Case 2 (pgma-rocklet-wena-manay-chuchi-pocha-jb)

Vergara, Rhoda Vicencio, Arlene Vierneza, Ma. Rowena Villafuerte, Shayne Villanueva, Irene Suzeth Villapando, Leda Villegas, Jose Bernabe

GYNECOLOGY Dr. Teresa Luna Section III-D

Case #2 A 53 year old G3P1 (1-1-1-1) was referred to you by a general physician for surgery. She was told to have an ovarian cyst. 1. What additional data should be asked? a. Personal Information (Name, Address, Occupation, Marital Status) b. Chief Complaint or Reason for Visit c. History of Present Illness • the patient should be asked about the principal symptoms and all the data that is related to it. d. Past Medical History • Childhood Illness • Adult Illness or Hospitalizations (Does she have any significant medical illnesses that might be aggravated by anesthesia or surgery? Ex. Cough, asthma, DM, HTN, Cardiac and Lung diseases • Operations (Has she undergone any previous surgical procedures? Especially obstetric and gynecologic surgeries) • Bleeding problems (Did she experience any surgical complications such as excessive bleeding; poor wound healing, deep vein thrombosis, bowel obstruction and peritonitis? • Accidents • Obstetric History - menstruation (duration, dysmenorrhea, amount, length, regular or irregular) - menopause (age) - age at pregnancy - mode of delivery - illnesses acquired during pregnancy - cause of abortion - methods of contraception • Medications (Has she been taking any medications during the past few months) • Allergies and Drug reactions (Is she allergic to any medications, food or environmental agents? Did she have any unusual response or reactions to anesthetic agents? Important data to prevent anaphylactic reactions)

• Psychiatric e. Current Health Status • Medications (Is she currently taking any medications specifically oral contraceptives? • Diet, Sleep, Exercise • Tobacco, Alcohol, Drugs • Immunizations f. Family History • Current health status of the family members • If there is a history of any significant illness like diabetes mellitus, cancer, hypertension, dyslipidemia, stroke, thyroid and renal disease, arthritis, TB, asthma or lung diseases, seizure disorder, mental illness and substance abuse. • If there is death in the family, the age and the cause of death • Does she have any family history of excessive intra/post-operative bleeding, malignant hyperthermia? g. Personal and Social History • Personality and interests • Sources of Support • Coping Style • Strengths and Fears • Employment History • Sexual History • Education • Family Relationships • Domestic Violence • Nutrition and Fitness h. Review of Systems • Head • Cardiovascular/ Respiratory • Gastrointestinal • Genitourinary • Neuromuscular • Psychiatric • Depression 2. What examinations should be done? Complete physical exam with pelvic exam a. Check for the vital signs b. Calculate the BMI • BMI = weight in kg/ height in sq cm. • BMI less than 22 increases the risk of malnutrition, less than 19 shows evidence of malnutrition • If nutritional deficiencies are noted, it should first be corrected before surgery.

c. Pelvic Examination • Bimanual palpation of the ovary (note the size, shape, consistency, mobility and tenderness ) d. Inspect the skin for any lesions (jaundice) • Jaundice may indicate a liver disease. Liver disease is usually related to other problems involving nutrition, coagulation, wound healing, infection and encephalopathy. e. Auscultation of heart sounds, PMI • Check for murmurs. It’s expected that during surgery, there may be significant amount of blood loss and patients with heart disease tolerate anemia poorly. f. Auscultation of Lung sounds • Inspect for pulmonary compromise. After a surgery, pulmonary physiologic changes occur due to immobilization, anesthetic irritation of airways and splinting of breath as a consequence of the incisional pain. If the patient shows signs of pulmonary compromise, he/she might have respiratory complications after the surgery. g. GI • Palpate all quadrants, note any tenderness especially in the right upper quadrant • Percuss the liver. Check for hepatomegaly by measure the vertical span dullness of the liver. • Test for shifting dullness and fluid wave. Check for ascites. 3. What ancillary procedures should be requested? Laboratory tests •

• • • •

An ovarian cancer-associated marker, Cancer Antigen 125 (CA-125), should be requested to aid in detecting malignant adnexal masses at an early stage. It is not a tumor-specific antigen as it may also be increased in patients in firsttrimester pregnancy, liver cirrhosis, pelvic inflammatory disease, endometriosis, pancreatitis, and in 40% of patients with advanced intraabdominal non-ovarian cancer. (3) Pregnancy testing is necessary for the differential of ovarian cyst. Complete Blood Count to monitor the levels of hemoglobin and hematocrit prior to surgery. White Blood Cell count with differential may show leukocytosis for a potential inflammatory process. Cross-matching should also be done in cases of possible blood transfusions that the patient may undergo.

Imaging Techniques •

Pelvic Ultrasonography can identify the origin of the mass if it is uterine, adnexal, bowel, or gastrointestinal. It may determine the size of the cyst and

•

•

its complex features whether it is a unilocular cyst, multiloculated cyst or a solid cyst that may aid in its management(3). It is simple, painless with no radiation risk(2). CT scan is seldom used as an initial diagnostic procedure but it may help in the treatment plan especially when the mass is suspected to be malignant or when another abnormality is present other than gynecologic(2). Magnetic Resonance Imaging generates a high-resolution, cross-sectional image of the body like CT scan. It utilizes nonionizing radiation, which has no negative effects on the body. It can distinguish various types of tissue such as inflammatory masses, cancers, and abnormal tissue metabolism. However, calcifications are not clearly appreciated and it is very expensive(2).

In a study conducted by Romagnolo et.al, entitled, An Analysis of Different Approaches to Ovarian Cysts in Italy, they conducted a descriptive study to evaluate the clinical and surgical approach to ovarian cysts in Italy, they administered multiple choice questionnaire to 214 members of the Italian Society of Gynecologic Oncology (SIOG) and to 230 members of the Italian Society of Gynecologic Endoscopy (SEGi). The result of the survey indicated that transabdominal and transvaginal ultrasound associated with CA125 determination represent the basis for the diagnosis, even if there is no univocal agreement on the ultrasound aspects that may define an ovarian cyst as doubtful. (4)

4. How will the patient be prepared for surgery? Before a patient undergoes surgery, the following should be done: • General medical and surgical history • Complete physical examination • Laboratory tests • Patient Education: When you talk to the patient, you should use terminologies which are easy to understand. Your explanation should include the significance of the disease/condition. Other materials such as pamphlets may help. You should also discuss the purposes of the operation whether it may be diagnostic or for rectifying a particular problem. Details about the surgery such as what organs to be removed, what type of incisions will be made; possible blood transfusions should also be mentioned as well as the foreseen end result. All risks and possible complications should all be explained. The physician should also not forget to explain the post operative course and if there are any alternative therapies available.(1) • Informed consent: This is a process which entails a discussion between the physician and the patient to facilitate the patients understanding and help him/her come to a decision with regards to his/her condition. A good patient education facilitates this process.(1) • Pre operative orders include(2): o Skin preparation: operative site could be washed the night before the operation with povidone-iodine or hexachlorophene and again should also be washed just before the surgery

o Diet: patient should be placed on NPO at least 8 hours prior to surgery o Preparation for the GIT: most surgeons suggest the use of a cleansing enema the night before surgery. Furthermore, mechanical and antibiotic bowel preparation are necessary when there is a chance of bowel resection or injury o Sedation: a sedative may be taken to ensure a good night rest o Pre-anesthetic medication: Midazolam could be used however it cannot be administered until after an IV line has been inserted o Other Medications: all other medications of the patient should be taken on the morning of the day of the surgery unless contraindicated (with minimal amount of water) o Antibiotics: prophylactic antibiotics are needed in all major surgeries. First generation Cephalosporin have been indicated in decreasing post operative febrile morbidity; o Blood Transfusions: blood typing and cross-matching should be done to prepare for any possible transfusion o Bladder Preparation: for minor procedures, instruct the patient to void before the procedure. For major procedures, an indwelling catheter should be inserted o Douches: this is to reduce the population of vaginal flora

References: (1)

Berek, J.S. Novak’s Gynecology 13th Edition. Lippincott Williams and Wilkins. Copyright 2002. pp. 390- 393. (2)

De Cherney, A.H. Nathan, L. Current Obstetrics and Gynecologic Diagnosis and Treatment 9th Edition. Copyright McGraw –Hill. pp. 590 – 592,825-835. (3)

Jeong, Y. MD, et al. Imaging Evaluation of Ovarian Masses. Department of Radiology, University of Arizona. 1998. (4)

Romagnolo, C. et al. An Analysis of Different Approaches to Ovarian Cysts in Italy. European Journal of Gynecological Oncology. Gynecologic Department, Sacro Cuore Hospital, Negrar (VR), Italy.