Transcript Adnexal Mass - Josh Craig, FNP

Adnexal Mass
Joshua A. Craig
State University of New York Polytechnic Institute
Subjective History
Patient Information
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Patient: SP
Age: 57
Clinical Site: Alice Hyde Women’s Health
Student: Josh Craig, FNP- Student
Date of Encounter: November 10, 2014
Chief Complaint & History of Present Illness
• Chief Complaint: I am here today to follow up with Dr. O'Garro after my primary
care provider found a mass in late August.
• HPI: Presents today to follow up on a mass found by her PCP during a routine
physical exam in late August. Onset is new since pelvic exam last year. Located on
the right side during pelvic exam. Has had no associated abdominal pain or
cramping. Has experienced no limitations in ADLs. Has experienced no associated
vaginal bleeding or spotting. Has had no previous history of ovarian cysts or masses
upon past physical or gynecological examinations. Recently positive for goiter found
upon examination of thyroid during routine physical examination which is being
managed by her PCP. Has no further medical complaints or medical problems at
this time.
Review of Systems
• General: Denies change in appetite, body aches, chills, fainting, fatigue, fever, insomnia,
pain, feeling weak and weight change. General health stated as good.
• Skin: Denies any rashes, lesions, masses, dryness or changes in nail texture.
• CV: Denies arrhythmia, CAD, CHF, chest pain, dizziness, dyspnea, irregular heartbeat,
palpitations and swelling.
• Resp: Denies difficulty breathing, chest heaviness, chest tightness, cough, congestion,
dyspnea, hemoptysis, poor sleep quality, shortness of breath and wheezing.
• Neck: Positive for goiter. Denies having any swollen glands, pain, stiffness, decreased ROM,
difficulty breathing or swallowing.
ROS
• GI: Denies abdominal pain, abdominal cramping, abdominal swelling, change in appetite,
constipation, diarrhea, flank pain, heartburn, nausea, difficulty swallowing and vomiting.
• GU: Menarche at age 12. Menopause at age 50. Last pap test on performed on August 28, 2014- results
normal. Reports postmenopausal, but denies bloating, postcoital bleeding, sexual dysfunction, uterine fibroids,
vaginal problems, bleeding, discharge, foul smell, itching, lesion, mass, soreness and vulvar lesions. LMP was
7 years ago. Reports having genital warts in 1976 which cleared after treatment. Positive for an additional
STI , unable to specify what the STI was, lesions cleared after receiving an antibiotic several years ago.
Remains sexually active with her husband, neither use STI protection. Husband has had a vasectomy.
Positive for urinary incontinence with sneezing and heavy lifting. Denies having urgency or dribbling. Denies
having difficulty voiding, hematuria, sexual difficulites and frequent UTIs.
ROS
• Obstetrical: G 3 T 2 P 0 A 1 L 2
• Breast: Denies cancer, discharge, hot flashes, lumps, masses, pain, rash and
tenderness. Performs self breast examinations monthly.
• Psych: Denies anxiety, mood changes and sleep pattern disturbance.
• Endocrine: Reports goiter but denies diabetes, high cholesterol, hot flashes,
polyphagia, excessive thirst or excessive urination.
Past Medical History
• General Health: Last comprehensive examination September 2014
• Medical Illnesses: Hyperthyroidism, chronic rhinitis
• Health Maintenance: Mammogram on October 7, 2014, Bone Density Scan in 2006,
Depression Screening in October 1, 2014, Gynecologic Exam in 2014, Pap test on August 28,
2014.
• Surgical Hx: Tonsillectomy as a child, year unspecified.
• Hospitalizations: Childbirth in 1983 and 1986.
Allergies: Positive for allergy to Penicillin, causes hives. Positive for seasonal allergies. Denies any
allergies to food or latex.
Medications: Allegra 180mg PO daily
PMH
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Family Hx
Father: Positive for dementia and heart disease.
Mother: Negative for medical problems.
Children: 1 son and 1 daughter. Son positive for HTN. Daughter has no medical
history.
• No personal or family history of uterine, ovarian, endometrial, breast or colorectal
cancers.
• Social Hx: Patient has never smoked. Drinks twice weekly, would not specify
amount. Uses no illegal drugs. Drinks 2-4 cups of coffee daily.
Objective History
Physical Examination
• Vital Signs: BP 118/84, HR 81, R 18, T 98.4 F, Spo2 98% RA, Pain Level 0/10.
• General: A well-developed, well-nourished 57 year-old female who is alert, oriented and in no
apparent distress.
• Skin: Skin is uniformly pink in color with brisk skin turgor. No lesions or masses present. Skin
remains moist.
• Neck: Palpation reveals no lymphadenopathy. Thyroid exhibits goiter, but no nodules or tenderness on
palpation. Trachea remains midline.
• Resp: Vesicular lung sounds present bilateral lungs anteriorly and posteriorly. AP diameter 1:2.
No wheezing, rhonchi, rales or crackles present.
• CV: Rate is regular. Rhythm is regular. S1 & S2 intact. No S3, S4, murmurs, rubs, heaves or thrills
present.
Physical Examination
• Abdomen: Exam was done with a chaperone present. Positive bowel sounds in all 4
quadrants. Tympany present with percussion throughout abdomen. No tenderness with light
palpation. No organomegaly, splenomegaly or hepatomegaly present with deep palpation.
• GU: Did not examine.
• Lymph: No visible or palpable anterior or posterior cervical lymphadenopathy. No visible
or palpable supraclavicular lymphadenopathy. No visible or palpable axillary
lymphadenopathy. Inguinal nodes unremarkable. No adenopathy of the submandibular
nodes bilaterally.
• Psych: Mood/Affect: Patient's attitude is appropriate. No anxiety or depression present.
Affect is bright.
Assessment
Diagnostics Reviewed
CBC
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Glucose 80
BUN 17
Cr 0.88
Na 140
K 4.5
Cl 105
Ca 9.1
BMP
• WBC 5.0
• RBC 4.72
• Hgb 13.9
• Hct 43.0
• PLT 318
Diagnostics Reviewed
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TSH 0.877 (0.34-5.60)
LDL Cholesterol 101
HDL Cholesterol 72
Triglycerides 78
• All lab work drawn on August 28, 2014
Diagnostics Reviewed
• Transvaginal Pelvic US (October 7, 2014)
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Small calcification in the anterior aspect of the body of the uterus suggesting of small calcified fibroid.
Left ovary is not seen
Well defined hyperechoic mass could represent adnexal tumor on the right.
A follow-up MRI with and without contrast is recommended.
• MRI Pelvis With and Without Contrast (October 7, 2014)
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No definite fibroid seen
2.7cm x 2.4cm lesion with enhancement seen.
2cm simple cyst visualized in right ovary.
Uterus shows no abnormality.
No free fluid seen.
Diagnostics Reviewed
• MRI Abdomen (October 7, 2014)
• No abnormality seen.
• Mammography (October 7, 2014)
• Benign calcification in the upper out quadrant of the right breast. No mammographic
evidence for malignancy.
Differential Diagnoses
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Ovarian cancer
Uterine fibroid
Uterine cancer
Peritoneal cyst
Ovarian cyst
Diagnosis
• 620.2 Ovarian cyst
Etiology and Pathophysiology
• An ovarian cyst is a fluid filled sac or pouch that forms on the ovary. They most commonly occur during the
childbearing years, can develop one or more cysts, and can vary in size. They can also be harmless and benign
or problematic and malignant. (American Congress of Obstetricians and Gynecologists [ACOG], 2014).
• Neoplastic cysts: Arise via the inappropriate overgrowth of cells within the ovary and may be malignant or
benign. The most frequent neoplastic cysts arise from the ovarian surface epithelium (mesothelium). (Helm,
2014).
• Serous Cystadenomas: A form of neoplastic cysts. Arise from the ovarian epithelium. Serous
cystadenomas can become very large and are prone to torsion because of their size (Schuiling & Likis, 2013,
p. 693).
• Endometriomas (Chocolate cysts): Blood-filled cysts which are associated with endometriosis (Helm,
2014). Causes a classic triad of painful, heavy periods and dyspareunia (Helm, 2014). More commonly occurs
on the left ovary (Schuiling & Likis, 2013, p. 694).
Etiology and Pathophysiology
• Teratomas (Dermoid cysts): A form of germ cell tumor containing element from
all 3 embryonic germ layers- the ectoderm, endoderm and mesoderm (Helm, 2014).
They are filled with sebaceous material and often contain hair, bone, teeth, or other
tissues from the germ layers (Schuiling & Likis, 2013, p. 693). Ovarian torsion
occurs in as many as 10% of teratomas (Schuiling & Likis, 2013, p. 693).
• Functional cysts: Functional cysts are the most common forms of ovarian cysts
and include follicular cysts and corpus luteal cysts. Follicular cysts occur from a lack
of physiologic release of the ovum due to excessive FSH stimulation or lack of the
normal LH surge at midcycle just before ovulation. Hormonal stimulation causes
these cysts to grow. Corpus luteal cysts occur when there is failure of dissolution of
the corpus luteum after 14 weeks’ time. (Helm, 2014).
Incidence
• Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to 18% of
post-menopausal women.
• Mature cystic teratomas, or dermoids, represent more than 10% of all ovarian neoplasms.
• Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with a race
predilection. Women from northern and western Europe and North America are affected most frequently.
• For women aged 55-69 years, the highest rates occur in white women followed by Hispanic and Japanese
women.
• The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors
rises exponentially with age until the sixth decade of life at which point the incidence plateaus.
• Tumors of low malignant potential occur at a mean age of 44 years.
(Helm, 2014)
Diagnostic Screening Recommendations
• Medical Imaging
• CT Scan
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Best for imaging hemorrhagic cysts. More sensitive but less specific than US.
• MRI
• Reserved for cases in which US and CT scan results are indeterminate in identifying a mass as an
ovarian cyst.
• Ultrasound
• Primary tool for a patient suspected to have an ovarian cyst
(Helm, 2014)
Diagnostic Screening Recommendations
• Blood Work
• Cancer antigen 125
• Indicated for women past menopause
• CBC
• Evaluate H&H for anemia and WBC for potential infectious causes
• Urinalysis
• Indicated if experiencing abdominal or pelvic pain
(Helm, 2014)
Treatment Recommendations
• For postmenopausal women
• Repeat US and Ca-125 in 4-6 weeks
• Referral for surgery if simple ovarian cysts remain persistent, symptomatic and size
increases to 5-10cm
(Helm, 2014)
Plan
Plan
• Diagnostics: CA 125, Abdominal US
• Therapeutic: No medications or surgical interventions are required at this time. We will
continue to monitor the growth of the ovarian cyst via Abdominal US follow-up in 3
months. We will also draw labs to check for cancerous markers.
• Special Instructions: Call if you experience sudden onset of unilateral pelvic pain or if
you notice any spotting or vaginal bleeding.
• Patient Education: Discussed ovarian cancer, STI monitoring and safe sex practices,
hyperthyroid management.
• Follow-Up: Follow up in 4-6 weeks to review your Abdominal US results. Follow-up at the
women's health clinic for any further gynecologic issues.
References
• American Congress of Obstetricians and Gynecologists. (2014). FAQ:
Frequently asked questions gynecologic problems. Retrieved from
http://www.acog.org/Patients/FAQs/Ovarian-Cysts
• Helm, C. W. (2014). Ovarian cysts. Medscape. Retrieved from
http://emedicine.medscape.com/article/255865-overview
• Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.).
Burlington, MA: Jones & Bartlett Learning.