2. Patient F
• Chief Complaints:
• A 27-year-old female presents to the emergency department with a 3-
year history of progressive, significant abdominal enlargement, urinary
retention.
• History of Present Illness(Morbi):
• The patient denies genitourinary or digestive problems.
• No pain, fever, or vomiting reported. Vital signs are normal. Abdomen is
distended and dull to percussion. No other significant findings on
physical examination
3. • Anamnesis Vitae:
• Developmental History: Birth and Early Childhood developmental milestones met
on time, and development and intellect development normal
• Medical History: No chronic illnesses, no recent surgeries, no blood transfusions
• Family history: Unremarkable
• Infectious history: Denies viral hepatitis, denies sexually transmitted diseases.
• Mental and behavioral disorders: None noted during time of development
• Hereditary disease: denies
• Oncological history: denies
• Medications: No current medications
• Allergic history: not burdened
• Marital status: Single
• Employment history: unemployed
• Social history: Lives with mother
• Vaccinations: up to date
4. • Gyneo history: Menarche 13, regular 28 days 5 to 6 days no pain
• Sexual History:
• The patient is sexually active with one partner and uses oral
contraceptive pills for birth control. She denies any history of sexually
transmitted infections or abnormal Pap smears.
• Obstetric History:
• The patient is gravida 2, para 2, with two full-term normal vaginal
deliveries and no history of miscarriages or complications during
pregnancy. Her last menstrual period was 28 days ago, and her cycles are
regular.
5. Objective data
• Objective data: The condition is of moderate severity due to the main and accompanying pain.
Moderate nutrition. Appetite and sleep are not disturbed. Height 163 Weight 65 kg BMI 24.5 - normal.
• BP-110/82
• RR- 17
• HR- 87bpm
• Neurological status: nomal
• General examination: The skin is dry, has a physical coloration, There is no swelling. Peripheral lymph
nodes are not enlarged.
• Cardiovascular examination: There are no visible pulsations in the region of the heart. Auscultation
normal
• Respiratory examination: Normal
• Gastrointestinal and genitourinary examination: The tongue is dry and clean. The abdomen is soft,
somewhat enlarged, paternatsky sign negative
6. Gyneo exam
• Speculum Examination: On speculum examination, the cervix appears
normal with no visible lesions, erythema, or discharge. The os is closed
and no cervical motion tenderness is noted. The vaginal walls appear
healthy without any signs of atrophy, inflammation, or lesions. No
abnormal discharge or bleeding is observed.
• Bimanual Examination: During the bimanual examination, a non-
tender, mobile mass is palpable in the right adnexal region, consistent
with the location of the right ovary. The uterus is of normal size and
contour, with no palpable masses or tenderness. No cervical motion
tenderness is noted, and the left adnexa is unremarkable.
7. • Complete Blood Count (CBC):
• Hemoglobin: 13.5 g/dL (Reference Range: 12.0-15.5 g/dL)
• White Blood Cell Count (WBC): 8.0 x 10^9/L (Reference Range: 4.0-11.0
x 10^9/L)
• Platelet Count: 250 x 10^9/L (Reference Range: 150-450 x 10^9/L)
• Basic Metabolic Panel (BMP):
• Blood Urea Nitrogen (BUN): 10 mg/dL (Reference Range: 7-20 mg/dL)
• Creatinine: 0.8 mg/dL (Reference Range: 0.6-1.2 mg/dL)
• Electrolytes within normal limits
8. • Urinalysis:
• No protein, glucose, or blood in the urine
• Specific gravity: 1.015 (Reference Range: 1.005-1.030)
• Imaging:
• Ultrasound: Presence of a well-defined cystic mass in the right ovary
• CT scan or MRI: Further characterization of the cystic lesion
• Tumor Markers:
• CA-125: 20 U/mL (Reference Range: <35 U/mL)
• Alpha-fetoprotein (AFP): 5 ng/mL (Reference Range: <10 ng/mL)
• Differential Diagnosis (DDX) Tests:
• Inhibin A: 15 pg/mL (Reference Range: <100 pg/mL)
• Beta-human chorionic gonadotropin (β-hCG): <2 mIU/mL (Reference Range: <5 mIU/mL)
11. histo
• Dermoid cyst histopathology reveals ectodermal, mesodermal, and
endodermal tissues, confirming teratoma with diverse elements such
as skin, hair, and neural tissue.
