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Q$O=%PܹǽKǏ(A|ҵ}A%L~> Zoݰ)QEQEQEQEYӬ;y.GfJļp1 pOJi⛧[-H<\NfOG4> Y;"IaړK8Hw2{B(((((((((((((#2:2[E1~vdy;庸yIdbrI5QEQEQEQEQEQEQEQEQEQEQEQEQEQEi( / 0DTimes New Roman``P ׯ0DArialNew Roman``P ׯ0" DLcwfontw Roman``P ׯ02@ .  @n?" dd@  @@`` H !  oR$Q\Ol[e%3LR$@Hgg-%Ԡxٗ'3L$$R$.UiL(46:EsR$nW!_W}? 0AA@w?O ʚ;>a8ʚ;g4MdMd ׯ0ppp@ <4!d!d,vS0`, <4dddd,vS0`,  80___PPT10 ? %   Pt. suffered from chronic intermittent abdominal pain for the last 3-4 months. Over the 24 hours prior to coming into the ER her pain is greatly worsened in severity. The pain radiates to her back and is accompanied by nausea and bloating. She has not had a bowel movement in three days, but has had flatus. She is afebrile. Pt. has a history of a partial bowel resection in 2004 for rectal prolapse. Abdomen is diffusely tender on physical exam. Her labs are negative, including HCG and CEA.,JD^ Upright AXR   Axial Abdominal CT  Adnexal Mass Differential Cystadenoma (serous or mucinous) or cystadenocarcinoma Hemorrhagic cyst (fenestrated without solid component) Endometrioma (diffuse low level echoes) Ectopic pregnancy Teratoma (contains calcium and/or fat) Abscess (air-fluid level) Hematoma Functional cyst (follicular, corpus luteum, or theca lutein) Malignant lesions are more likely to have irregularities within the wall, thick septations, papillary projections, solid components, ascites, and size >9 cm. Blood flow within septations is a good marker of neoplasm, either benign or malignant. DePriest score can be used to determine likelihood of malignancy. Its scoring system is based upon cystic wall structure, septation structure, and tumor volume. A score of 5 confers a higher likelihood of malignancy. Z76'&  9 .f R +$ ;r V References  .Gay, Spencer and Woodcock, Richard. Radiology Recall. Lippincott, Williams, and Wilkins, 2000. pp. 582-584 Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed. Churchill, Livingston Inc., 2001. Pp. 2215-2218. Medical Student: Nicholas Nacey SMD  07r$CC8CHcccg 0` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> f(    6=  P   T Click to edit Master title style! !  0t@     RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  00H  ``   >*  0P  `    @*  0 `    @*H  0޽h ? Default Design 0 0$(  r  S  P   r  S J P0    H  0޽h ? ̙33z  0 ld@ (   r  S 0P    Z  C $A AXR 1"`P L  C $A AXR 2`    6@  0 `,$D0 ^ Supine AXR   2  6jJ0p@` ,$D0  0{0 ( 2j  0X@ `,$D0 AXR shows bowel loops being displaced out of pelvis by a circular shaped 19 cm mass with soft tissue density. It appears to be distinct from the bladder wall.8ZH  0޽h ? ̙33___PPT10+ D:' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D3' =4@BB BB%(D' =1:Bvisible*o3>+B#style.visibility<* %(D' =-o6Bdissolve*<3<* DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(+8+0+ 0 +4 0   '(  r  S ` @   V  C ACT1"`p   !  6  `@,$D0 Transabdominal Ultrasound    0X 0 F ,$D0 CT shows a large pelvic mass that appears to be arising from the right adnexa. Multilocular cyst with one primary cyst and some septations.(2>G % B  0D|@,$D0#   00 ,$D0 US shows well-defined borders around hypoechoic space with acoustic enhancement posteriorly. There are septations and a mural nodule in the posterior wall. Mural does not show blood flow on Doppler but septations do. DePriest score of 8.8Zb% !  Y     C 0AUS1_I0022_1 P ,$D0H  0޽h ? ̙33E = ___PPT10 +ڰDY ' = @B D ' = @BA?%,( < +O%,( < +D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<* %(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<* %(++0+0 ++0+0 ++0+ 0 + 0 p$(  r  S `0   r  S p  H  0޽h ?  0 UM`(  r  S HP    r  S H     6   cHospital Course   0<  p  Pelvic mass was not appreciated on AXR overnight, but was seen the following morning. A CT had already been order at the point due to the patient s continued pain. The housestaff was notified of the mass, and the US was order for better characterization. A review of her February 2005 CT showed no mass at that time. She was admitted to the GYN service. She was taken to the OR after several days for exploratory laparotomy, TAH, RSO, removal of pelvic mass, and left oophoropexy. The frozen path was consistent with mucinous cystadenoma. She was discharged after about a week. JR  #cCb  - & *H  0޽h ? r$Pq( =?XH1Oh+'0,? `h  $Cecile Graves yo Female MR# 1533488 Mary NaceyHSCS7Microsoft PowerPoint@0=@P|@PE |G>g  &" WMFC .lx EMF.3A8F(GDICx!b $$=='% % V0xx x % % $$AA" FGDICF(GDIC l.vFGDICF(GDIC6ljvFGDICF(GDICaFGDICRp@"ArialHPlj͉lj0>Pp͉͉̉0T^0>SA0U0%0в?P͉܆ڏ0?콉dv%    Tt!!&( BUB!&1LPt. suffered from chronic intermittent abdominal  % ( Rp@"ArialPljΉljA 07Pp̉ΉΉ0T^07SA0U0%0в8PΉ܆ڏ08dv%    T(8-( BUB-Ltpain for the last 3 % ( Rp@"ArialΉΉ0T^07| !Q|Hm|8 Y ! !в8Ή܆ڏ0SA0U0%0p dvPΉ܆Ɔ %e e!dv%    TT9(:-( BUB9-LP- % ( Rp@"ArialQ|Hm|8 Y ! !в8| !Q|Hm|8 Z ! !p dvΉ܆SA0U0%0 !dvPΉ܆XɆ %e e!dv%    T,;(-( BUB;-%L4 months. Over the 24 hours prior to  % ( Rp@"ArialxPlj͉lj01Pp̉lj͉͉T^01SA0U0%0в2P͉܆ڏ02콉dv%    T.3( BUB33Lcoming into the ER her pain is greatly worsened in  % ( Rp@"AriallPlj͉lj#0-Pp̉lj͉͉T^0-SA0U0%0в.P͉܆ڏ0.콉dv%    Th4|9( BUB9/Lseverity. The pain radiates to her back and is  % ( Rp@"ArialPlj͉lj02Pp͉͉̉0T^02SA0U0%0в3P͉܆ڏ03콉dv%    T;@( BUB@4Laccompanied by nausea and bloating. She has not had  % ( Rp@"Arial}HPlj͉lj02Pp̉lj͉͉T^02SA0U0%0в3P͉܆ڏ03콉dv%    TAF( BUBF4La bowel movement in three days, but has had flatus.  % ( Rp@"ArialvPljΉlj 04Pp̉ljΉΉT^04SA0U0%0в5PΉ܆ڏ05dv%    TxHM( BUBML\She is  % ( Rp@"ArialvΉΉT^04| !Q|Hm|m ! !в5Ή܆ڏ0SA0U0%0p dvPΉ܆`ۆ %e e!dv%    T| H1M( BUB ML\afebrile % ( Rp@"ArialvQ|Hm|m ! !в5| !Q|Hm|m ! !p dvΉ܆SA0U0%0 !dvPΉ܆݆ %e e!dv%  &WMFC.  T82HM( BUB2M'L. Pt. has a history of a partial bowel  % ( Rp@"ArialuPljΉlj00Pp̉ljΉΉT^00SA0U0%0в1PΉ܆ڏ01dv%    TNOS( BUBSLresection in 2004 for rectal  % ( Rp@"ArialuΉΉT^00| !Q|Hm|8 t ! !в1Ή܆ڏ0SA0U0%0p dvPΉ܆ %e e!dv%    T|PNdS( BUBPSL\prolapse % ( Rp@"ArialuQ|Hm|8 t ! !в1| !Q|Hm|8 u ! !p dvΉ܆SA0U0%0 !dvPΉ܆ %e e!dv%    TeNS( BUBeS Lh. Abdomen is  % ( Rp@"ArialpPlj͉lj0.Pp̉lj͉͉T^0.SA0U0%0в/P͉܆ڏ0/콉dv%    TlTY( BUBY0Ldiffusely tender on physical exam. Her labs are  % ( Rp@"ArialTЉArialpw @"Arial 0 Չlj xO0SA0U0%0вljd͉͉Ԅ M !0M lj\0Hdv%    T [a`( BUB` Lnegative, including HCG and CEA. % (   x--$xx--'@"Arial?????-. Q2 &!1Pt. suffered from chronic intermittent abdominal s."System-@"Arial???-. $2 -pain for the last 3.-@"Arial???-.  2 -9-.-@"Arial???-. ?2 -;%4 months. Over the 24 hours prior to .-@"Arialx??-. T2 33coming into the ER her pain is greatly worsened in .-@"Ariall??-. N2 9/severity. The pain radiates to her back and is .-@"Arial???-. U2 @4accompanied by nausea and bloating. She has not had .-@"Arial}????-. U2 F4a bowel movement in three days, but has had flatus. .-@"Arialv??-. 2 MShe is e.-@"Arialv??-. 2 M afebrile.-@"Arialv??-. B2 M2'. Pt. has a history of a partial bowel .-@"Arialu??-. 32 Sresection in 2004 for rectal E.-@"Arialu??-. 2 SPprolapse.-@"Arialu??-. 2 Se . Abdomen is .-@"Arialp??-. O2 Y0diffusely tender on physical exam. Her labs are .-@"ArialT??-. 72 ` negative, including HCG and CEA..-՜.+,0<   $, 4 On-screen Show,University of Virginia School of Medicine B'  Times New RomanArialLcwfontDefault DesignSlide 1 Upright AXRAxial Abdominal CTAdnexal Mass Differential References  Fonts UsedDesign Template Slide Titles_HnHSCSHSCS  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|~Root EntrydO)PicturescCurrent UserSummaryInformation(\?PowerPoint Document(}HDocumentSummaryInformation8