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Case 5

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Case 5 Powered By Docstoc
					Shannon Armbruster
            Jen Ha
     Dana Foradori
         Sobia Raja
Chief Complaint
 26 y.o. F came into the OB/Gyn with complaint of
  vaginal spotting and lower abdominal pain.
 PMH – previous pregnancy w/o incident and
  pelvic infection 3 years prior to pregnancy
 HCC- no significant vaginal discharge (other than
  spotting).
   No trauma
   No recent intercourse
Physical Exam
   Vital signs:
   BP – 90/60
   Pulse – 110
   Rhythm – Regular
   Temeprature - 98.6°F
   Respiratory rate – 17
   Height – 5’3’’
   Weight – 125 lbs.
HEENT Exam
 Lungs/CV/Abdominal /Musculoskeletal/Neurologic
 exam were normal except for:
   Moderate tenderness in the right lower quadrant of the
    abdomen.
 Transvaginal sonogram showed an empty uterus with
 free fluid in the “cul-de-sac”
Cecum

Appendix

Right ovary

Right Fallopian
  Tube

Right ureter
                                 RIGHT UPPER QUADRANT (RUQ )
RIGHT LOWER QUADRANT (RLQ)                        Liver
            Cecum                              Gallbladder
          Appendix                             Duodenum
     Right ovary and tube                   Head of pancreas
                                        Right kidney and adrenal
         Right ureter
                                         Hepatic flexure of colon
                                 Part of ascending and transverse colon

  LEFT LOWER QUADRANT (LLQ)
      Part of descending colon     LEFT UPPER QUADRANT (LUQ)
           Sigmoid colon                          Stomach
        Left ovary and tube                        Spleen
              Left ureter                     Left lobe of liver
        Left spermatic cord                  Body of pancreas
                                          Left kidney and adrenal
            MIDLINE                       Splenic flexure of colon
               Aorta             Part of transverse and descending colon
        Uterus (if enlarged)
       Bladder (if distended)
                                           University of Pittsburgh
Appendicitis
 Symptoms: acute abdominal pain moving to lower
 right abdomen, nausea, vomiting, diarrhea, low-grade
 fever
             Ectopic Pregnancy
 Consider due to unidentified pelvic
 disease

 Rule out due to no reported recent
 intercourse and no unusual
 pregnancy shown by ultrasound
            Pelvic Exam
1. External examination of vulva
2. Internal examination/palpation of vagina
   and cervix
3. Pap smear
4. Transvaginal palpation of uterus and
   ovary
5. Retrovaginal exam: insertion of index
   finger into vagina and another finger into
   rectum, assess for uterus and ovaries

On pelvic exam, external genitalia was
   normal and uterus was palpable and
   normal.
           Transvaginal Sonogram
 Type of pelvic ultrasound in which
  probe is inserted into vagina

 Used to identify source of pelvic pain,
  infertility, abnormal bleeding

 Creates images of vagina, cervix,
  uterus, fallopian tubes, and ovaries

A transvaginal sonogram showed an
  empty uterus with free fluid in the
  “cul-de’sac”.
  Pelvic Inflammatory Disease
 Infection of uterus or fallopian tubes due to bacteria
  entering through vagina
  -Gonorrhea and Chlamydia greatly increase risk
  -Increases risk of ectopic pregnancy and infertility
      Symptoms: pelvic pain, irregular vaginal bleeding,
  fever, abnormal discharge
  -Diagnosis: painful palpation, enlargement of
  structures on ultrasound
              Ovarian Cancer
•Symptoms: pressure or pain in the abdomen, pelvis, back, or
legs, a swollen or bloated abdomen, nausea, indigestion,
diarrhea, feeling very tired all the time

•Symptoms usually do not present until cancer has advanced


•Appears in ultrasound, biopsy may confirm diagnosis


•Antigen 125 (CA-125) in blood
               Endometriosis
 Retrograde menstruation: shedding endometrium flows
  backward through fallopian tubes and into peritoneal
  cavity
 May implant on any mucous membrane in cavity, most
  likely in the rectouterine pouch
 Deposited tissue responds to estrogen, progesterone,
  LH, and FSH in the same way as the endometrium
                Endometriosis
 Symptoms include pelvic
  pain, dysmenorrhea,
  infertility, painful
  intercourse, abnormal
  menstrual bleeding,
  chronic fatigue, cyclical
  bowel or bladder
  symptoms
 Most common tenderness
  is upon palpation of
  posterior fornix
                             Ovarian Cysts
 Very common but may cause pelvic pain if
   they exceed 2 centimeters in diameter (may
   be detected by ultrasound)

 Several types of cysts, type can only be
   determined by histological techniques

 Follicular cysts are most common. They are
   caused by a follicle that did not rupture
   during ovulation. These generally
   degenerate in a few days or months.

 Granulosa luteal cysts form from the corpus
   luteum and therefore do not hold an egg.
   They are normal in the ovary but may
   rupture and cause peritoneal irritation

 Laparoscopy is most effective diagnostic
   procedure
                 Ovarian Cysts
 Symptoms: onset of unilateral
  lower abdominal pain, light
  vaginal bleeding (spotting),
  possible pressure on rectum or
  bladder, possible nausea and
  vomiting

 Vaginal bleeding may be caused
  by elevated estrogen produced
  by persistent theca cells. This
  causes endometrial
  abnormalities.
                    Culdocentesis
 Sampling of ascites in cul-de-sac
 Use aspiration
 Needle pierces the posterior fornix of the vagina
 Ultrasound generally preferred over culdocentesis due to risks:
  -bowl perforation
  -trauma to pelvic cavity
  -infection from vagina transmitted to peritoneal cavity
                   Cul-de Sac
 Also called Rectouterine Pouch and Pouch of Douglas
 Lowest point of peritoneal cavity when standing
 Excess fluid (ascites) accumulates here, indicative of
 abnormality within peritoneal cavity
                 Laparoscopy
 Small scope inserted through a 2-centimeter incision
 below umbilicus, inert gas pumped into
 pneumoperitoneum, and pelvis is elevated so that
 intestines slide toward head, insert laparoscope

 May be used to view and take pictures of fluid
 accumulation, scar tissue, adhesions
                Nerve Supply
 Ascites causes pressure on and irritation to the parietal
  peritoneum

 Peritoneum around Cul-de-Sac is innervated by
  visceral afferent nerves of the uterovaginal plexus, a
  division of the inferior hypogastric plexus

 Ovarian Plexus is sympathetic innervation to the ovary
  and fundus of the uterus. It comes from the renal
  plexus.
                     Ascites
 Depending on the results of the laparoscopy, the type
 of fluid can be determined

 Fluid from a ruptured cyst would be serous or mucous


 Fluid caused by hemorrhage from surrounding vessels
 would be bloody
   Arterial/Venous/Lymphatics to Uterus
 Uterus:
   Arterial: common illiacinternal iliacanterior internal
    iliacuterine arteries (and some collateral supply from ovarian
    arteries)
   Venous: uterine venous plexusuterine vein internal iliac
    common iliac vein

   Lymphatics: 3 main routes
       Fundus and superior uterine body lumbar lymph nodes lumbar
        lymph trunkschyle cisternthoracic duct
           Fundus near uterine tube entrance  superficial inguinal lymph nodes
       Uterine body  external iliac lymph nodes
       Uterine cervix  Internal iliac lymph nodes/sacral lymph nodes
   Arterial/Venous/Lymphatics to Uterus
 Uterus:
   Arterial: common illiacinternal iliacanterior internal
    iliacuterine arteries (and some collateral supply from
    ovarian arteries)
   Venous: uterine venous plexusuterine vein
    internal iliac common iliac vein

   Lymphatics: 3 main routes
     Fundus and superior uterine body lumbar lymph nodes
      lumbar lymph trunkschyle cisternthoracic duct
           Fundus near uterine tube entrance  superficial inguinal lymph nodes
       Uterine body  external iliac lymph nodes
       Uterine cervix  Internal iliac lymph nodes/sacral lymph nodes
Uterine Body
                 Fallopian tube
 Arterial: uterine and ovarian arteries  anastomosing terminal
  branches  tubal branches

 Venous: tubal veins  uterine venous plexus/ovarian veins


 Lymphatics: lumbar lymph nodes
                         Ovary
 Arterial: ovarian artery enter suspensory ligament 
  branches through mesovarium to ovary
 Veinous: ovarian veins  pampniform plexus of veins 
  ovarian vein
   Right ovarian vein IVC
   Left ovarian vein  left renal vein IVC
 Lymphatics: follow ovarian blood supply (of uterine tubes
  & fundus of uterus)  lumbar lymph nodes

				
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