Case #4
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Physical Exam
04/04/XX
48-year-old female with pelvic pain and abdominal distention/shortness of breath worsening over several days. She has a history of liver problems and reports weight gain.
X-Rays & Scans
04/15/XX
CT Chest/Abd/pelvis: small to moderate R pleural effusion w/RLL segment atelectasis. Mild to moderate ascites. Pericardial effusion. 22 x 10 cm fluid filled mass/cyst anterolateral aspect of liver. L adnexal mass suspicious for ovarian carcinoma.
Laboratory
04/XX/XX
CA 125 = elevated, no value given.
Operative Findings
08/12/XX
Minimal disease in abdomen. Uterus slightly enlarged. Ovaries bilaterally abnormal c/w cancer. No gross significant ascites noted.
Pathological Reports
05/01/XX
Pleural fluid: adenoca.
08/12/XX
Omentum: metastatic adenoca. Both ovaries/L tube: adenoca. R tube: negative. Umbilical region: hernia sac w/mets. Uterus: negative.
Treatment
06/01/XX
Chemotherapy: neoadjuvant Carbo/Taxol.
08/12/XX
Surgery:Tumor debulking; omentectomy; supracervical hysterectomy; BSO; repair of umbilical hernia.



