1. Gynecology 성균관대학교 의과대학 2007313075 손의영

2. Chief Complain 정 O 록, F/76 외부 건강 검진상 발견된 이상소견 Onset : 1MA

3. Present Illness Previously healthy 2011.04 보라매병원에서 건강검진 시행 MRI 상 ovary cancer 의심되어 수술 권유 받음 2011.05.04 본원으로 전원 후 w/u

4. Other History PMHx. HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) Hypothyroidism (+), MDD (+) 약물력 : 씬지로이드 (40YA) 정신과약 – 가스모틴, 사미온정, 자나팜정, 졸로푸트정 수술력 : 없음 FHx. 당뇨 : 넷째 여동생, 다섯째 여동생 위암 : 첫째 오빠 SHx. Marriage : 기혼 smoking: no alcohol: no

5. Review of system GW / EF ( - / - ) Weight change (-) fever/chill ( - / - ) Headache/dizziness ( - / - ) Rhinorrhea/ cough /sputum ( - / - / - ) Dyspnea (-) chest pain / palpitation ( - / - ) anorexia/nausea/vomiting ( - / - / - ) abdominal pain/discomfort ( - / - ) constipation/diarrhea ( - / - ) hematemesis/melena/hematochezia ( - / - / + ) Urinary Sx (-) Arthralgia (-) Myalgia (-)

6. Physical Exam Vital Sign2011-05-22 17:26 147/69 mmHg - 45 - 20 - 36 ℃ G/AGenerally well-looking appearance MentalityAlert & well orientation AbdomenPalpation – Soft & flat No tenderness/rebound tenderness

7. CT

8. Problem List / Assessment Problem List #1. Left ovary mass #2. Hypothyroidism Assessment #1. : R/O ovary cancer

9. Therapeutic Plan Surgery & Biopsy BSO Omentectomy (total) LAVH, adhesiolysis

10. Pathology Granulosa cell tumor, adult type, left ovary 1) tumor size : 7 x 6 x 4 cm 2) surface involvement : cannot be evaluated 3) mitosis : 2/10 HPF 4) confined to left ovary Complex hyperplasia w/o atypia Chronic cervicitis, cervix No diagnostic abnormalities recognized left salpinx, right ovary and salpinx No evidence of malignancy, omentum