DR. JOSE R. REYES MEMORIAL MEDICAL CENTER DEPARTMENT OF SURGERY General Data: This is a case of FM, 63/F, married, Roman Catholic from Malolos, Bulacan who was admitted at our institution for the first time on March 15, 2009. Chief complaint: abdominal mass History of Present Illness: The patient was apparently well until 8 months PTA, patient noted palpable mass at the epigastric region. The mass was described to be palpable,solitary, movable and non tender. There were no associated vomiting, weight loss, nor easy satiability. No consult was done nor medications were taken. 2months PTA, persistence of the above mentioned complaints prompted consult at our institution. Ultrasound was done revealing a solitary solid mass with surrounding fluid at the left lobe of the liver. CT Scan was also requested revealing gastric vs hepatic mass. The patient was then advised to have an EGD done. 1 month PTA, endoscopy was done which showed an extraluminal compressing mass at the antral-pyloric area. Biopsy was done which revealed chronic inflammation with fibrosis, negative for malignant changes. Patient was advised operation. Few days PTA, patient experienced pain over the epigastric mass. Review of Systems: (-) fever (-) chest pain (-) hematemesis (-) anorexia (-) orthopnea (-) hematochezia (-) weight loss (-) PND (-) melena (-) malaise (-) dysphagia (-) weight loss (-) headache (-) odynophagia (-) urinary changes (-) dyspnea (-) hoarseness (-) constipation Past Medical History: S/P Excision of TB adenitis 20 years ago S/P EGD with biopsy (2/23/09 JRRMMC) (-) DM, HPN, HD, BA, CVD, PTB Family Medical History: (-) HPN, HD, DM, BA, CA, PTB, CVD Personal and Social History: Non-smoker and non-alcoholic beverage drinker, denies illicit drug used Physical Examination: Awake, conscious, coherent, ambulatory BP- 130/80 HR-80 RR-19 T-afebrile Ht-1.57m Wt- 47kg BMI-19 Pink palpebral conjunctivae, anicteric sclera, no lymphadenopathies, no TPC No alar flaring, no retractions, ECE, CBS, no rales, no wheezes No heaves, no thrills, AB at 5th ICS LMCL, distinct heart sounds, normal rate and regular rhythm, no murmurs No scars, Flat abdomen, NABS, (+) 2x2 cm mass at the epigastric area movable nontender, NABS, no hepatomegaly, no tenderness Pink nailbeds, no jaundice, full and equal pulses Admitting Diagnosis: Antral-pyloric mass T/C Ca Course in the wards: Hospital Day 1 S> 67/F complaining of abdominal mass, no other associated symptoms O> BP = 130/90, HR 82, RR=20, T= 36.8, essentially normal physical exam except for 2x2 cm epigastric mass A> Gastric Mass T/C Malignancy P> DAT, secure OR needs Hospital Day 2 S> no subjective complaints, seen by anesthesia O> stable vital signs A> same P> preop meds ordered, NPO postmidnight, venoclysis started Hospital Day 3 S> underwent operation O> BP=130-160/80-90, HR=80-110, RR=20-24 A> Same + S/P Exploratory Laparotomy, Frozen section of antral-pyloric mass, subtotal gastrectomy, Billroth I, JP drain. P> Tramadol 50mg IV LD as LD then 250mg D5W 500cc x 15ugtts/min Ranitidine 50mg IV q12 Cefoxitin 1g IV q8 For post op CBC, Na, K . Hospital Day 4 S> 1st post op day, afebrile, (-) BM, (-) flatus, VAS =8/10 O> soft flat abdomen, hypoactive bowel sounds, minimally soaked dressing with blood JP drain output:144 cc serous A> same P> NPO daily wound care deep breathing exercise ambulation encouraged IV meds continued D10W 10cc q2 per NGT started tramadol drip to increased to 20ugtts/min NSS (2cc) nebulization q6 initiated Hospital Day 5 S> 2nd Post op day, (-) nausea, (-) vomiting, (+)minimal to moderate operative site pain, (-)BM, (-) flatus O> afebrile, soft and flat abdomen, hypoactive bowel sounds, JP output=38cc serous A> same P> NPO Cont. IV meds foley catheter removed Daily wound care NGT feeding increased to 30 CC q2 Hospital Day 6 S> 3rd post op day, (-) nausea, (-)vomiting,(-)BM, (-)flatus, minimal operative site pain O> afebrile, soft and flat abdomen, hypoactive bowel sounds, JP output= 14 cc serous A> same P> NPO IVF continued , Cefoxitin consumed D10W x 50ccq2 Hospital Day 7 S> 4th post op day, (+) flatus , (-) vomiting, (-) abdominal pain, NGT pulled out O> afebrile, , (-) BM, soft abdomen, hypoactive bowel sounds, JP output: 10 cc A> same P> Clear liquids with SAP Ranitidine and Tramadol drip continued Hospital day 8 S> 5th Post op day (-) nausea, (-) vomiting, (-) abdominal pain, (-) abdominal distention, (-) fever, (+) BM, (+) flatus O> soft abdomen, normoactive bowel sounds, dry well coaptated wound, JP output: 44 cc A> same P> GL-SD-DAT IVF and IV meds consumed Start Etoricoxib 120mg/tab 1 tab OD Hospital Day 9 S> 6th Post OP day, (-) fever, (+) BM, (+) flatus O> normoactive bowel sounds, dry well coaptated wound, (-) discharge/surgical site A> same P> DAT Pull out JP drain prior to discharge Discharged improved Scheduled for OPD ff-up after 1 week Laboratories: HEMATOLOGY: Date Normal 2/25/09 3/17/09 WBC 5-10 x109/L 10.7 16.50 RBC 4.2-5.4 x109/L 3.78 Hgb 120-160g/L 120 113 Hct 0.38-0.47% 0.36 0.34 Platelets 150-400 x109/L 188 Neut% 0.5-0.7 .88 Lymph% 0.2-0.5 .07 Mono% 0.02-0.09 .05 Eo% 0.0-0.06 .00 Baso% 0.0-0.02 0.00 PROTHROMBIN TIME DATE Normal 1/13/09 2/25/09 Protime Ctrl 10-14 secs 14.01 14.17 Patient 17.51 15.0 Activity 79% 92% INR 1.0 1.40 1.10 ACTIVATED PARTIAL THROMBOPLASTIN TIME Date Normal 1/13/09 2/25/09 Control 23.4-36.2 Patient 32.21 28.29 BLOOD CHEMISTRY Date Normal 1/13/09 1/20/09 1/22/09 2/25/09 3/17/09 Glucose 65-110mg/dL 96.18 95.09 BUN 7-17 mg/dL 10 12.61 Creatinine 0.7-1.2mg/dL 1.1 1.08 Sodium 135-145mmol/L 136 142 Potassium 4.0-4.5mmol/L 4.8 3.5 Total protein 6.6-8.7g/dL 7.59 7.49 Albumin 3.8-5.1g/dL 2.29 5.39 5.32 Globulin 2.8-3.6g/dL 2.30 2.10 URINALYSIS Date Normal 2/25/09 Color Yellow Yello Transparency Clear/hazy Slightly turbid SG 1.016-1.022 1.010 pH 4.6-6.5 7.0 Sugar (-) (-) Albumin (-) Trace RBC 0/0-2/hpf 5-10 WBC 0-2/0-5/hpf 1-2 Casts hyaline, coarse, None fine, granular, RBC, WBC, waxy Crystals Small amounts Amorphous urates crystals Epith cells Small amounts (+) Bacteria (-) (-) Mucus thr Small amounts TUMOR MARKERS Marker Normal Result CEA 0-3.4ng/ml 2.28 AFP 0-8.5ng/ml 0.1 RADIOGRAPHS Date Exam Results 1/13/09 CXR Atheromatous aorta 1/15/09 Whole Liver is normal in size with rounded solid echopattern surrounded by anechoic or fluid echo in the left abdominal lobe 3.7 x 2.9 cm in size; ducts and portal vessels not dilated, gallbladder 5 x 2 cm x 1.2 cm in size no UTZ stones, wall nott thickened; pancreas normal in size and echogenicity; spleen not enlarged with normal echopatttern. Bilateral kidney, small or tiny lithiasis, ureter not dilated, normal bladder; uterus small and atrophied; ovaries not enlarged Impression: 1. Consider solitary solid mass with surrounding fluid left lobe liver 2. Small or tiny lithiasis both kidneys 3. Gallbladder, pancreas, spleen, ureters, urinary bladder, ovaries are unremarkable 4. Small atrophied uterus 1/21/09 CT Scan of 4 x 3.5 cm minimally embracing isodense fairly defined soft tissue forms at epigastric region, the inseparable with the gastric antralpyloric portion and the Left Liver lobe; Normal parenchymal Abdomen attenuation with smooth contour, intrahepatic ducts not dilated; gallbladder normal in size and configuration, wall not thickened, no stones;unremarkable pancreas, adrenal glands, spleen, no calcifications; slightly enlarged peripancreatic, paraaortic and aorto-caval nodes seen, no infiltration/thickening of mesenteric fat; unremarkable kidneys, proximal ureters are normal; opacified stomach appears to have thickend wall with fullness seen at its antral-pyloric portions; urinary bladder well opacified with smooth wall Impressions: Left liver lobe vs. gastric antral pyloric mass 2/25/09 CXR Atheromatous aorta, normal chest findings ELECTROCARDIOGRAMS Date Exam Results 2/26 ECG Normal sinus rhythm with occasional PAC, NSSTTWC EGD with Biopsy (Feb 23, 2009): Chronic inflammation with fibrosis, negative for malignant changes SURGICAL PATHOLOGY REPORT SO9-1314 Gross. Specimen consist of a segment of the gastric measuring 14x7.5x 4.5 cms. External surface shows rubbery, smooth, tan-brown. Cut section shows prominent edematous mucosal folds with thickened muscular wall near the distal line of resection measuring 4.0 x 3.5cm smooth with white streak surface. Microscopic. Microsections show proliferationof plump to elongated myofibroblasts arranged in short fascicles embedded in a collagenous stroma are numerous lymphoplasmacytic infiltrates penetrating the muscular wall. Some areas of the gastric muscular have been replaced by myofibroblastic proliferation. Diagnosis: Inflammatory Pseudotumor Frozen Section Diagnosis: Malignant T/C Gastrointestinal Stromal Tumor Remarks: Request for Vimentin and smooth muscle actin immunistatins for more definitive diagnosis.
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