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Hypogastric and Lower Back Pain

Hypogastric and Lower Back Pain. Tugano-Ventigan. GENERAL INFORMATION. S.B., 47/F, married, unemployed, from Tanay , Rizal. CHIEF COMPLAINT. CC: “masakit ang puson, likod, at ovary ”. History. HISTORY OF PRESENT ILLNESS. 3 years PTA:

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Hypogastric and Lower Back Pain

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  1. Hypogastric and Lower Back Pain Tugano-Ventigan

  2. GENERAL INFORMATION S.B., 47/F, married, unemployed, from Tanay, Rizal.

  3. CHIEF COMPLAINT CC: “masakit ang puson, likod, at ovary ”

  4. History

  5. HISTORY OF PRESENT ILLNESS 3 years PTA: • post-coital bleeding: “pulang-pula”; blood stain on sheets about 5” in diameter; lasts for 1 day, would resolve spontaneously • (+) dysuria, gross hematuria, (-) dyspareunia • (+) malaise, mood swings, perineal pruritus upon sexual intercourse • These prompted patient to palpate her vaginal canal – “hindi pantay ang kwelyo”.

  6. HISTORY OF PRESENT ILLNESS 2.5 years PTA: • Symptoms persisted and patient consulted at Labor Hospital in Quezon City • Patient had an UTZ and she was told that she had myoma. • Pap smear – unknown results • Advised to undergo biopsy of an undetermined area, but she refused • Hemostan 2x/day for 2 weeks – cessation of bleeding. • Amoxicillin – 2x/day for 1 month. • Advised to refrain from sexual intercourse no sexual contact since then.

  7. HISTORY OF PRESENT ILLNESS 2.5 years – 9 months PTA: • (-) abnormal vaginal bleeding, associated symptoms 9 months PTA: • Alternating episodes of prolonged vaginal bleeding (3 weeks) and yellowish discharge (1 week) • Bleeding – “buo-buo, mabaho, maitim” • Discharge – yellowish, watery, “malansa”

  8. HISTORY OF PRESENT ILLNESS 9 months PTA: • Lower back pain: “kumikirot”, 6/10, no radiations, persistent, aggravated by strenuous work (paglalaba) • Suprapubic pain: “kumikirot”, 6/10, radiation to perineum; perineal pain was described as “tinutusok” • Pain relieved by mefenamic acid, 2x/day • Paresthesia from knees up to gluteal area

  9. HISTORY OF PRESENT ILLNESS 4 days PTA: • consult at a medical mission in Tanay, was advised to undergo “Echocardiography, Uterus” Upon consult: • Pain has become worse (9/10), same areas • Bleeding also has become worse (1-2 small diapers/day)

  10. PAST MEDICAL HX • (+) Ectopic pregnancy (1985), underwent right oophorectomy • (-) Other hospitalization & surgery, known allergies • (-) Heart problems, kidney diseases, PTB, DM • (+) Chicken pox, mumps and measles

  11. PAST MEDICAL HX • (+) Gunshot on the face (unrecalled exact date), healed, no complications • 2009: Rashes in extremities which lasted for 1-2 months – consulted an albularyo, treated with “luyang dilaw at langis” • High blood sugar: 140, using glucometer (July 24, 2010)

  12. FAMILY HISTORY (-) DM, asthma, cancer, TB, heart problems Genogram as follows:

  13. Legend: HTN d. 105 85 Unknown Cause Ectopic Pregnancy 6 2nd to 6th 8th to 12th Abortion Vaginal Bleeding (Suspected Cervical CA) Intimate Relationships 44 47 3 Adopted Patient Household Members 17 7 30 Baduyem Family Genogram, July 2010

  14. PERSONAL AND SOCIAL HX • (+) Cigarette smoking ½ pack per day (12.5 pack years), started aged 21 y/o, stopped 2009 • Occasional alcoholic drinker • (-) Illicit drug use • Unemployed, occasionally works as a laundry woman (“tagalaba”) • 5 sexual partners, monogamous • (-) contraception

  15. OB Hx • M: 12 y.o., I: regular, D: 3 days, A: 3 pasador/day, S: Dysmennorhea (3/10), no meds taken • G3P1 (1021) > 1 ectopic pregnancy > 1 abortion (2 mos.) > normal delivery, full term, at a hospital • LMP: June 21, 2010 – patak-patak May 2010 : bleeding for 3 weeks, heaviest on the 3rd day then the rest was spotting (“patak-patak”)

  16. REVIEW OF SYSTEMS • General: Weight loss (150 lbs about a year ago), chills • Skin: occasional erythematous patches/plaques/wheals (“pantal”); cystic mass (1 cm dm.), non tender, in the dorsum of the left foot (20 y duration, non changing in appearance) • Eyes: Uses reading glasses; occasional cloudy/hazy sight “maulap”; (-) eye pain, erythema; (+) dimming of vision (nandidilim ang paningin) • Ears: good hearing; (+) occasional dizziness • Nose: (+) sinusitis, occasional nasal obstruction (just last year); (-) epistaxis • Mouth and Throat: (-) dysphagia, sores, gum bleeding; loss of two front teeth (upper)

  17. REVIEW OF SYSTEMS • Respiratory: (+) occasional chest pain during coughing (started 3 months ago); “hingalin” and easy fatigability; (-) productive cough • Cardiology: (+) occasional chest tightness; (-) PND, edema, claudication • GI: (+) occasional heartburn (this year), gas (“kabag”), allegedly “green” stools, decreased frequency of bowel movements • Endocrine: Drinks 2-3 glasses of water, (-) cold/heat intolerance, polydipsia, polyphagia, polyuria • MSK: (-) Limitation of motion, intact reflexes • Psychiatric: (-) irritability, anxiety

  18. Physical Examination

  19. General Assessment • Awake • Alert • Ambulatory • Speaks in sentences

  20. Vital Signs • BP 110/80 • PR = 100 bpm • RR = 18 /min. • T = 36.9 C

  21. Physical Exam • Pale conjunctivae • Slightly icteric sclerae • Bilateral 1-cm fixed nontender masses near the angle of the jaw • Distinct S1 and S2 • No S3 and S4, no murmurs

  22. Physical Exam • Clear breath sounds, no adventitious breath sounds • Breast exam: 3 cm x 1 cm clearly demarcated, smooth, fixed and nontender mass - upper right quadrant of left breast • Flat, nontender epigastric and periumbilical areas of the abdomen • Tenderness on light palpation in the hypogastric area • (-) Inguinal LAD

  23. Internal Examination • Grossly normal external genitalia • Multiple pea-sized nodular masses around the vaginal wall (posterior and lateral walls) • Cervix also with multiple nodular masses • (+) Blood on examining finger (Bleeding started upon IE)

  24. Assessment

  25. Primary Impression • Cervical CA, t/c metastasis, myoma uterii • R/o TB lymphadenopathy

  26. Plan • Refer to GYNE • Monitor vital signs – possible ER admission • Refer to patho for biopsy– definitive diagnosis for TB lymphadenopathy • Order FBS

  27. Gynecologic Plan • Clinical Staging: FIGO stage IIIA (preliminary) • Involvement of lower 1/3 of the vagina • Evaluate further w/ DRE for lateral pelvic wall involvement (upgrades to stage IIIB) • Consider MRI as additional modality • Histopathology: determine prognosis, treatment • CLAD – biopsy may rule out metastasis • Treatment: Chemoradiotherapy (for stage IIB and above)

  28. Sources • WHO Comprehensive Cervical Cancer Control: A guide to essential practice • Harrison’s Principles of Internal Medicine 17th ed. • Novak’s Gynecology 14th ed. • ACR Appropriateness Criteria: Staging of Invasive Cancer of the Cervix. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonWomensImaging/InvasiveCanceroftheCervixDoc5.aspx

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