypergonadotropinemia. Hormonal disorders, as well as immune disorders, are not considered primary from the standpoint of evidence-based medicine. It is possible that hyperhormonemia is associated with low levels of SHBG.
It is known that the use of vegetable fiber with food leads to the release into the lumen of the small intestine and re-absorption into the bloodstream of compounds with weak estrogenic activity, which increase the synthesis of SHBG by the liver. This mechanism increases the content of free steroids in the blood serum.
In the pathogenesis of ovarian tumors, the role of violations of the barrier functions of the small intestine and associated endotoxemia has been proven.
Sex cord tumors and stromal cell tumors develop from embryonic anlages against the background of hypergonadotropinemia and unrealized reproductive function.
15. Preoperative epicrisis
The patient has been in the gynecological department since February 24, 2015, with a diagnosis of cystoma of the left ovary.
From the anamnesis: during the last 6 months, pulling pains in the lower abdomen began to disturb. Has addressed to the gynecologist. On ultrasound from 01/26/2015 - the left ovary is 47 * 32 * 38 mm. Usually located. It contains a liquid formation with dense contents 38*22*32 mm in size, with a hyperechoic parietal inclusion d=7 mm. The thickness of the capsule is 2 mm. Tumor growth markers CA 125 39.7. Joint inspection with otd. Lyubimova A.Yu. Examined. Hospitalized.
Sent for hospitalization in the gynecological department of City Clinical Hospital No. 10.
Indications for surgery: cystoma of the left ovary.
Planned: removal of the tumor of the left ovary, the final volume to be determined during the operation.
Examined by an anesthesiologist: There are no contraindications.
Allergic reactions were not revealed.
Somatic history is not burdened.
Prepared for the operation. Agree. Possible complications are warned in an accessible form.
16. Operation.ventiotomy. Removal of the tumor of the leftovary. Resection of the rightovary. Rseparation of adhesions
Under aseptic conditions, under intubation anesthesia, the abdominal cavity was opened in layers using a lower median incision. Found: the peritoneum is smooth, the organs of the upper floor of the abdominal cavity are without pathology, the greater omentum is soldered to the peritoneum. In the small pelvis, a pronounced adhesive process. The left appendages are in an adhesive conglomerate with intestinal loops, the posterior surface of the uterus. The adhesions are separated by a blunt and a sharp path. The body of the uterus is of normal size, normal color. On the left ovary, a formation with a smooth surface, 4 cm in diameter. The formation has a smooth outer capsule. The volumetric formation of the ovary was removed; during its extraction, 30 ml of "chocolate" contents poured out, the ovary was sutured with catgut sutures. The right ovary is cystic, with endometriotic foci, resection was performed, the ovary was sutured with catgut sutures. The abdominal cavity is drained, additional hemostasis in the region of the posterior "Douglas" pocket, sutured tightly in layers. Intradermal Vicryl suture.
Macropreparation: the tumor contains endometrioid contents, without papillary inclusions, an ovarian area with foci of endometriosis.
Operational diagnosis: ovarian endometriosis, adhesions in the pelvis.
Blood loss 200.0
Urine through the catheter - light 200.0
17. Postoperative treatment
1. Ward mode
2. Table number 15
3. For antibacterial purpose: Ceftriaxone 1.0 IM for 2 days after surgery.
4. With an antiprotozoal purpose, it was prescribed: Sol. Trichopoli 0.5% - 100 ml. IV drip every 8 hours for 3 days.
5. For the purpose of detoxification, it was prescribed: Sol. NaCl 0.9%-500 ml + Sol. Glucosae 5%-500 ml. IV drip 1 time per day for 5 days
6. With analgesic purpose assigned: Sol. Promedoli 1% - 1.0 IM after 6 hours for 1 day, then, if necessary, Ketorol 1.0 IM (in case of pain).
18. Forecast
In relation to life - favorable.
With regard to disability - temporary disability (during the stay in the clinic).
Regarding specific functions:
menstrual function - preserved
sexual - preserved
childbearing - preserved
secretory - preserved
19. Stage epicrisis
ovary cyst tumor operative
The patient has been in the gynecological department of KKB No. 10 since February 24, 2015 with a diagnosis of dermoid cyst of the left ovary.
From the anamnesis: the gynecologist is observed regularly. During the year, aching pains in the lower abdomen are disturbing. She turned to the gynecologist, an ultrasound scan was performed on January 26, 2015, the conclusion: a dermoid cyst of the left ovary. Sent for hospitalization in the gynecological department of City Clinical Hospital No. 10 for planned surgical treatment.
02/25/2015 Surgical intervention was performed in the following scope: transection. Removal of a tumor of the left ovary. Resection of the right ovary. Separation of adhesions
Operational diagnosis: Endometriosis of the ovaries, adhesive process in the small pelvis.
It is planned to continue treatment in a hospital.
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Passport section.
Turenko Ludmila Alekseevna
2. Age
3. Gender
4. Profession
accountant.
5. Home address
Art. Bryukhovetskaya st. Gerasimenko d. 74.
6. Time of admission to the clinic
7. Diagnosis at admission
Right ovarian cyst.
II. Subjective examination data
Patient's complaints:
Irregular and very painful menstruation. Pain is localized in the lower abdomen and is intense.
Disease history:
She considers herself ill since December 1997, because the patient noted a menstrual irregularity, which manifested itself in the fact that menstruation was delayed for a week or two, in the first days of menstruation there was very severe pain in the lower abdomen, the patient could even lose consciousness. 1.06.99. after she lost consciousness for the second time (the first time during the previous menstruation), she was urgently admitted to the KKB, where she was diagnosed with a cyst of the right ovary. The doctor recommended surgical treatment. After stopping the pain, he sent me home and scheduled a consultation. During this time, menstruation should have passed. But when the patient arrived, he told her that there was no need for an operation, and a course of treatment with diclofenac was carried out for 10 days and Duphaston for 3 months. Menstruation was regular, painless during treatment, after discontinuation of the drug, the menstrual cycle was disturbed again, and intense pain appeared. I contacted the CMC for a consultation. From 10.03.99. to 03/26/99. underwent a course of absorbable therapy in the CMR hospital. Were prescribed: gentamicin, diclofenac, calcium gluconate, aloe, autohemotherapy, physiotherapy (electrophoresis with lidase). Surgery was recommended. 7.04.99. was admitted to the CMR for surgical treatment.
Anamnesis of life:
Heredity is not burdened.
Was born on time. Fed naturally. She grew and developed in accordance with sex and age. She started walking at 11 months. In psychomotor development, she did not lag behind her peers.
From childhood infections, she suffered from chickenpox, mumps, and often had acute respiratory infections.
Hemotransfusion denies. There were no allergic reactions.
In 1990, an appendectomy was performed, in 1990 and in 1993 - an adenoidectomy, in 1995 - alignment of the nasal septum. The operations went without complications.
Mensis from 12 years, irregular, duration 7 days, after 35-42 days, painful in the first 2 days from the first menstruation, copious. Last menstruation 03/28/99.
Has been sexually active since the age of 18 out of wedlock. Since the onset of sexual activity, menstrual and excretory functions have not changed. Contraceptives were not used.
There were no pregnancies.
12/23/97. urgently performed surgery for rupture of the cyst of the left ovary, healing of the suture by secondary intention.
She denies tuberculosis, STDs, viral hepatitis, mental illness in herself and her relatives.
Has no bad habits.
Working and living conditions are good.
III. Data from an objective study.
General inspection.
The patient's condition is satisfactory. The position is active. Consciousness is clear. Body temperature 36.7 o C. Correct physique, reduced nutrition. Height 165 cm, weight 50 kg. The skin is of physiological color, clean, turgor is normal. There were no hemorrhages on the skin and mucous membranes. The subcutaneous fat is poorly developed, the muscles are moderately developed. There are no edema. Lymph nodes are not palpable. The thyroid gland is not visualized. The joints are painless during active and passive movements, their configuration is not changed.
Respiratory system.
Breathing through the nose is not difficult. The type of breathing is mixed. NPV 16 per minute. The shape of the chest is normosthenic, there are no deformities, it is painless on palpation. Percussion - a clear pulmonary sound. Vesicular breathing is auscultated, no wheezing.
Inferior borders of the lungs:
| lines | On right | Left |
| parasthenal | 5th intercostal space | 5th intercostal space |
| mid-clavicular | VI rib | VI rib |
| anterior axillary | VII rib | VII rib |
| Middle axillary | 8th rib | 8th rib |
| Posterior axillary | IX rib | IX rib |
| scapular | X rib | X rib |
| Perivertebral | Spinous process of XI thoracic vertebra | |
The cardiovascular system.
There are no protrusions and pulsations of the carotid arteries. Palpation apex beat is located in the V intercostal space 1.5 cm medially from the mid-clavicular line. The cardiac impulse is not determined. The boundaries of relative and absolute cardiac dullness were not changed.
| Relative dullness | Absolute stupidity |
|
| Right | 1 cm outward from the right edges of the sternum | Left side of sternum |
| Upper | Upper edge of the third rib | Cartilage IV rib |
| Left | 1 cm medially from the mid-clavicular line |
The diameter of the heart is 11 cm. The configuration of the heart is not changed.
auscultatory. Heart sounds are loud, rhythmic. The heart rate is 70 beats per minute, no pathological murmurs are heard.
The pulse is rhythmic, weak filling and tension. BP - 120/70 mm Hg
Digestive system.
The tongue is moist and clean. Zev normal color. The shape of the abdomen is normal. There is no visible peristalsis.
On superficial palpation, the abdomen is soft, there are no areas of increased skin sensitivity; discrepancies of the rectus abdominis muscles, the phenomenon of "muscle protection" is absent; Shchetkin's - Blumberg's symptom is negative.
With deep methodical palpation: the sigmoid colon is palpable in the form of a rumbling roller, painless; the caecum is palpable in the form of a cylinder 2 fingers thick, painless; ileum growls; the transverse colon moves up and down easily. There are no infiltrates or tumors.
The liver is palpable at the edge of the costal arch: the edge is sharp, the surface is smooth, painless. The size of the liver according to Kurlov is 9cm-8cm-7cm.
The gallbladder is not palpable.
The pancreas and spleen are not palpable.
Chair without features.
Urogenital organs.
Examination of the lumbar region revealed no redness or swelling. There is no tension in the lumbar muscles. The tingling symptom is negative on both sides. The bladder is not palpable. There are no dysuric disorders.
Endocrine system.
The thyroid gland is not visualized during examination. Secondary sexual characteristics correspond to age and gender. Hair on the female type.
Nervous system.
Clear consciousness is oriented in place, time and situation. Attention is stable, memory for current and past events is preserved. Thinking is logical, speech is consistent. Meningeal symptoms are negative. Pathology from CCI, sensory and motor areas was not revealed.
Gynecological study.
The external genital organs are developed correctly. Pubic hair of the female type, large lips cover the labia minora, there are no scars or deformities. The mucous membrane of the entrance to the vagina is white-pink, the urethra is not changed. Bartholin and paraurethral glands without features.
In the mirrors: the vaginal mucosa is clean, pink, the folding of the mucosa is preserved. Discharges are mucous. The cervix is conical, the mucosa is clean, pink. The external pharynx is punctate. Bimanual vaginal-abdominal examination: the vaginal mucosa is folded, the walls are extensible, there are no cicatricial changes. The uterus is in anteflexio, of normal size and shape, dense, limited mobility, painless. The appendages on the left are hard, on the right and behind the uterus there is a tumor-like formation 6x5 cm of a tight-elastic consistency, painless. The vaults are free.
Preliminary diagnosis and its justification.
Based on the patient's complaints (of irregular and very painful menstruation), anamnesis of the disease (he considers himself ill since December 1997, when menstruation became very painful and irregular, during which the patient could lose consciousness, felt weak, dizzy, mood changes. 1.06. 99. was urgently admitted to the KKB, where she was diagnosed with: Cyst of the right ovary.A course of treatment with diclofenac was carried out, "Dufaston" was prescribed for 3 months.Menstruation was regular, painless during treatment, after discontinuation of the drug, the menstrual cycle was again disturbed, and appeared Intense pains.I went for a consultation at the CMR.From 03/10/99 to 03/26/99 I underwent a course of absorbable therapy in the CMR hospital.The following were prescribed: gentamicin, diclofenac, calcium gluconate, aloe, autohemotherapy, physiotherapy (electrophoresis with lidase).It was recommended surgical treatment), history of life (mensis from the age of 12, irregular, duration 7 days, after 35-42 days, painful in the first 2 days from the first menstruation, abundant; 12/23/97. an urgent operation was performed for rupture of a cyst of the left ovary, healing of the suture by secondary intention), the results of a gynecological examination (the appendages on the left are hard, on the right and behind the uterus a tumor-like formation of 6x5 cm of a tight-elastic consistency, painless) can be made a preliminary diagnosis: RIGHT OVARIAN CYST.
Data from laboratory and instrumental studies.
Ø General blood test 5.04.99
| red blood cells | |
| Hemoglobin | |
| Color indicator | |
| platelets | |
| Leukocytes | |
| Basophils | |
| Eosinophils | |
| Neutrophils: Myeloc. | |
| stab | |
| Segmented | |
| Lymphocytes | |
| Monocytes | |
Ø General analysis of urine 8.04.99.
light yellow color
sour reaction
specific gravity 1017
transparency p / p
No protein
no sugar
no acetone
Microscopy of sediment.
1. Epithelial cells
· Flat 1-1-2 in p/z
2. Leukocytes 5-3-3 in p / s
3. Erythrocytes neg.
4. Cylinders 0-2-1 in p / z
hyaline
grainy
5. Cells of the renal epithelium neg.
6. Slime +++
7. Bacterin neg.
8. Salts neg.
Ø MOR 5.04.99
negative
Ø Vaginal swab 04/06/99
Leukocytes 8-12
Epithelial cells 1-3
Flora - mixed
Ø Stroke on gn, trich
Negative
Ø study of the blood coagulation system 04/07/99
plasma tolerance to heparin - 7 min
plasma recalcification – 15""W16""
prothrombin time - 105 ""
thrombotest degree - 4 degree
fibrinolytic activity - 3 hours
total fibrinogen -2.6 g/l
fibrinogen "B" - negative.
Ø Blood test for Rh - accessory 04/07/99
AB (IV) Rh "+"
Ø Blood glucose 6.04.99
5.6 mmol/l
Ø Blood serum test 6.04.99
Billyrubin 17.101 µmol/l
Total protein 74 g/l
Protein fractions - no disorder
The rhythm is sinus, slow. Normal position of the electrical axis. Slow intraventricular conduction along the right leg of p. Giss.
Ø ENT doctor:
Perforation of the nasal septum. Synechia n / nasal passage.
Ø Dentist:
The oral cavity is sanitized.
differential diagnosis.
A follicular cyst must be differentiated from a serous (cilioepithelial) smooth-walled cystoma. As with a cyst, so with a cystoma, pains are noted in the lower abdomen and in the lower back, as well as with relatively large sizes or interligamentous located tumors, dysuric phenomena occur. But a cystoma is more often found at the age of 45, while a cyst occurs more often at a young age. The cyst on bimanual examination is smaller than the cystoma. Cystoma does not have hormonal activity, therefore, the menstrual cycle is not disturbed with it, while with a cyst, its violation is noted. But histological examination is of decisive importance in differential diagnosis. Also, a follicular cyst must be differentiated from a subserous myoma on a leg. Fibroids often occur in women 30-35 years of age and older, while cysts occur more often at a young age. In a bimanual vaginal-abdominal examination, patients with fibroids find an enlarged and painful uterus, and in our patient, as a result of a vaginal-abdominal examination, a uterus of normal size, dense, painless is determined. In the blood with subserous myoma, leukocytosis, a shift of the leukocyte formula to the left and an increase in ESR are noted, which this patient does not have. In the process of diagnostic search, it becomes necessary to differentiate the follicular cyst from the dermoid. A dermoid cyst, like a follicular cyst, is more common at a young age, the symptoms of these diseases are similar. A vaginal examination of women with a dermoid cyst reveals a tumor-like formation of uneven consistency, with an uneven surface, which is usually located on the side and anterior to the uterus and has great mobility. And in our patient, on the right and behind the uterus, a tumor-like formation of a tight-elastic consistency with a smooth surface is determined.
Final diagnosis and justification.
Based on the preliminary diagnosis, the differential diagnosis carried out, the final clinical diagnosis can be made:
Right ovarian cyst.
Etiology and pathogenesis of this disease.
Retention ovarian cysts are a formation resulting from the accumulation of fluid in the corresponding cavity. The increase in the size of the cyst does not occur due to the multiplication of cellular elements, but as a result of the accumulation of fluid, which is a blood plasma transudate. Ovarian cysts occur at any age but are more common in younger women. The ovarian follicular cyst is the most common.
The pathogenesis is associated with a decrease in the estrogenic function of the ovaries, which leads to an increase in the level of gonadotropic hormones, which changes the ratio between LH and FSH towards an increase in the level of the latter. Inflammatory processes are also important.
The follicular cyst in its development goes through several stages. Under the influence of FSH, the follicles in the ovaries increase in size. One of the follicles increases especially significantly. The resulting cyst grows at the expense of the cavity of the follicle. Cysts can form from atretic and persistent follicles. The cyst cavity is filled with homogeneous light contents, not much different from the secret of a normal follicle. At this stage of development, the inner surface of the cyst is lined with well-preserved granulosa cells. The inner membrane of the cyst thickens, its cells increase in size, the nuclei swell, the cell protoplasm vacuolizes. The outer shell does not noticeably change. The next stage of cyst development is characterized by various dystrophic and atrophic changes in granulosa cells. Vacuolization of the protoplasm, pyknosis and disintegration of the nuclei into small clumps of chromatin sets in. The inner shell is also involved in similar processes. As a result of this, the cyst turns into a thin-walled cavity filled with liquid secretion. Follicular cysts are not active in relation to the production of hormones (estrogens). Often in one ovary there are several cysts that are in different stages of development.
I. SURGICAL. 8.04.99.
Premedication: Sibazon 0.5% -2 ml
Atropine 0.1%-0.5 ml
Anesthesia: NO 2 - O 2 = 4 - 2 l / min
Fentanyl
calypson
Protocol of the operation: the beginning of the operation 9.50 - the end of 11.30
LAPOROTOMY WITH EXCISION OF AN OLD SCAR: EXCLUSION OF THE RIGHT OVARIAN CYST.
Under endotracheal anesthesia, after appropriate treatment of the hands of surgeons and the surgical field, the abdominal cavity was opened with a Pfannenstiel incision with excision of the old scar.
Found: an omentum was soldered to the anterior abdominal wall all the way from the navel to the entrance to the small pelvis. The right ovary is 6.0x5.0 cm in size with a thin capsule, the tube is unremarkable. Uterus in rough adhesions with omentum, intestines. Left appendages in adhesions with omentum and intestines.
Diagnosis during surgery: adhesive process in the abdominal cavity. Right ovarian cyst.
Produced: the right appendages were removed from the abdominal cavity, after which the cyst capsule was sharply and bluntly isolated from the bed. A clamp is applied to the capsule leg, the capsule is cut off. The ovary is sutured with separate catgut sutures. Control. Hemostasis. Abdominal toilet. Account of napkins and tools. The surgical wound was sutured in layers: the peritoneum and muscles were brought together with continuous, the aponeurosis with knotted sutures, the pancreas and skin - with lavsan sutures, passed through the edges of the incision.
The duration of the operation is 1 hour 40 minutes.
Total blood loss 100 ml
Macropreparation: contents - serous fluid, smooth capsule.
The results of the post-mortem examination (12.04.99.):
The nature of the material is a capsule of a cyst of the right ovary, ovarian tissue, scar tissue.
Simple serous cyst. Small follicular cysts in the ovary. Scar tissue.
II. CONSERVATIVE.
1. Cold, weight on the stomach, circular cans at 22.00, castor oil 30 ml per
2. Table number 15
3. Anti-inflammatory therapy to prevent postoperative complications:
Ampicillin 1.0 x 3 times / m N7. It is active against G “+” and a number of G “-” microbes, is considered as a broad-spectrum antibiotic and is used in diseases caused by mixed infections.
Rp.: Ampicillini - sodium 0.5
S. Dissolve the contents of 2 vials in 4 ml of water for injection and inject intramuscularly 3 times a day.
4. Pain relief and anti-inflammatory therapy:
Sol. Analgini 50% - 2.0
ý IM 4 times a day
Sol. Dimedroli 1% - 1.0
Analgin has a pronounced analgesic and antipyretic effect. The analgesic effect is due to the suppression of the biosynthesis of pain mediators. Diphenhydramine, being a blocker of histamine receptors, has antiallergic activity, has a local anaesthetic, antispasmodic and moderate ganglioblocking effect.
Promedol 2.0% x 1.0 ml / m. Synthetic narcotic analgesic, reduces the perception of pain impulses by the central nervous system.
Rp.: Sol. Promedoli 2% - 1 ml
D.t.d. N 6 in amp.
S. 1 ml / m.
5. For the prevention of intestinal and bladder atony:
Prozerin 0.05% 1.0 x 2 times a day / m. It has a strong anticholinesterase activity and has a predominant effect on the peripheral nervous system.
Rp.: Sol. Proserini 0.05%-1ml
D.t.d. N 4 in amp.
S. 1 ml 2 times a day / m.
| BP 110/70 mmHg | for pain in the area of the postoperative wound. On examination: In the lungs - vesicular breathing, no wheezing. Heart - clear, rhythmic tones. The tongue is moist and clean. The abdomen is soft, moderately painful in the area of the postoperative wound. The dressing is dry and clean. Peristalsis is heard. Urine through the catheter 350 ml, light. There are no discharges from the genital tract. | Ward mode Cold, weight on the stomach Round banks at 22.00 Castor oil 30 g per os · For analgesic purposes, Promedol 2% - 1 ml according to indications. Analgin 50% - 2.0 Dimedrol 1% - 1.0 V / m 4 times a day. Prozerin 0.05% -1.0 x 2 times / m. |
| BP 120/70 mmHg | For minor pain in the area of the postoperative suture. The dressing is dry and clean. The abdomen is soft, moderately painful in the area of the postoperative suture. Gases are not a concern. She urinates herself. | Table No. 15 Ampicillin 1.0 x 3 times / m. Analgin 50% - 2.0 Dimedrol 1% - 1.0 |
| AD 115/65 mm. Hg | For pulling pains in the region of the p / o seam. In the lungs - vesicular respiration. Heart - tones are loud, rhythmic. Bandage is dry and clean. The abdomen is soft and painless. St. genitalis: the external genitalia are developed correctly. The urethra and paraurethral passages without features. In the mirrors: the cervix is clean, conical. Discharges are mucous. Bimanually: uterus in anteflexio - versio, normal size, dense, limited mobility. The appendages on the left are stringy, on the right they are not defined. Stool and diuresis are normal. | Table N 15 · UFO p / o seam. · Stitches removed. |
Patient Turenko Lyudmila Alekseevna, 19 years old, was admitted on 7.04.99. with complaints of irregular painful menstruation. Based on the preliminary, differential diagnosis, the final clinical diagnosis was made: a cyst of the right ovary. 8.04.99. an operation was performed: laparotomy with excision of the old scar: husking of the cyst of the right ovary. The postoperative period was uneventful, a course of anti-inflammatory therapy was prescribed. The sutures were removed on the 8th day. Wound healing by primary intention.
Forecast: for life and reproductive function - favorable.
References.
1. GYNECOLOGY.
Ed. prof. L.N. Vasilevskaya
M. Medicine 1985
2. acad. Petrovsky B.V.
M. Soviet Encyclopedia 1978
3. Kukes V.G.
CLINICAL PHARMACOLOGY
M. Medicine 1991 pp. 131-134, 380-383
4. VIDAL Handbook
CJSC M. AstraPharmService 1996
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In gynecology, ovarian cysts are quite common. Most often, their formation process occurs at childbearing age. There are several reasons for the development of a cyst, but they all practically come down to a violation of the hormonal background in a woman. An ovarian cyst is a hollow formation in the ovary or on its wall, filled with fluid or blood. Usually this tumor is benign, but it is possible that in the absence of proper treatment, the cyst may degenerate into a malignant one. A timely visit to the gynecologist will prevent the risk of complications and significantly shorten the healing process.
Symptoms of the disease
Most patients in whom it is pathological in nature note the following symptoms:
Aching pain in the lower abdomen, most often on one side. This pain may increase with physical activity or sexual intercourse;
Painful and prolonged menstruation;
With the growth of the cyst, as well as its torsion, nausea, vomiting, loss of strength, short-term loss of consciousness are noted;
An increase in the abdomen, frequent urge to defecate appear due to tumor growth and compression of neighboring organs of the gastrointestinal tract;
Prolonged infertility appears due to dysfunction of the ovaries.
At the first symptoms of malaise, it is recommended to contact the medical center, where you will be assisted by specialists. If a woman felt acute pain and a sharp decrease in blood pressure, it is urgent to call an ambulance and carry out emergency hospitalization.
Diagnosis of the disease
In order for the diagnosis to be accurate, and the treatment chosen correctly, it is imperative to conduct a diagnostic examination. During the initial visit to the gynecologist, the doctor will listen to your complaints, conduct a gynecological examination in the chair and, if necessary, make an ultrasound diagnosis. During the ultrasound, the doctor will determine all the indicators of the pelvic organs in accordance with the day of the cycle, and also identify or exclude the presence of ovarian cysts.
In the presence of small cysts up to one centimeter and not dangerous to the health of a woman, the doctor may decide to monitor this formation during subsequent cycles. Diagnosis of the disease is an important tool in the diagnosis and choice of treatment.
Treatment of the disease
After receiving all the diagnostic and laboratory tests, the doctor decides on the method of treatment. A conservative method of treatment is aimed at reducing and completely resolving ovarian cysts by taking hormonal drugs. In the absence of the effectiveness of hormone treatment, as well as in the presence of non-functional ovarian cysts, surgical treatment is usually used. The main goal of the surgical intervention is the removal of the ovarian cyst and the maximum preservation of the reproductive organs for further planning of children.
In modern gynecology, one of the most effective methods of dealing with ovarian cysts is the laparoscopic method of treatment. The advantage of this method lies in the minimal damage to soft tissues and the rapid postoperative period. Through small skin incisions measuring 1.5 cm, instruments and a microscopic camera are inserted into the area of \u200b\u200bthe woman's uterus. After a few months, there will be no trace of incisions on the patient's skin. The goal of the operation is to preserve healthy ovarian tissue as much as possible.
The presence of ovarian cysts is of a different nature. In order to detect this disease in time, it is necessary to visit a gynecologist regularly. A timely visit to the doctor will help prevent the risk of complications, as well as preserve the childbearing function of a woman. By contacting our medical center, you are guaranteed to receive qualified assistance from experienced doctors. Our gynecologists have extensive experience in dealing with diseases of the female reproductive system. We will do everything in our power to ensure that your history of ovarian cyst left in the past!
1. Complaints
At the time of hospitalization, she complained of pulling pains in the lower abdomen.
2. medical history (Anamnesis morbi)
During the last 6 months, pulling pains in the lower abdomen began to disturb. Has addressed to the gynecologist. On ultrasound from 01/26/2015 - dermoid cyst of the left ovary. Examined. Sent for hospitalization in the gynecological department of the city clinical hospital No. 10 for planned surgical treatment.
3. The history of the life of the patient (Anamnesis vitae)
She was born in the Republic of Azerbaijan in 1984. In mental and physical development, she did not lag behind her peers. She grew and developed normally. The patient is the first and only child in the family. She studied well at school, graduated from 11 classes. Currently not working.
Housing conditions are currently satisfactory.
Bad habits are denied.
Heredity is not burdened.
Allergic reactions to drugs, food, household allergens denies.
Past diseases: SARS
4. Gynecological history
1. Menstrual function:
First menstruation: 15 years
Periods regular after 28 days
Duration: 5 days
The first day of menstruation is accompanied by pain.
· With the onset of sexual activity, the duration and frequency of menstruation did not change.
Date of last menstrual period: 02/17/15
2. Secretory function:
The first discharge appeared at the age of 15.
Discharges in moderate amounts are liquid, transparent, odorless, do not irritate the surrounding tissues.
3. Sexual function:
· Sexual life since 20 years.
· Married.
· She is currently sexually active and has a permanent sexual partner.
· During sexual intercourse, pain, bloody discharge from the vagina is not noted.
· Method of contraception: condoms.
4. Childbearing function:
In 2007 urgent delivery
5. present state (Status gifts)
The general condition is satisfactory, the patient's position is active, consciousness is clear, the face is calm, the physique is proportional, height 164 cm, weight 60 kg, normosthenic. The gait is even. Body temperature 36.6 o C Skin of normal color.
Visible mucous membranes of the lips, mouth, nose, eyes are light pink in color. There are no rashes on the mucous membranes. There is no dryness of the mucous membranes.
Subcutaneous tissue is moderately developed, fat deposits are uniform. Edema is absent.
Lymphatic system: submandibular lymph nodes are the size of lentils, axillary nodes are palpable the size of a pea, inguinal nodes are the size of beans. Occipital, supraclavicular, subclavian, parotid, ulnar lymph nodes are not palpable. Lymph nodes have a soft texture, are not enlarged, with surrounding tissues and are not fused with each other, are painless on palpation. The condition of the skin over the palpable nodes is unchanged.
Muscles are developed moderately, evenly. The tone is preserved, the strength is good. Soreness on palpation, compaction in the muscles, local hypertrophy, atrophy are absent.
The bones of the skull, spine, limbs without features. There is no pain on palpation and tapping of the sternum, ribs, tubular bones, and vertebrae.
Joints. Pain in all joints is absent. Movements in all joints are active, free.
Respiratory system
Lungs: No chest pain. Shortness of breath, suffocation are absent.
Examination of the chest: the shape of the chest is normosthenic, the epigastric angle is 90°. The chest is symmetrical, there is no protrusion or retraction of half of the chest. The width of the intercostal spaces and the direction of the ribs were not changed. The shoulder blades are close to the chest. NPV 16 per minute.
Palpation of the chest: no pain on palpation of the chest. Chest resistance is normal. Voice trembling is not changed.
Percussion of the chest: with comparative percussion, a clear lung sound over symmetrical areas is determined.
With topographic percussion, the height of standing of the tops of the lungs in front of the clavicle is 3 cm on both sides, behind - at the level of the spinous process of the VII cervical vertebra. The width of the Krening fields is 5 cm on both sides.
Inferior border of the lungs
Auscultation of the lungs: auscultatory over the entire surface of the lungs breathing is vesicular. There are no side breath sounds. Bronchophony is not changed.
Circulatory system
Pain in the region of the heart is absent. On palpation, the arteries are soft. The arterial pulse is the same on both radial arteries - 76 beats / min, the rhythm is correct, the same, there is no pulse deficit, the shape of the pulse wave is normal, the pulse is of normal filling, normal value.
Arterial pressure 110/70 mm. rt. Art.
Examination of the heart area: when examining the heart area, cardiac, apex beat and epigastric pulsation are not detected, the cardiac hump is not detected.
Palpation of the cardiac region: the apex beat is not defined. Cardiac impulse, trembling in the region of the heart, pulsation in the epigastric region are absent.
Auscultation: heart sounds are clear, rhythmic. There is no splitting and bifurcation of tones. Pathological tones and noises are not heard.
Digestive system
Inquiry: no complaints. Appetite saved. Swallowing is free, painless. The mucous membrane of the inner surface of the lips, cheeks, hard and soft palate is light pink in color, without damage and the presence of a rash. The tongue is light pink in color, not coated. The pharynx is of normal color, without plaque. The tonsils are not enlarged. The pharynx is of normal color, the mucosa is smooth. According to the approximate superficial palpation of the abdomen, the tone of the abdominal muscles is normal; the abdominal wall is soft, supple. The abdomen is painless, not swollen. Shchetkin-Blumberg's symptom is negative. The state of the navel, muscles, white line of the abdomen without pathological changes. Abdominal percussion of free and encysted fluid in the abdominal cavity revealed no liver. There is no visible enlargement of the liver. The size of the liver according to Kurlov - along the right midclavicular line - 9 cm, along the midline - 8, along the left costal arch - 7 cm. On palpation, the edge of the liver is smooth, rounded, painless.
Urinary system
There are no complaints. Urination is free. The frequency of urination is 4-6 times a day. Diuresis is normal. There is no pain in the region of the kidneys. Pasternatsky's symptom is negative on both sides.
Endocrine system
There are no complaints. There is no visible enlargement of the thyroid gland. Palpation of the thyroid gland of dense consistency, painless, not enlarged.
Nervous system
Inquiry: no complaints. Memory is good. Sleep is good. Sense of smell and taste are not changed. The pupils are round, reactive to light. Hearing is not reduced. Speech is clean. Movement coordination preserved
6. Gynecological status
The external genital organs are formed correctly, the female type of hair is moderately developed. Hyperemia, edema, soreness, scars, in the perineal area are not observed. The integrity of the hymen is broken.
Inspection of the vagina and cervix in the mirrors: the mucous membrane is pink, the cervix is deformed, the pharynx is closed. No additional formations were found.
Bimanual study:
The cervix is dense, conical.
The uterus is of normal size, dense, mobile, painless, the position is anteflexio.
· Adnexa of the uterus on the right are not defined. On the left, the formation d = 4.5 cm is determined. The discharge is light, liquid, odorless.
7. Preliminary diagnosis
Based:
History of the disease: observed by a gynecologist regularly. The last year she noted low-intensity, dull, non-radiating pains in the lower abdomen. Didn't ask for help. Over the past week, the pain has intensified, in connection with which she turned to a gynecologist at the place of residence. An ultrasound examination of the pelvic organs was performed (01/26/15), the conclusion: a dermoid cyst of the left ovary.
· Ultrasound (26.01.15): dermoid cyst of the right ovary A preliminary diagnosis can be made: dermoid cyst of the left ovary.
8. Special methods of gynecological examination
· Ultrasound of the pelvic organs from 26.01 :
Day 7 m/cycle Dimensions 54×39×52 mm (normal sizes).
The structure of the myometrium is homogeneous.
Thickness of the endometrium: 6 mm. The structure is homogeneous. The walls of the cavity are even. Reflections from the endometrium correspond to physiological changes - the initial stage of proliferation.
Ovaries: left - 47 × 32 × 38 mm. Usually located. It contains a liquid cavity formation with dense contents 38×22×32 mm in size, with a hyperechoic parietal inclusion d=7 mm. The thickness of the capsule is 2 mm.
Right: dimensions - 28 × 12 × 30 mm. Located along the rib of the uterus.
Dominant follicle d=16 mm.
The ovarian stroma was not enlarged.
Fallopian tubes: not visualized.
Cervix: 28×23 mm. Endocervix cysts max d=8 mm.
Endocervix: 6 mm. Without features.
Pelvic space: no free fluid detected.
Conclusion: Dermoid cyst of the left ovary.
9. Laboratory research methods
1. Complete blood count dated 09.02. 15 G. :
Erythrocytes - 4.09 × 10 12 / l
Hemoglobin - 122 g / l
Hematocrit - 38.1%
Leukocytes - 7.0 × 10 9 / l
Platelets - 246 × 10 9 / l
Eosinophils - 2.4%
Neutrophils - 65.4%
Lymphocytes - 23.8%
Monocytes - 8.1%
ESR - 59 mm / h
2. clotting time : start - 4"11" end - 4"37" duration - 1"17"
3. Definition of g ruppy blood and Rh factor from 09.02. 15 G. : B (III) Rh (+)
4. General analysis of urine from 09.02. 15 G. :
· Yellow color
Urine pH: 5.5 units
Clarity: slightly cloudy
Specific Gravity: 1.035 g/ml
Protein: 0.160 g/l
Glucose: negative
Ketones: negative
Bilirubin: negative
Erythrocytes 1−0 in p/z
Single leukocytes
squamous epithelium 1−0
Mucus a lot
5. ODA Dividing the Wassermann reaction from 1 2.02. 15 G. : negative.
6. Blood for ELISA from 12.02. 15 G. : Abs for HIV, hepatitis B, C virus were not detected.
7. Electrocardiography from 12.02. 15 G. : sinus rhythm. Normal position of the EOS.
8. Biochemical blood test from 09.02. 15 G. :
Blood glucose - 4.72 mmol / l
AlAT - 14.6 U / l
AST - 15.6 U / l
Bilirubin total - 8.3 µmol / l
Creatinine - 60.0 µmol/l
Urea - 5.1 mmol / l
Total protein - 73.9 g / l
Biochemical blood test dated 09.02.15 :
Residual nitrogen 16.4
Urea 5.2
9. Oncomarkers from 09.02. 15 G. : SA 125 - 13.2 U / l
Oncomarkers from 09.02 . 15 G. :
Alpha-fetoprotein<0.500
SA 15−3 10.8
10. Hormonal studies about t 09.02. 15 G. :
Chorionic gonadotropin<0.100
11. Smear on flora dated 10.02. 15 G. :
Leukocytes 5-7 in p / s
Squamous epithelium unit. in p / s
Gonococci - 0
Dr. bacteria - 0
10. Consultants' opinion
Consultation of the therapist from 06/04/14:
Makes no complaints. The general condition is satisfactory. Skin of normal color. In the lungs, vesicular breathing, no wheezing. NPV 17 min. Heart sounds are clear, rhythmic. AD 110/70 mm. rt. Art. Pulse 70 beats / min. The abdomen is soft, painless. Urination, stool normal. ECG: sinus rhythm. Normal position of the EOS. FLH - no pathology was detected.
Conclusion: surgical treatment is not contraindicated.
Anesthesiologist consultation from 24.02.15 :
Makes no complaints. Allergological anamnesis is not burdened.
The general condition is satisfactory. The physique is correct, satisfactory nutrition. Height 164 cm, weight 60 kg. Skin of normal color. With percussion, a pulmonary sound is determined over the entire surface of the lungs. In the lungs, vesicular breathing, no wheezing. NPV 16 per min. Heart sounds are clear, rhythmic. AD 110/70 mm. rt. Art. Pulse 72 beats / min. The abdomen is soft, painless. Urination, stool normal.
There are no contraindications to surgical treatment.
Anesthetic risk II degree.
Consent for the operation was obtained.
Assumed: endotracheal anesthesia
11. Differential Diagnosis
Benign ovarian tumors must be differentiated from a number of diseases:
Ovarian cancer in its early stages, especially if it develops in a pre-existing benign tumor, does not give clinical signs to distinguish it from a benign neoplasm. Therefore, all tumor formations of the ovaries, which do not even cause the doctor to suspect malignancy, are subject to prompt removal and careful treatment. histological examination to rule out cancer.
· Chronic inflammatory diseases of the uterine appendages are often bilateral. Inflammatory tubo-ovarian formations have bizarre fuzzy outlines, usually soldered to the uterus, the parietal peritoneum of the small pelvis and adjacent organs, as a result of which their mobility is sharply limited, and palpation causes pain. Patients have a history of frequent exacerbations of the inflammatory process and long-term conservative treatment.
· Uterine fibroids with a subserous node present difficulties for differential diagnosis with ovarian cystadenoma. For this purpose, the technique of bringing down the cervix, captured by bullet forceps, is used, together with the uterus downwards. The transfer of movement to a tumor palpable in the small pelvis indicates its direct connection with the body of the uterus. The position of the ovarian cystadenoma does not change during this diagnostic procedure. For differential diagnosis, X-ray methods are also used: pneumoperitoneum, transuterine visceral phlebography.
A benign ovarian tumor of significant size should be differentiated from a long-term pregnancy on the basis of secondary signs of pregnancy, listening to the fetal heartbeat and abdominal fluoroscopy data. In case of an ovarian tumor that has a long stalk and is relatively freely movable when examined in the abdominal cavity, it should be differentiated from mobile tumors of the abdominal cavity. In addition to the data of an objective examination, in such cases, X-ray examination using pneumoperitoneum is of great help in the diagnosis.
12. Final Diagnosis
Based:
Complaints: pulling pains in the lower abdomen.
History of the disease: observed by a gynecologist regularly. Last year, she noted low-intensity, dull, non-radiating pain in the lower abdomen, mainly on the right. Didn't ask for help. Over the past week, the pain has intensified, in connection with which she turned to a gynecologist at the place of residence. An ultrasound examination of the pelvic organs was performed (26.02.15), the conclusion: a dermoid cyst of the left ovary.
Gynecological status: uterine appendages are not determined on the right, an elastic, rounded, mobile, painless formation measuring 4.5 cm is determined on the left.
Ultrasound (26.02.15): dermoid cyst of the left ovary
Laboratory research methods: Oncomarkers: CA 125 - 13.2 U / l, Alpha-fetoprotein<0.500, СА 15−3 — 10,8
· Differential diagnosis It is possible to formulate the final clinical diagnosis:
Primary: dermoid cyst of the left ovary Complication: none Concomitant: none
13. Etiology
The etiology of ovarian tumors is unknown. In the origin of tumor-like formations of the ovaries, hormonal disorders and, possibly, inflammation play a large role. However, it was not possible to reliably prove the role of certain hormonal disorders. There is a concept of increased ovulatory load on the ovary, the so-called hypothesis of continuous ovulation, confirmed by the more frequent occurrence of tumors in the only remaining gonad after unilateral adnexectomy.
It is believed that epithelial tumors arise from inclusion cysts of the integumentary epithelium that have arisen in places of frequent ovulation. However, the role of ovulation stimulants in this regard has not been conclusively proven.
The theory of the development of epithelial ovarian tumors from the integumentary epithelium is widespread.
It is suggested that sex cord tumors and germ cell tumors may develop as a result of embryonic disorders against the background of hypergonadotropinemia, which explains the age peaks in the incidence of ovarian tumors during puberty and perimenopause.
Risk factors for ovarian tumors:
early menarche
Late menopause
Reproductive disorders
A high-calorie diet high in saturated fatty acids
a genetic predisposition
infertility
· smoking Neuroendocrine disorders, thyroid disease, obesity are not significantly associated with ovarian tumors and are not described in evidence-based models.
14. Pathogenesis
The pathogenesis of ovarian tumors is not well understood and causes a lot of controversy. It is believed that epithelial ovarian tumors develop from the surface epithelium as a result of the formation of inclusion cysts, possibly against the background of hypergonadotropinemia. Hormonal disorders, as well as immune disorders, are not considered primary from the standpoint of evidence-based medicine. It is possible that hyperhormonemia is associated with low levels of SHBG.
It is known that the use of vegetable fiber with food leads to the release into the lumen of the small intestine and re-absorption into the bloodstream of compounds with weak estrogenic activity, which increase the synthesis of SHBG by the liver. This mechanism increases the content of free steroids in the blood serum.
In the pathogenesis of ovarian tumors, the role of violations of the barrier functions of the small intestine and associated endotoxemia has been proven.
Sex cord tumors and stromal cell tumors develop from embryonic anlages against the background of hypergonadotropinemia and unrealized reproductive function.
15. Preoperative epicrisis
The patient has been in the gynecological department since February 24, 2015, with a diagnosis of cystoma of the left ovary.
From the anamnesis: during the last 6 months, pulling pains in the lower abdomen began to disturb. Has addressed to the gynecologist. On ultrasound from 01/26/2015 - the left ovary is 47 * 32 * 38 mm. Usually located. It contains a liquid formation with dense contents 38*22*32 mm in size, with a hyperechoic parietal inclusion d=7 mm. The thickness of the capsule is 2 mm. Tumor growth markers CA 125 39.7. Joint inspection with otd. Lyubimova A. Yu. Examined. Hospitalized.
She was referred for hospitalization to the gynecological department of City Clinical Hospital No. 10.
Indications for surgery: cystoma of the left ovary.
Planned: removal of the tumor of the left ovary, the final volume to be determined during the operation.
Examined by an anesthesiologist: There are no contraindications.
Allergic reactions were not revealed.
Somatic history is not burdened.
Prepared for the operation. Agree. Possible complications are warned in an accessible form.
16. Operation. ventiotomy. Removal of the tumor of the left ovary. Resection of the right ovary. Rseparation of adhesions
Under aseptic conditions, under intubation anesthesia, the abdominal cavity was opened in layers using a lower median incision. Found: the peritoneum is smooth, the organs of the upper floor of the abdominal cavity are without pathology, the greater omentum is soldered to the peritoneum. In the small pelvis, a pronounced adhesive process. The left appendages are in an adhesive conglomerate with intestinal loops, the posterior surface of the uterus. The adhesions are separated by a blunt and a sharp path. The body of the uterus is of normal size, normal color. On the left ovary, a formation with a smooth surface, 4 cm in diameter. The formation has a smooth outer capsule. The volumetric formation of the ovary was removed; during its extraction, 30 ml of "chocolate" contents poured out, the ovary was sutured with catgut sutures. The right ovary is cystic, with endometriotic foci, resection was performed, the ovary was sutured with catgut sutures. The abdominal cavity is drained, additional hemostasis in the region of the posterior "Douglas" pocket, sutured tightly in layers. Intradermal Vicryl suture.
Macropreparation: the tumor contains endometrioid contents, without papillary inclusions, an ovarian area with foci of endometriosis.
Operational diagnosis: ovarian endometriosis, adhesions in the pelvis.
Blood loss 200.0
Urine through the catheter - light 200.0
17. Postoperative treatment
1. Ward mode
2. Table No. 15
3. For antibacterial purpose: Ceftriaxone 1.0 IM for 2 days after surgery.
4. With an antiprotozoal purpose, it was prescribed: Sol. Trichopoli 0.5% - 100 ml. IV drip every 8 hours for 3 days.
5. For the purpose of detoxification, it was prescribed: Sol. NaCl 0.9%-500 ml + Sol. Glucosae 5%-500 ml. IV drip 1 time per day for 5 days
6. With analgesic purpose assigned: Sol. Promedoli 1% - 1.0 IM after 6 hours for 1 day, then, if necessary, Ketorol 1.0 IM (in case of pain).
18. Forecast
In relation to life - favorable.
In relation to working capacity - temporary disability (during the stay in the clinic).
Regarding specific functions:
menstrual function - preserved
sexual - preserved
childbearing - preserved
secretory - preserved
19. Stage epicrisis
ovary cyst operative tumor The patient has been in the gynecological department of KKB No. 10 since February 24, 2015 with a diagnosis of dermoid cyst of the left ovary.
From the anamnesis: the gynecologist is observed regularly. During the year, aching pains in the lower abdomen are disturbing. She turned to the gynecologist, an ultrasound scan was performed on January 26, 2015, the conclusion: a dermoid cyst of the left ovary. Sent for hospitalization in the gynecological department of City Clinical Hospital No. 10 for planned surgical treatment.
02/25/2015 Surgical intervention was performed in the following scope: transection. Removal of a tumor of the left ovary. Resection of the right ovary. Separation of adhesions Operational diagnosis: Endometriosis of the ovaries, adhesions in the small pelvis.
It is planned to continue treatment in a hospital.
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