Southwestern University

Medical Center
Department of Pediatrics

ENDORSEMENT
 General Data
● C.L.G
● 11yr old female
● filipino, Roman Catholic
● born on december 08, 2009
● Tuba,Dalaguete Cebu.
● Admitted for the first time in our institution

INFORMANT: Mother (80% reliability)

CHIEF COMPLAINT

ABDOMINAL MASS
 History of Present Illness
Two months prior to consultation, patient noted palpable fixed non-painful
abdominal mass at the level of umbilicus area, approximately fist-size of a newborn as
stated by the patient. No consultation done. Patient tolerated the condition.
One month prior to consultation, there is increased in abdominal girth
approximately fist-size of an adult associated with abdominal pain especially at
night, with a pain scale of 4/10, non-radiating to the lumbosacral area. No
urinary or bowel changes noted. No vaginal discharges. Undocumented weight
loss was noted. The patient sought consultation at Bogo Hospital and seen by
a GP and diagnostic work up done with cbc, urinalysis, HBsAg & blood chem
test, SGPT, SGOT, Creatinine and whole abdomen ultrasound.
Ultrasound Result:
Interpretation
● Huge complex cystic abdominopelvic mass.
● Mild pelvocaliectasia, Right kidney likely
secondary to extrinsic compression on the
right ureter by the mass
● Gallbladder, pancreas and uterus not
delineated
 Parameter Result Ref.range

WBC 14.6 5-12

Na 134.2 135-
Lymp# 1.9 1.5-9.5 145mmol/
L
Mid# 1.4 0.2-1.2

Gran# 11.3 1.5-8.5 K 3.73 3.5-

Laboratory result

5.5mmol/
Lymph% 12.9 20-60
L
Mid% 9.8 3-15

Gran% 77.3 50-70

HGB 79 115-135

RBC 3.30 3.90-5.30

Hct 25 34-40

MCV 75.9 75.9_87.3

Mchc 316 320-348

MCH 23.9 25.4-29.2

RDW 17.5 11-16

PLT 685 150-400

2 weeks PTA, patient was referred to Cebu Provincial Hospital at Carcar City and advised for a
diagnostic work up with Transrectal and Transabdominal ultrasound and other diagnostic tests such
as CT scan of the whole abdomen, CA125, betaHCG, AFP, LDH, CEA, (other test were not done due
to financial problem). Patient was given multivitamins + zinc + copper (Clusivol) syrup 10ml/day for
vitamin supplementation but poor compliance.

Test Result Ref-range

LDH 1094 100-227

AFP 965.30 <5.80

1 week PTA, there was noted increased in abdominal pain from 4/10 to 7/10,
associated with onset new-onset dyspnea noted after a few steps and while climbing
the stairs. The patient sought consultation to VSMMC with her mother but was not
seen by a medical doctor due to high number of patient.
3 days PTA, persistence of severe abdominal pain noted with a maximum
pain scale of 10/10 , she was crying due to pain as verbalized by the mother
and was unable to sleep at night. In addition, there was noted decrease of
appetite and early satiety. Patient together with her mother sought consult
initially to Miller Hospital, unfortunately it was cut-off , thus, she was advised to
SWU-MC ER for further evaluation and management. The patient was seen
initially by General Surgery, serum creatinine was done. Advised to follow up
CT scan of whole abdomen with contrast. Then the patient was referred to
Pediatric department and was advised admission at SWUMC.
Past Medical History- No past illness, and no
history of surgeries or any hospitalization. No psychiatric
problem.
Immunization History
Vaccines Timing

BCG At brith

Hep B 1st dose given at birth, 4-8w, 10-16w

(3doses)

DTaP 3 doses (at 2,4,6m)

OPV 3 doses (at 6,10,14)

Hib 3 doses (at 6,10,14)

PCV 3 doses (at 6, 10, 14)

RV Single dose around 6w

Influenza 1 dose (min age of 6mos)

 Mother is a 33y/o during her pregnancy
PREGNANCY AND BIRTH HISTORY
●
● G
● First prenatal check-up: 2mos AOG
● Total Prenatal visits: unrecalled
● Prenatal testing: patient unable to recall
● Vaccines: 2dose tetanus shot
● Prenatal Vitamins: folic acid (poor compliance) Iron & Vit.C (good compliance)
● No maternal illness during pregnancy

Natal History: Px G, 38w AOG delivered via NSD.

● Duration of labor: unrecalled

● Birth weight & length: unrecalled

Postnatal History:

● Newbornscreening: completed and unremarkable

● (-) jaundice
Developmental History
School performance Temporarily absent due to her operation
(Module class)

Tanner stage (Breast) 2

Tanner stage (Genital) 1

 REVIEW OF A SYSTEM
General appearance: No complaints of fatigue but unable to tolerate activities of daily
living. Weight loss 1 month ago. Afebrile.

Skin: No rashes, lumps, sores, dryness noted on the skin and nails. No unusual changes
in color and size of the moles. Pale palms and soles noted.

HEENT: Pale palpebral. Moist tongue, dry lips. No hearing changes and ear infection
noted. No sore throat noted. No lumps/lymphadenopathy noted.

Cardiovascular: no chest pain or discomfort noted. Palpitations noted.

REVIEW OF A SYSTEM
Breast: no complaints of breast tenderness, lumps, or even nipple discharges.

Abdomen: (+) pelvo abdominal mass, cystic, approximately 29x21cm with superior
border of 1 cm above the umbilicus.

Extremities: pale palms and soles, no edema noted.

Hematologic: no history of coagulation or bleeding problems

Neurologic: no tremors, no convulsion, intact

Menstrual History - patient is not yet menstruating.

Past Medical History- No history if asthma, and no history of

surgeries or any hospitalization. Patient completed her childhood immunization.
Family history- Heredofamilial disease includes
hypertension on both mother and father

Personal Social History- Patient is a grade 6

student of Tuba, Dalaguete Elementary School and is having
module class but she stopped schooling on the month of
September due to increasing abdominal mass. She is
currently living with her family. She is the 4th child in her
family. She is non-smoker, non-alcoholic beverage drinker.
Physical Examination
General Survey: Patient is awake, conscious, coherent, oriented and not in
respiratory distress with the following vital signs of:

Temp: 36.6 PR: 115bpm RR: 30cpm

BP: 90/60mmHg Ht: 140cm Wt: 32kg

Anthropometric Data:

Length: 140cm Weight: 32kg Abd girth: 74cm

BMI for AGE PERCENTILE

Interpreation

BMI for Age

<5th percentile

Underweight
LENGTH & WEIGHT PERCENTILE

H
PHYSICAL EXAMINATION Breast: Tanner stage2 (palpable breast
tissue under the nipple, (+) breast
budding)
Skin: No rashes, Warm to touch
Abdomen: +pelvoabdominal mass,
HEENT: normocephalic head, Anicteric prominent viens, visible viens,
sclera, pale palpebral conjuction, pupil increasing abd girth
equally round, reactive to light and
accommodation. Dry lips noted. No
lymphadenopathy.

C/L: equal chest expansion, clear

breath sounds, tachypneic, No rales, no
wheezes noted.

Cardio: Distinct heart sounds. No

murmur noted. External Genitalia: Tanner stage 1:
Prepubertal. No hair.

Ext: pale palms and soles noted.

CNS: intact with no neurologic deficit.

ADMITTING IMPRESSION
Abdominal mass t/c Dysgerminoma vs. Ovarian
Immature Teratoma
Differential Diagnosis
Rule in Rule out

● Age ● Vomiting
● Asian ● Changes in bowel movements
● Abdominal mass ● Night sweat
● Abdominal pain ● Vision problems
● Elevated AFP
Juvenile Granulosa cell Tumor

Rule in Rule out

● Age ● Vaginal bleeding

● Abdominal pain ● Precocious pseudopuberty
● Abdominal palpable mass
● Increasing abdominal girth
● Elevated LDH & AFP
Primary Choriocarcinoma (a.k.a NGCO)

Rule in: Rule out

● Age ● Nausea and vomiting

● Abdominal Mass ● (-) AFP
● Abdominal Pain ● (+) hCG
● Bowel habits changes
● Vaginal bleeding
● Precocious puberty
 Final Diagnosis
Right Adnexa: Ovarian Immature
Teratoma
Course in the Ward
 Day 1 S: No headache, No nausea,
No vomiting, Dry lips
O: awake, afebrile, not in
respiratory distress,
tachypneic and tachycardic
VS:
BP:110/80mmhg, RR: 35cpm,
PR: 106bpm,
Progress Notes

temp: 3, O2: 99%

Skin: Good turgor, warm to
touch, pale palms and soles
HEENT: Pale palpebral,
anicteric sclerae
C/L: decrease breath sounds
on lower lung fields
Abdomen: distended
abdomind (74cm abd girth)
Ext: No edema, strong pulse
Medication: Multivitamins
10mL/day (clusivol syrup)
A: ovarian new growth
probably malignant germ cell
tumor, severe anemia
P: monitor VS q 1hr
Refer unusualities
Progress Note (Day 2)

S: no headache, no nausea, no Ext: no edema, strong pulses

vomiting, Dry lips
Medication: Multivitamins 10mL/day
O: patient is asleep, febrile, febrile, not
in respiratory distress, Intravenous: D5LR 500mL, 40cc/hr

VS: PR- 111bpm, RR- 35cpm, Temp-38.3, A. Ovarian Growth Malignant Germ
O2Sat- 95% cell tumor, severe anemi

Skin: Good turgor, warm to touch, pale P: Monitor VS q 1hr

palms & soles

HEENT: pale palpebral, anicteric sclerae

ABD: distended with abdominal girth of

75cm
Pre-op Medication (10/17/21)
● Cefazoline 1g q 8hrs (mkD) IVTt as IV drip (30 mins
before induction of anesthesia)
● To ensure another 1 unit of PRBC
● Make PRBC from the available 1
● Ranitidine 30mg IVTT (1mkD) unit WB
● 2 units PRBC
● Metodypamide 1amp (5mg/2mL) (should follow up
confirmation of frozen section biopsy) ● Insert another IV line heplock
● Refer for surgery service for
● Mefenamic acid 250mg/5mL 10mL by 12noon possible bowel resection
● Chlorhexidine digluconate (GYNEPRO) full body bath
appendectomy & for the
at bedtime and then at morning 6am evaluation & co-mgt
● Change compression stockings to
Apply compression stockings prior to surgery
●
elastic bandage
Pre-op Orders:

● Soft diet for breakfast (10/18/21)

● General liquids after breakfast to consume 1 bottle of

500mL of Gatorade by 12noon

● NPO by 12n
3 hrs S/P Exploratory laparotomy, peritoneal fluid cytology, adhesiolysis, right salphingo-oophorectomy with frozen section,
omentectomy, appendectomy under general anesthesia

Px complaints of abd pain (8/10), no nauseam no vomiting

Examined awake, coherent, afebrile, not in respiratory distress

VS: T-36.7, HR-98bpm, RR-19cpm, BP-115/86mmgh, 02sat-98%

“FROZEN SECTION DX- CONSISTENT WITH IMMATURE TERATOMA”

HEENT: anicteric sclerae, slightly pale conjunctiva

Abdomen: Dry & intact dressing, minimal bowel sounds noted

GUT: with fooley catheter attached to urobag with urine level of 50cc

Ext: no edema, elastic bandage wrapped at both lower ext, Bounding pulses(strong) noted both upper and lower ext, CRT <2sec

On going IVF of PLR 600cc level at 70cc/hr. Done with post op blood transfusion@9pm. Repeat cbc taken at 9:15pm.

Due pain relievers given: Paracetamol 480mg IVTT, Ketorolac 21mg IVTT

Total intake: 947cc (IV and BT)

Total out: 430cc

Ab
 GUT: FBC removed around 9am with the urine level of
S. Abdominal pain (8/10), no nausea, no vomiting noted 8cc, px urinated at 5pm with urine output of 67cc

O: awake, concious, coherent to time and place, Ext: no edema ( still wearing elastic bandage in both
afebrile, not in respiratory distress legs, CRT <2sec

VS: 100/70mmhg, RR: 20cpm PR:67bpm, temp:36.2, A: post op Dx: Immature teratoma, ® ovary with frozen
02sat: 99% weight: 24kg, abd girth: 62cm section, Intraop stage 1C, severe anemia partially
corrected, clinically stable 18hrs post op
Skin: good turgor, warm to touch, no cyanosis, no lesion
● Plan: inc IVP (D5LR) to 30cc/hr,
HEENT: anicteric sclerae, slightly pale conjunctiva, ● Continue medication: paracetamol PO
edema over the eyelid (esp. At right) no alar flaring no 250mg/50ml, 6mL q6hrs
Day 4

eye discharge ● Ketorolac 21mg IVTT q6hr x 2days

● Give furosemide 16mg via IVTT with 3rd of
albumin drop with BP precaution
C/L: equal chest expansion, clear breath sounds
● Continue albumin connection
● Meal: general liquid with crackers now and soft
CNS: distinct heart sounds, no murmur diet for lunch, dieat ast tolerated for dinner
(2egg white meal) no carbonated drinks, nor
Abd: dry & intact dressing, minimal bowel sounds dairy product. & encourage to drink more water
● Lab: repeat cbc tom at 5am & continue HGT
q8hrs (10/19/2 @8pm is 91mg/dL, prev.
113mg/dL.

Monitoring & Evaluation: VS q 2hrs, monitore abd girth q

shift & look for any signs of distention

● Encourage for ambulation

● Refer if the BP > 140/90mmhg, HR:100, RR:>30
Temp of >38*C
Day 5

S: Pain at the incision site (9/10) during dressing, no A: Post-op Dx: Immature teratoma, right ovary with
nausea, no vomiting, (-) bowel movement/defecate, frozen section
voided Intra-op stage 1C, Severe anemia (partially corrected),
Clinically stable
O: awake, not in respiratory distress
V/S; PR: 94bpm, RR:23cpm, Temp:35.7, abdominal girth: P: High protein diet (2eggwhites with pedia sure milk)
59cm Every morning Dressing of the incision site.
BP: 100/70, albumin result: 1.76g/dL from 1.79g/dL Monitor the IV site
Refer any unusuality
Skin: no cyanosis, warm to touch, good turgor
HEENT: anicteric sclera, slightly pink conjunctiva, no eye
discharge
C/L: symmetric chest expansion, clear breath sounds
Heart: distinct heart sounds with normal rate and rythm,
no murmur
Abdomen: dry and intact dressing with abd girth of
59cm
Ext: no edema, strong pulses CRT <2sec
Day 6
S. No abdominal pain, no nausea, voided, defecate (-) Present IVF: D5LR 1L + 20mEq kCL @65mL/hr
IVTF: D5LR 1L + 20mEq kCL @ 65ml/hr
O: awake, not in respiratory distress IVTF D5LR 1L + 18 mEq kCL @ 65mL/hr
Vs: HR- 132bpm RR- 21cpm T-36c 02sat-99% Repeat K after a bottle of kCL is consumed
TFI: 2260ml TFO: 950 TFB: 1310 AUO; 1649cc/kg/hr
Serum Albumin: 2.6g/dL Assessment: Post op Dx: Immature Teratoma Right
ovary with frozen section
Skin: warm to touch, ood turgor, no lesion. Intra-Op Stage 1C, Severe anemia Partially corrected,
HEENT: anicteric sclerae, pale conjunctiva, no nasoaural Clinically stable
and eye discharges
C/L: clear breath sounds, no murmurs P: Monitor surgical site every time which changing
Heart: distinct heart sound dressing for inflammation
Abdomen: dry and intact dressingat surgical site, - Monitor VS q 2hr
normoactive bowel sound - Monitor intake and output everyshift
Extremities: no gross deformities, strong peripheral - Encourage ambilation and deep breathing
pulse CRT <2sec exercise
- Encourage to heat High protien diet
Medication: Cefuroxime 250mg/mL-give 7mL BID PO - Monitor IV site for inflammation
(8am-6pm)
Alb Drip 20%: 1bottle (50mL) over 4hrs via I.D (2am)
Furosemide 16mg slow IVTT
Mefenamic Acid: 50mg/mL 16mL PO TID after ketorolac
consumed
Day 7
Ext: no gross deformities, no edema, CRT
S: no nausea & vomiting, no sign of infection
<2sec
no tachypnea, no tachycardia
Assessment: Clinically stable
O: asleep, not in respiratory distress, afebrile
V/S: HR-95cpm, RR-20bpm, AG- 55cm, Temp-
Plan: MGH
36.1, BP- 100/60mmhg, 02sat-98%
- encourage ambulation & deep
TFI: 800cc, TFO: 950cc, TFB: -150cc,
breathing exercise
UO:1.24cc/kg/hr
- High protein diet (atleast 2 eggs/meal)
- Continue intake of multivitamins
Skin: warm to touch, no rashes, no jaundice,
(Clusivol) syrup 10mL OD for 3mos
warm to touch, good turgor
@8am
- Continue intake of K-lyte tab 1tab TID 3-
HEENT: anicteric sclerae, no
5days @ 8am-1pm-6pm
lymphadenopathy, no eye & nasal discharge
- Continue intake of Cefuroxime
150mg/mL give 7mL BID for 5 days
C/L: equal chest expansion, clear breath
@8am-6pm
sounds
- Continue to drink pediasure
3glasses/day in between meals
Heart: distinct heart sound
- Monitor VS q4hr
- Refer for any unusualities
Abd: dry and clean intact wound dressing,
- Follow up at RHU after 1-2weeks with
normoactive bowel soun, non-tender
final biopsy result
Thankyou!