Case Conference April 18th 2011

01-Jun-2011, Divisi ginekologi onkologi RSCM

Mrs. A/52 yo/P3/Umum
 (30/3/11) Patient come to CM hospital with chief complain defecation from vagina

History:
December 2011 „³ Patient felt pain when micturition especially at suprasymphisis then patient went to Bakti Husada hospital „³ D/ appedicytis „³ perform appedictomy. Patient inward for 6 days. But after the operation patient still felt pain when micturition.

February 2011 „³ 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 „³ Patient arrived at CM hospital, with complain defecation from vagina.

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

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

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

NOW
General status conscious, 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
Cor and pulmo wnl
Abdomen : normal, no mass palpated.
Extremities were warm, edema -/-
Gynecological status
I   : v/u normal
Io :  vaginal stump 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)
ƒÞ Uterine anteflexion size and shape normal.Miometrium homogen
ƒÞ Endometrium homogeny and both ovarian normal.
ƒÞ There was peristaltic mass at uterine cavity possible originated from fistula uterine ¡V colon. Dilatation colon with irregular margin
ƒÞ 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
Intra abdominal organ:
ƒÞ Multiple metastases at hepar.. Paraaortic lymph node size 2,8 x 1,9 cm 
ƒÞ 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 Departement, Colonoscopy
CT Scan Abdomen.