STAFF ROUND PRESENTATION

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STAFF ROUND PRESENTATION

• Presented by
• Resident Aisha El Sharkawy

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Members of the unit

• Prof. Dr. Gamal Esmat.
• Prof. Dr. Hassan Elgarem.
• Prof .Dr.Maissa Elraziky.
• Dr. Mohamed Ibrahim.
• Dr. Wafaa Elakel.
• Dr. Ahmed Fouad.
• Dr. Dina Ismaiil.
• Dr. Mohamed hamed.
• Dr. Fatma elkady.
• Dr. Mohmed abd Elhafez.

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Personal history

• A female patient, N. A. N , 40 years old,
  married 20 years ago, having 4 offsprings, the
  youngest 12years.
• She is a housewife, she was born in Assiut but
  3 years ago, she moved to Helwan .
• There is history of contact with canal water
  but she didnt receive antischistosomal
  treatment.

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• Menarche at the age of 13 with history of
  regular cycles.
• History of using several methods of
  contraception oral contraceptive pills 11 years
  ago for one year followed by hormonal injection
  for one year and lastly IUD which was removed
  after an attack of vaginal bleeding, 9 years ago.

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Complaint

• Abdominal distention.

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Present history

• The condition started 8 years ago by
  gradual onset progressive course of abdominal
  distention which was not associated with lower
  limb edema, no abdominal pain, no fever and with
  normal bowel habits.

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• However the patient experienced an attack of
  hematemesis at the onset of the condition, about
  one cup of fresh blood, not associated with
  melena or disturbed conscious level ,for which
  she sought medical advice and upper endoscopy was
  done to her which revealed mild gastritis.

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• During this 8 years ,the abdominal distension
  was progressively increasing with loss of weight
  during the last 3 years.
• Nine months ago, the patient developed cough,
  expectoration of white sputum, small in amount,
  not related to posture with dyspnea on the second
  floor but no orthopnea , PND or hemoptysis.

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• No urological symptoms.
• No musculoskeletal or neurological symptoms.

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Past history

• No history of T.B or admission to fever hospital.
• The patient is not known to be diabetic or
  hypertensive.
• No history of blood transfusion.
• No history of operations.
• No history of drug intake.

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Family history

• No similar condition .
• -ve consanguinity.
• No family history of T.B.

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Summary

• A female patient, 40 years old complaining of
  abdominal distension 8 years ago, loss of wt 3
  years, recurrent attacks of productive cough
  during last 9 months.

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• EXAMINATION

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General examination

• The patient is fully conscious, co-operative,
  average intelligence well oriented to time,
  place persons.
• -She is lying comfortable in bed.
• -She is underweight.
• -Pulse80/min.
• -Temp 37C .
• -BP 120/80

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• No pallor.
• No cyanosis no jaundice.
• No thyroid swelling no lymphadenopathy.
• No congested neck veins
• Upper limb
• No pallor.
• No ecchymotic patches at site of injections.
• No clubbing.
• Lower limbs No lower limbs oedema.

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Abdominal examinationInspection

• Generalized abdominal distension with bossy
  appearance and full flanks.
• No divarication of recti.
• Wide subcostal angle.
• Umbilicus shifted down and everted.
• Ecchymotic patch at RT hypochondrium.
• No scars, no abdominal wall veins, no hernias

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Superficial palpation

• No abdominal tenderness.
• There is a large abdominal mass felt in all
  quadrants of the abdomen except the RT iliac and
  lower suprapubic quadrants.

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Deep palpation

• Liver
• Upper border 7th space MCL.
• The abdomen is occupied by a mass which is
  inseparable from the lower border of the liver.
• -site in all quadrants of the abdomen except
  RT iliac and lower suprapubic quadrants.
• -size 16 cm below RT costal margin, 30cm below
  xiphisternal junction with a transverse diameter
  of 40 cm.

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• -soft to firm in consistency, with rounded edge
  and bossy surface.
• -Auscultation revealed no bruit or rub.
• Spleen not felt and traubs area resonant.
• No ascites detected in the suprapubic area.

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Cardiac examination

• Free.

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Chest examination

• Inspection Free
• Palpation Free
• Percussion Free
• Auscultation
• -Vesicular breathing with prolonged
  expiration.
• - generalized inspiratory and expiratory
  rhonchi.

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Neurological examination

• - Clinically free

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URINALYSIS

• Protien Nil.
• Glucose Nil.
• Bile pigment Nil.
• Pus cells 1-2/HPF
• No RBCs, casts, crystals or ova.

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Stool analysis

• Free

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CBC

• RBCs 3.3 million
• HGB 10.1gm
• MCV 87 fl.
• MCH 30 pg.
• MCHC 34 g/dl.
• PLT 350,000.

• WBCS4800
• B0
• E2
• St1
• Seg56
• LYMPH36
• MONO5

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ESR (after correction)

• 1st hour 13 mm
• 2nd hour 29 mm

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Liver biochemical profile

• BIL T 0.9 mg/dl (0.2-1.2)
• AST 15 u/l (0-41)
• ALT 6 u/l (0-41)
• TOTAL POTEINS 7.7 g/dl. (6.4-8.3)
• ALBUMIN 4 g/dl (3.5-5)
• ALP 87 u/l (35-104)

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• PT 15 sec
• PC 70

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RENAL FUNCTIONS

• Urea 41 mg/dl (10-50)
• Creatinine 0.6 mg/dl (0.7-1.3)

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• FBS 90
• 2 hours post prandial blood sugar 110

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ABDOMINAL U/S

• Liver Averaged sized right lobe with homogenous
  ecchopattern. The right lobe is displaced
  downward by a large hyperechoic well defined mass
  measuring 1913 cm. The left lobe is compressed
  by a huge mass reaching the left iliac fossa with
  heterogenous eccopattern with cystic areas and
  lobulated at the lower part .No IHBRD Portal vein
  is not dilated and patent.
• G.B average in size wall thickness with a
  small 3 mm single calculus . CBD is not dilated.

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• Spleen average in size ,homogenous
  ecchopattern,longest axis 9 cm.
• Kidney average in size, parenchymal
  echogenecity, no typical calculi or back pressure
  changes.No suprarenal masses
• Pancreas Free
• IVC and aorta are mildly compressed by the mass
  and displaced medially but patent with average
  flow

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Upper endoscopy

• 2 small upper oesophageal venous blebs.
• Small sliding hiatus hernia.
• Mild congestive gastropathy at the body and
  fundus of the stomach.
• External gastric compression.

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C.T chest,abdomen and pelvic

• The chest revealed scattered areas of
  bronchiectatic changes and peribronchial
  thickening are seen in the medial segment of the
  right middle lobe and posterior segment of the
  left lower lobe.
• Normal C.T appearance of the great vessels and
  heart.
• No pleural or pericardial collection and no
  enlarged hilar or mediastinal L.N.

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• The liver is markedly enlarged crossing to the
  left hypochondreal region with the presence of
  huge hypodense mass lesion occupying the whole
  left hepatic lobe, two other mass lesions are
  seen involving the right hepatic lobe.the mass
  lesions are inseparable from each other with same
  hypodensity texture and peripheral irregular
  enhancement .No dilated biliary radicles.Portal
  vein is demonstrated at porta hepatis and its
  right branch.

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• Normal appearance of spleen,both kidneys and
  pancreas which are all compressed by the enlarged
  mass.
• No ascites or lymphadenopathy.
• Normal appearance of the pelvic organs.

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Conclusion

• Hepatomegaly with multiple liver masses likely
  neoplastic for biopsy.
• Bronchiectasis in the medial segment of the right
  middle lobe and posterior segment of the left
  lower lobe.

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Pathology

• Grossneedle core biopsy specimen 1 cm .
• Microscopic revealed benign lesion compossed of
  variable sized blood spaces lined by endothelial
  cells with focal cystic changes showing
  frequently intraluminal RBCs with intervening
  connective tissue showing heterogenous fibrosis.
  No liver tissue was encounterd in all examined
  serial sections.

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Conclusion

• needle core biopsy from a case of large
  abdominal mass
• Cavernous haemangioma .

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Doppler

• Normal arterial and venous duplex of both lower
  limbs and abdominal vessels.

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Echocardiography

• Normal RT atrim, RT ventricle, LT atrium, and LT
  ventricle.
• The contrast material filled the right atrium and
  right ventricle and did not appear in the left
  side.
• Intact cardiac septa
• No intracardiac masses, no thrombi and no
  pericardial effusion.

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• Thank you