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Case Presentation

Case Presentation . Gynecology 성균관대학교 의과대학 2007313075 손의영. Chief Complain. 정 O 록 , F/76 외부 건강 검진상 발견된 이상소견 Onset : 1MA. Present Illness. Previously healthy 2011.04 보라매병원에서 건강검진 시행 MRI 상 ovary cancer 의심되어 수술 권유 받음 2011.05.04 본원으로 전원 후 w/u. Other History. PMHx .

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Case Presentation

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  1. Case Presentation Gynecology 성균관대학교 의과대학 2007313075 손의영

  2. Chief Complain • 정O록, F/76 • 외부 건강 검진상 발견된 이상소견 • Onset : 1MA

  3. Present Illness • Previously healthy • 2011.04 보라매병원에서 건강검진 시행 MRI 상 ovary cancer 의심되어수술 권유 받음 • 2011.05.04 본원으로 전원 후 w/u

  4. Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) • Hypothyroidism (+), MDD (+) • 약물력: 씬지로이드(40YA)정신과약– 가스모틴, 사미온정, 자나팜정, 졸로푸트정 • 수술력: 없음 • FHx. • 당뇨 : 넷째 여동생, 다섯째 여동생 • 위암 : 첫째 오빠 • SHx. • Marriage : 기혼 • smoking: no • alcohol: no

  5. Review of system • GW / EF ( - / - ) • Weight change (-) • fever/chill ( - / - ) • Headache/dizziness ( - / - ) • Rhinorrhea/ cough /sputum ( - / - / - ) • Dyspnea(-) • chest pain / palpitation ( - / - ) • anorexia/nausea/vomiting ( - / - / - ) • abdominal pain/discomfort ( - / - ) • constipation/diarrhea ( - / - ) • hematemesis/melena/hematochezia ( - / - / + ) • Urinary Sx (-) • Arthralgia(-) • Myalgia (-)

  6. Physical Exam • Vital Sign 2011-05-22 17:26147/69mmHg - 45- 20 - 36℃ • G/A Generally well-looking appearance • Mentality Alert & well orientation • AbdomenPalpation – Soft & flat No tenderness/rebound tenderness

  7. CT

  8. Problem List / Assessment • Problem List • #1. Left ovary mass • #2. Hypothyroidism • Assessment • #1. : R/O ovary cancer

  9. Therapeutic Plan • Surgery & Biopsy • BSO • Omentectomy (total) • LAVH, adhesiolysis

  10. Pathology • Granulosacell tumor, adult type, left ovary • 1) tumor size : 7 x 6 x 4 cm • 2) surface involvement : cannot be evaluated • 3) mitosis : 2/10 HPF • 4) confined to left ovary • Complex hyperplasia w/o atypia • Chronic cervicitis, cervix • No diagnostic abnormalities recognized • left salpinx, right ovary and salpinx • No evidence of malignancy, omentum

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