Case Conference February 113th 2013

13-Feb-2013, Divisi Ginekologi Onkologi RSCM

Clinical conference                         

Mrs C ,61 yo, 331-40-56

Pap Smear : Squamous Cell Ca

PA: Moderate-Severe Dysplasia (CIN 2-3) With Focus of Carcinoma In Situ

Conization PA: CIN 3 with edge of incision still contain dysplastic cell

 

 

2-11-2012

CC : Vaginal bleeding since 2 mo BA.

Hist :  Spotting since 2 mo ago. Not taking any medication to stop the bleeding. Pain (-), Mass (-), leukorhea (-). Post coital bleeding since 3 mo ago. No weight loss, good intake. Voiding and defecating wnl. Still having sex regularly with her husband Pap Smear 2x, first at 50 yo, with normal result. Second at September 2012, Result: HSIL, Moderate dysplasia

Married 1x at 20 yo, huspand 25 yo

Menopouse since 4 years ago

No significant past illnes history

Not taking any spesific medication

 

Physical exam:

St gen: wnl

St ginekologis :  I : wnl

Io : Portio smooth, ost closed

Vt: CUT smaller susp atrophic, adnexal mass -/-, parametrium soft

 

Lab : 4-1-2013

CBC : 14,6 / 43,3 / 9440 / 231.000

OT/PT : 32/42  Albumin : 5.13   Ur/Cr : 27/0,8 

GDP / 2JPP : 114 / 131    Na/K/Cl : 145 / 4,04 / 100,2

 

A : Post menopousal bleeding with HSIL

P : Repeat Pap Smear

 

 

5-11-2012

Pap smear : not adequate to asses due to suboptimal fixation

Suggesting squamous cell Carcinoma

Repeat PAP Smear and guided biopsy with colposcopy àSatisfactory, High grade lession

 

20-11-2012

Pap Smear : Adequate to asses, Sugesting Squamous cell Carcinoma

 

26-11-2012

Biopsy: Moderate-DevereDysplasia (CIN 2-3) With  FocusCarcinoma In Situ

 

11-1-2013

Did cold knife conization (diagnostic)

 

18-1-2013

PA result: Dysplasia grade 3 with edge of incision still contain dysplastc cell

 

11-2-2013

Plan for total hysterectomy and bilateral salphingoophorectomy