Case Conference 6th March 2011

19-Mei-2011, Divisi Ginekologi Onkologi

Mrs.A/52 yo/P3/Umum

(30/3/11)Patient come to CM hospital with chief complain defecation from vagina

 

History:

December 2011à Patient felt pain when micturition especially at suprasymphisis then patient went to BaktiHusada hospital à D/ appedicytisà perform appedictomy. Patient inward for 6 days. But after the operation patient still felt pain when micturition.

February 2011 à patient had stool from vagina. Patient then went to Suyoto hospital then referred to CM hospital. No vaginal bleeding. Patient married once (P3). Menopause7 years ago.

30/3/2011 à Patient arrived at CM hospital, with complain defecation from vagina.

31/3/2011 à assessment by consultant à there was uterine adhesion with anterior rectum (extraluminer). Mass at anterior wall vaginaàsuspCa corpus IIIBà advised Biopsy at mass at anterior wall vagina and USG

1/4/2011 à Biopsy result (PA 1102447): Adenosquomous carcinoma moderate differentiated.

4/4/2011 à USG (FM) result: Colorectal carcinoma with complication fistula colon-uterine, metastases at anterior peritoneum and liver.

 

NOW

General statusconscious, mildly ill, vital sign BP 120/80 mmHg, HR 84x/minutes, RR 24 x/minutes, temp afebris

Conjunctiva not anemic

No enlargement of supraclavicular, axilla and inguinal lymph node

Corand pulmownl

Abdomen : normal, no mass palpated.

Extremities were warm, edema -/-

Gynecological status

      I : v/u normal

Io :portio was smooth, mass (-), fluor (+), there was no fistula at vaginal wall. Faeces (+) from OUE.

RVT: mass palpated noduler 3 fingers below umbilicus, Uterine adhesion with anterior rectum. parametrium was normal. Rectum mucous is smooth, mass (-).Ampulla rectum not collapses.

US (FM) (04/04/11)

n  Uterine anteflexion size and shape normal.Miometriumhomogen

n  Endometrium homogeny and both ovarian normal.

n  There was peristaltic mass at uterine cavity possible originated from fistula uterine – colon. Dilatation colon with irregular margin

n  Group of peristaltic mass at cranial and in front of uterine and douglas cavity size 11,2 x 5,9 cm, originated from colorectal carcinoma. There was mass adhere to anterior peritoneum wall

Intraabdominal organ:

n  Multiple metastases at hepar..Paraaortic lymph node size 2,8 x 1,9 cm

n  Both kidney normal.

Conclusion:Colorectal cancer with complication fistula uterine-colon, metastases at anterior peritoneum and liver metastases.

SUPPORTIVE EXAMINATION

(30/03/11) Blood Count :Hb : 11,0, Leuco : 12.300, Trombo : 505.000

                                    GD : 91 Ur/Cr: 10/0,5, Alb: 2,9, AST/ALT : 80/12

PROBLEM :

Colorectal cancer with fistula with complication fistula colon-uterine, metastases at anterior peritoneum, liver, and vagina (PA: Adenosquamous carcinoma)

PLAN:

Consult Digestive Departementà Colonoscopy

CT Scan Abdomen.