36 year old female with low backache and past ovarian tumor

 

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Case:

This is a case of a 36 year old female with chief complaints of chest pain since 26/05/2023.

HISTORY OF PRESENTING ILLNESS:

In December 2020

Patient had complained of pain abdomen on the left side which was insidious in onset and gradually progressive. She went to the hospital and was diagnosed to have a huge cystic lesion in the pelvis extending into abdomen and ovarian cysts.

In January 2021, 

The histopathology report showed that she had a  left ovarian cyst (serous papillary adenocarcinoma)

 low grade  & case was referred to another hospital where USG & CA-125 were done  and CA-125 was found to be normal

In February 2021,

The biopsy was reviewed and it showed that she had seromucinous adenocarcinoma in one ovary and simple serous cyst in the other ovary. She was operated and was advised for chemo but they were not affordable.

In February 2023 

she complained of low back ache which is radiating to left lower limb till the thigh which was dragging type followed by tingling sensation and was on medication.

In March 2023

 She  went to the hospital  and was diagnosed with potts spine and was on anti tubercular  medication.

10 days later, she visited another hospital as her left lower limb swelling had increased till the foot and she wasnt able to walk and was given medication.

10 days ago, she complained of vomiting (2 episodes/day), food as content, non foul smelling,non bilious and non projectile everyday after taking ATT medication.

5 days ago, patient had noticed yellowish discoloration of eyes and went to the hospital and was diagnosed to have jaundice.

 On 26/05/2023

She started herbal medication to treat jaundice.

She developed fever which is on and off with chills and rigors.

On 26/05/2023, 6pm

 She developed chest pain,non radiating,prickling type of pain and taken to another hospital where they gave her medication but the pain had not subsided.

On 27/05/2023, 3:30am

She came to the casuality.

Daily routine:

Patient was a nurse until 2008. 

She is a homemaker now.

She wakes up at 5am and does the household chores and has her breakfast around 7am.

She has her lunch around 1pm and takes a nap.

In the evening she prepares snacks for her kids and cooks dinner for her family.

She has her dinner around 8pm and goes to bed at 10pm.

PAST HISTORY:

-Not a known case of DM,HTN,TB,Asthma,epilepsy and thyroid abnormalities.

- surgical history of an ovarian tumor 4 years ago.

PERSONAL HISTORY:

Diet:non vegetarian 

Apetite: decreased

Sleep: decreased 

Bowel and bladder:regular

Addictions: none

She has lost weight (10kg) since 4 months

GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative

No pallor,icterus,cyanosis,clubbing,lymphadenopathy and pedal edema.

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

CNS: no focal neurological deficits

Abdomen: soft  and non tender

RS: Bilateral air entry present

Investigations done in another hospital:

29 December 2020

30th December 2020

19th January 2021

30th January 2021

8th February 2021

16th February 2021

 

4th April 2023

Gandhi hospital discharge (15/04/2023 to 22/04/2023)

24th April 2023

X rays:

Investigations:

27/05/2023

28/05/2023:

29/05/2023

30/05/2023

27/05/2023:

Ward : ICU

Unit : 5

DOA : 27.5.2023

36 year old female with chest pain since 1 day

S  

No fever spikes

Stools passed

 O: 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 140/90mmhg

PR -96bpm

RR-28cpm

GRBS-112mg/dl

Spo2 99% at room air 

Temperature -98.5F

CVS:s1,s2 heard ,no Murmurs,jvp not raised 

RS:BAE,no added sounds ,NVBS, 

P/A: soft, non tender

CNS:NFND

A: 

Low backache with left lower limb swelling under evaluation 

?Potts spine with renal AKI

P: 

1.Inj.Pan 40mg IV OD

2.Inj.Zofer 4mg IV SOS

3.Inj.Lasix 40mg IV BD

4.Tab.Isoniazid 5mg/kg-200mg

5.Tab.Rifampicin 10mg/kg-400mg

6.Tab.Pyrazinamide 25mg/kg-1000mg

7.Tab.Ethambutol 15mg/kg-600mg

8.Tab.Benadone 40mg PO OD

9.Inj.Piptaz 4.5gm IV STAT f/b 2.25gms IV TID

28/05/2023

Ward : ICU

Unit : 5

DOA : 27.5.2023

S  

Chest pain (subsided)

No fever spikes

Stools passed

 O: 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 120/80mmhg

PR -92bpm

RR-24cpm

GRBS-106mg/dl

Spo2 - 98% at room air 

Temperature -98.6F

CVS:s1,s2 heard ,no Murmurs,jvp not raised 

RS:BAE,no added sounds ,NVBS, 

P/A: soft, non tender

CNS:NFND

A: 

Low backache with left lower limb swelling under evaluation 

?Spine metastasis

 ?Deep vein thrombosis of left lower limb with renal AKI

P: 

1.Inj. Piptaz 2.25g IV/BD

2.Inj.Lasix 40mg IV BD

3.Inj.Tramadol 1amp in 100ml NS IV/BD

4.Inj.Zofer 4mg IV BD

29.5.2023

Ward : ICU

Unit : 5

DOA : 27.5.2023

S  

-Chest pain (subsided)

-fever spikes

3pm:101.2F

6pm:100.9F

-Stools passed

 O: 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 130/80mmhg

PR -70bpm

RR-18cpm

Spo2 - 98% at room air 

Temperature -98.2F

CVS:s1,s2 heard ,no Murmurs,jvp not raised 

RS:BAE,no added sounds ,NVBS, 

P/A: soft, non tender

CNS:NFND

A: 

Low backache with left lower limb swelling under evaluation 

?Spine metastasis

 ?Deep vein thrombosis of left lower limb with renal AKI

K/c/o low grade serous papillary adenocarcinoma of left ovary and simple serous cyst of right ovary (2020)

P: 

1.Inj. Piptaz 2.25g IV/BD

2.Inj. Clexane 40mg S/C OD

2.Inj.Lasix 40mg IV BD

3.Inj.Tramadol 1amp in 100ml NS IV/BD

4.Inj.Zofer 4mg IV BD

30/05/2023

Ward : AMC

Unit : 5

DOA : 27.5.2023

S  

-c/o nausea

-back ache and left lower limb swelling decreased compared to yesterday 

- fever spike at 1pm since yesterday 

1pm: 99.8F

-Stools passed

 O: 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 120/80mmhg

PR -82bpm

RR-18cpm

GRBS:104mg/dl

Spo2 - 98% at room air 

Temperature -98.6F

I/O:1850/900ml

CVS:s1,s2 heard ,no Murmurs,jvp not raised 

RS:BAE,no added sounds ,NVBS, 

P/A: soft, non tender

CNS:NFND

A: 

Low backache with left lower limb swelling under evaluation 

?Spine metastasis

 ?Deep vein thrombosis of left lower limb 

?Liver metastasis; Renal AKI

B/L cervical lymphadenopathy 

S/P FNAC of right supraclavicular lymph node

K/c/o low grade serous papillary adenocarcinoma of left ovary and simple serous cyst of right ovary (2020)

S/P ? Left salpingoopherectomy in 2020

P: 

1.Inj. Clexane 40mg S/C OD

2.Tab.Lasix 40mg PO/BD

3.Tab.Dolo 650mg PO/SOS

4.Tab.Zofer 4mg PO/BD

DISCHARGE SUMMARY: