Case conference Nov 2nd 2011

02-Nov-2011, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

November 1^th 2011

1 OUTPATIENT

 

Mrs. P/ 47yo/P2/352-43-43/SKTM

 

 

 

HISTORY

 

Oct 25th, 2011

 

Patient came to RSCM with chief complain abdominal enlargement since 4 months before admission. Since 4 month ago, patient complain abdominal enlargement, solid, low appetite. Sometimes dyspneu, nausea and vomiting (+).

 

Patient already menopause since 2 years ago.

Decreasing BW (+)

Difficulties in micturition and defecation.

History of operation (-)

Astma (-), Hipertension (-), DM(-)

 

Married 1x, P2

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 110/80 mmHg     Pulse 104x/min         RR 20x/min   T 34,7 c

Height ... cm    BW ... kg

Conjunctiva    : not anemic

Heart/lung     :wnl

Abdomen       :cystic mass with solid part, fixed until 3 finger under Proc. Xiphoideus, tenderness (+), irregular surface

Extremities     : edema -/-

 

Gynecological status

Inspection      :wnl

Inspeculo       : portio retraction to anterior,smooth, close of ostium

VRE                 : Uterus retracted to anterior looks normally, feel cystic mass with solid part  at cranial and posterior of uterus.

 

 

 

 

 

 

 

USG examination on Oct 25^th 2011

-          Retroflexed uterus , form, contur, and size wnl, pressured by mass

-          Stratum basal of endometrial is regular and slight

-          Portio and endoservical wnl

-          Abdominal cavity fulled by solid mass wih cystic part, probably derived from neoplasms of ovarium

-          Ascites (-)

-          Liver: there are nodular masses in both hepatic lobes, size 35x36 mm (right) and 76x24mm (left), corrispond to metastases mass

-          Hydronephrosis bilateral with diameter 19mm (right), 17mm (kiri)

 

Conclusion :

      -Solid with cystic neoplasms of the ovary permagna accordance with malignancy.    

       Metastases mass multiple at hepatic.

      -Hydronephrosis bilateral

 

 

Tumor marker examination on Oct 25^th 2011 (first admission)

Ca125             245 U/mL

LDH:               1318 U/ml

 

Laboratory examination on Oct 25^th 2011 (first admission)

WB :hb/ht/leu/tromb    

          8,3/26/9700/381000

Ur/Cr : 38/1,9

Urid Acid : 13,4

OT/PT: 36/14

Alb : 2,9

Electrolite : Na/K/Cl : 125/6,7/91

Blood Sugar : 882

Laboratory examination on Oct 29^th 2011  

WB :hb/ht/leu/tromb    

          10,2/29,3/15.760/645000

Ur/Cr : 63/3,2

Alb : 2,5

Electrolite : Na/K/Cl : 121/4,11/86,5

Protrombin time (PT): Patient :13,6 second

                                          Control : 12 second

 

APTT : Patient :49,6 second

              Control : 30,9 second

 

Level of Fibrinogen : 436,9 mg/dl

D-Dimer : 2300 µg/L

 

 

 

 

 

 

Radiology examination result  (Thorax PA) on Oct 25 2011

Cardio not enlargement, CTR<50%

Aortic and Mediastinum superior not becaome wide

Trachea in the middle. Both of Hilus not become thick

Multiple of noduler various sizes in both lung fields

Both of hemidiaphragma are smooth. Both of costophrenica sinus are sharp

Bone and soft tissue are good

Conclusion : appropriate picture of lung metastases

 

Review CT scan on Oct 31 2011

Multiple coin lesion on both pulmo. No pleura effusion. Hipodense mass septation, clear border, no contrast enhancement, size 15x10x12 cm. And also hiperdense inhomogen mass with enhancement, size 14 x 9 x12 cm from the uterus.

Conclusion : endometrium carcinom and ovarium cyst. Pulmonal metastatic, with bilateral hydronephrosis with nefrolithiasis.

 

 

Assesment : suspected ovarian cancer advanced stage,  dd/endometrial cancer.

 

Plan:  Lap biopsy

             Or

             Palliative supportive