DE LEON, JAYZELLE ANNE M.

MY-9

Case 1

A 50-year old male came in to the ER due to a painful mass in his right inguinal area. He
claims to have lost bowel function for 1 day and with bouts of billous vomiting. (Inguinal
Hernia)

History

What other points of the history do you think is relevant for this case? What are your
differential diagnoses?

Usually, the sexual history is asked

Differential Diagnoses are: Acute Epididymitis, Hydrocele, or Testicular Torsion

Physical Examination

What are the pertinent positive and negative findings you should look for? What are
the maneuvers you must perform?

pain or discomfort usually in the lower abdomen

weakness, pressure, or a feeling of heaviness in the abdomen
a burning sensation at the site of the bulge
pain during coughing/Valsalva maneuver
pain and swelling in the scrotum around the testicular area

Laboratory/Imaging Studies

What laboratory tests should you request and what do these mean? Any imaging
studies you may want to do?

Physical exam inspection and palpation of the bulge may indicate hernia
Urinalysis used to rule out urinary tract infection

Management

How would you manage this patient pre-operatively, intra-operatively and post-
operatively? What should you watch out for? Other treatment options for this case.

Comparison of Laparoscopic and Open Techniques to Repair Primary Inguinal

Hernias

OUTCOME COMPARISON

Operative time Longer with laparoscopy

Equal24

Length of hospital stay Shorter with laparoscopy

OUTCOME COMPARISON

Equal

Complications More common with open technique

Equal

Return to usual activity Earlier with laparoscopy

Chronic pain More common with laparoscopy

Equal

Chronic numbness More common with laparoscopy

Equal

Case 2

A 39-year old female went to the OPD due to solid breast mass 2x3 cm, non-movable, firm
and with irregular borders, in the right. She claims that she noticed the mass for almost 3
years. She is a known smoker. (Breast Cancer)

History

What other points of the history do you think is relevant for this case? What are your
differential diagnoses?

Increased exposure to estrogen

Early menarche
Nulliparity
Older age at first live birth
Differential diagnoses may be: Fibroadenoma of the breast, Breast lymphoma, Ductal
Carcinoma In-Situ

Physical Examination

What are the pertinent positive and negative findings you should look for? What are
the maneuvers you must perform?

Swelling of all or part of a breast

 Skin irritation or dimpling.
Breast or nipple pain.
Nipple retraction
Redness, scaliness, or thickening of the nipple or breast skin.
Nipple discharge

Laboratory/Imaging Studies

What laboratory tests should you request and what do these mean? Any imaging
studies you may want to do?

Mammography
Ultrasonography
Breast Biopsy for nonpalpable lesions

Management

How would you manage this patient pre-operatively, intra-operatively and post-
operatively? What should you watch out for? Other treatment options for this case.

Depending on the staging and type of the tumor, just a lumpectomy may be
necessary, or removal of larger amounts of breast tissue may be necessary. Surgical
removal of the entire breast is called mastectomy.

Lumpectomy techniques are increasingly utilized for breast-conservation cancer

surgery. Studies indicate that for patients with a single tumor smaller than 4 cm,
lumpectomy may be as effective as a mastectomy. Prior to a lumpectomy, a needle-
localization of the lesion with placement of a guidewire may be performed, sometimes by
a radiologist if the area being removed was detected by mammography or ultrasound, and
sometimes by the surgeon if the lesion can be directly palpated.

Case 3

A 25-year old female went to the ER due to vague abdominal pain for 1 day. Upon
examining the patient at the ER, you noticed that she complains more on her right
hemiabdomen. She is a known case of PCOS.

History

What other points of the history do you think is relevant for this case? What are your
differential diagnoses?

OB-Gyne History is relevant

Differential diagnoses are: Pelvic Inflammatory Disease, Endometriosis, and Ovarian
Cyst

Physical Examination

What are the pertinent positive and negative findings you should look for? What are
the maneuvers you must perform?

Anorexia

Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the
lower right abdomen

Loss of appetite
 Nausea and/or vomiting soon after abdominal pain begin

Inability to pass gas

Laboratory/Imaging Studies

What laboratory tests should you request and what do these mean? Any imaging
studies you may want to do?

Abdominal exam to detect inflammation.

Urine test to rule out a urinary tract infection.
CT scans and/or ultrasound.
Management

How would you manage this patient pre-operatively, intra-operatively and post-
operatively? What should you watch out for? Other treatment options for this case.

Appendectomy remains the only curative treatment of appendicitis, but management

of patients with an appendiceal mass can usually be divided into the following 3 treatment
categories:
Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic
therapy, an interval appendectomy can be performed 4-6 weeks later.
Patients with a larger well-defined abscess: After percutaneous drainage with
IV antibiotics is performed, the patient can be discharged with the catheter in
place. Interval appendectomy can be performed after the fistula is closed.
Patients with a multicompartmental abscess: These patients require early
surgical drainage.

Case 4

A 45-year old female was referred to you by an internist due to a left anterior neck
mass which moves with deglutition. She has stable vital signs and no other subjective
complains. Upon physical examination, you noticed the mass to be 3x2 cm in size, firm and
with smooth borders. You were also able to palpate cervical nodes on the same side.
(Tumors of the Head and Neck)

History

What other points of the history do you think is relevant for this case? What are your
differential diagnoses?

Physical exam on HEENT

Differential diagnoses are: Squamous cell carcinoma, Nasopharyngeal carcinoma and
Thyroid carcinoma

Physical Examination

What are the pertinent positive and negative findings you should look for? What are
the maneuvers you must perform?

Mass in the neck

Neck pain

Painless ulcer or sores in the mouth that do not heal

 Lump in the lip, mouth or gums

Enlarged lymph glands in the neck

Slurring of speech

Hoarse voice which persists for more than six weeks

Sore throat which persists for more than six weeks

Difficulty swallowing food

Change in diet or weight loss

Laboratory/Imaging Studies

What laboratory tests should you request and what do these mean? Any imaging
studies you may want to do?

Ultrasonography of the neck

MRI of the neck

Management

How would you manage this patient pre-operatively, intra-operatively and post-
operatively? What should you watch out for? Other treatment options for this case.

Surgery is frequently used in most types of head and neck cancer. CO2 laser
surgery is also another form of treatment. Transoral laser microsurgery allows surgeons to
remove tumors from the voice box with no external incisions. It also allows access to tumors
that are not reachable with robotic surgery. During the surgery, the adequacy of excision is
assessed (margin status), minimizing the amount of normal tissue removed or damaged.
This technique helps give the patient as much speech and swallowing function as possible
after surgery.