PROBLEM SOLVING
A 60 year old house wife presented with history of distension of lower abdomen since last 6 months. She has noticed that it is gradually increasing in size and is associated with mild pain in the lower abdomen which is dull aching in nature and doesn’t radiate. She has noticed an increase in the frequency of micturition, though her bowel habits are normal. No history of fever, cough with expectoration, vomiting, nausea. No history of similar complaints in the past. She is not a known diabetic or hypertensive. She is married and has 3 children, all normal vaginal deliveries and she has undergone tubectomy. She has attained menopause 12 years back. No history of postmenopausal bleeding and she has not been on HRT. She is not a smoker or alchoholic, a vegetarian and sleeps sound. On examination she is well built & nourished with a BMI of 27.She is not anemic, peripheral lymphnodes not palpable .Thyroid and Breast examination was normal. RS/CVS – NAD. Abdominal examination revealed a well defined circumscribed swelling of about 4x5 cms,below the level of the umbilicus, appears to be arising from the pelvis. Skin – normal, smooth surface, no prominent veins or pulsations . Fluid thrill present. Liver and spleen not palpable. No other organomegaly. Bowel sounds present. Vaginal examination revealed a fluctuant swelling occupying the pouch of douglas, non tender,tense, uterus not felt separate. Cervix and vagina healthy
1)List out the differential diagnosis. 2)What are the relevant investigations? 3)How would you proceed with the management?