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تشکر ویژه از :. استاد ارجمند جناب اقای دکتر واحدیان اردکانی. خانم 28 ساله با اسیت وتوده لگنی. سناریو. بیمار خانم 28 ساله که از 6 روز قبل با علائم زیر مراجعه نمود با ادم ژنرالیزه بدن بصورت پیشرونده درد شکم در ناحیه پری امبلیکال استفراغ به دنبال غذا خوردن ضعف و بیحالی تنگی نفس فعالیتی - PowerPoint PPT Presentation

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: 28 28 6 13

PMHRenal Stone 1/5 IBS 1/5

PH/EXlab BP=100/70 PR= 144RR= 30T= 39 Oral Pale (+)Icteric (-)

Distent Shifting dulnessRLQ Tenderness Firm RLQ Mass with size 4*6 No splenomegaly ,No hepatomegaly left CVA tenderness Left foot tenderness with +4 edema SONOGRAPHY:89/11/4LIVER And biliary tract: NLNo ASCITISMultiple stones in right kidneyOvary :small folicules

:90/2/19Lab testsWBC=9800RBC=3.36HGB=8.9HCT=28.8MCV=85.7MCH=26.5MCHC=30.9PLT=278000FERITIN=51PT=13PTT=37INR=1.2ESR=27UREA=19CR=0.7NA=132K=3.5Bili-----T:0.8 D:0.3AST=35ALT=32ALKP=395Serum Alb=2.2AMYLASE=19UA=NLSONOGRAPHY : 70*135 RLQ .

SONO COLLOR DOPPLER . .

Minimal pericardial effusionEF = %55Tachycardia secondary to anemia

colonscopyNo fistula ,no mass ,no polyp,no lesion up to transverse colonExternal hemorrhoidBulging of rectal wall to external pressure effect

high gradianSAAG>1.1Serum alb=2.2Peritoneal alb=0.4

ASCITIS CYTOLOGYSUGGESTIVE FOR ACUTE INFLAMMATORY PROCESS THORAX AND ABDOMAN AND PELVIC CT SCAN WITH CONTRAST:3 13*12*16 TUMOR MARKERSCEA = 2.9 NLBHCG = < 0.1 LOWfp = 2.51 NLCA125 = 705.6 HighCA19-9 = 32.45LDH = 1067 HighFERITIN = 245.4 High

2 : : 9

FINDINGS

SAAG>1.1 WITH INFLAMMATORY PROCESS RIGHT ADNEXAL MASSCT:LARGE MASS IN PELVIC AND RLQ CA125=HIGHCA125SCREENING For ovarian cancerElevated in 50% early stage dis80% in advanced ovarian cancer(epithelial tumors)1% in healthy womenFlactuates in menstural cycleElevates in benign and malig dis:a-endometriosisb-LeiomyomaC-cirrhosis with or with out ascitisd-pelvic inflammatory dise- cancer of endometrium,breast,lung,pancreasf-pleural or peritoneal fluid due to any caused-lymphoma

20WHAT ARE DIFFERENTIAL DIAGNOSIS? DD:Premenopausal womenThe differential diagnosis of an adnexal mass discovered in women of reproductive age is broad, including physiologic or functional cysts, ectopic pregnancy, inflammatory etiologies such as a tuboovarian abscess, endometrioma, benign and malignant ovarian neoplasms, or neoplasms metastatic to the ovary PELVIC LESION BIOPSY

LYMPHOMA B -CELL TYPEIHC RESULTSCD45:strongly positive(lymphoma)CD20:Positive(lymphoma)CK20:NegativeEMA:NegativeCK7:NegativeCKAE1/AE3:Focally positiveCD117:Negative

Based on IHC and H and E finding its compatible with B Cell lymphoma

stagingStage I refers to NHL involving a single lymph node region (stage I) or a single extralymphatic organ or site (stage IE)

Stage II refers to two or more involved lymph node regions on the same side of the diaphragm (stage II) or with localized involvement of an extralymphatic organ or site (stage IIE).

Stage III refers to lymph node involvement on both sides of the diaphragm (stage III), or with localized involvement of an extralymphatic organ or site (stage IIIE) or spleen (stage IIIS), or both (stage IIIES).

Stage IV refers to the presence of diffuse or disseminated involvement of one or more extralymphatic organs (eg, liver, bone marrow, lung), with or without associated lymph node involvement.The presence or absence of systemic symptoms should be noted with each stage designation. (A = asymptomatic; B = presence of fever (>38 degrees C), sweats, or weight loss >10 percent of body weight over six months.)CSF CYTOLOGYNeg for maligTreatment :

RCHOP+IT 3 4 :Lab tests:

WBC=10200RBC=2.38HGB=6.6MCV=89.5MCH=25.5MCHC=28.6PLT=437000UA .UC=NL 2

What is diagnosis?Brain metastasis?Others?SONOGRAPHY2 ( ) 3*7 24 .CXR(PA)NORMALBrian MRI with and without contrastHypersignal in right orbitCsf cytology was negative

Ophthalmology consultation:exudative retinal detachment+cellules in retin

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