Case Conference September 7th 2011

07-Sep-2011, Divisi ginekologi onkologi RSCM

Mrs. Y/ 48 yo/ P4A1

 

HISTORY

On June 13^th 2011, patient came to Policlinic, referred  from Trimitra hospital. She underwent curettage on that hospital on may 30 2011 with PA result was endocervical  polyp and squamous cell carcinoma insitu and microinvasive cervix.  She had history of vaginal bleeding since 1 month before curretage, post coital bleeding (-), leucorrhea (-), no complain in defecation, micturition.

Patient married 1 x at 18 years old

P4A1

 

PHYSICAL EXAMINATION (June 13^th 2011)

General status :

compos mentis

BP 110/70 mmHg, HR 84x/minutes, RR 20 x/minutes, temp 36,8˚C

Conjunctiva not anemic

No enlargement of supraclavicular/axilla/inguinal limph nodes

Heart/Lung : wnl

Abdomen: supel, no abdominal mass

Extremities : no edema

 

Gynecologic status:

Inspection : no vaginal bleeding

Inspeculo : portio enlarged sized 3x3x2 cm (endophytic lesion), IVA (+) à biopsy

Rectal Vaginal Examination : endophytic mass sized 3x3x2 cm, loose  parametrium, CUT normal, smooth  rectum mucous

 

ANALYSIS  (June 13 2011) : Ca cervix IB1 endophytic

MANAGEMENT : Plan for Review slide, staging

 

Supportive Finding :

Fetomaternal ultrasound (01/07/2011) : Suspect very small (insitu) cervical cancer

Review slide PA 1104691 (30/06/2011) : endocervical polyp with multiple nabothyan cyst

 

Performed biopsy on July 4 2011, PA result  1105051 : endocervical polyp with chronic cervicitis, suspected from HPV infection

                                            

Performed Re-biopsy on July 15 2011, PA result 1105421 : chronic cervicitis

 

July 22, 2011 : Discussion with consultant : suggestion to perform colposcopy

 

Colposcopy on August 1 2011 :

Satisfied for examination

Colposcopy finding : High Grade SIL and perfomed LEEP

With PA result  1105930 :

I.  moderate-severe dysplasia

II. cervicytis with mild dysplasia (CIN I)

 

Laboratory finding (23/07/2011) : Hb 9.7/ Ht 30.8/ Leuko 19580/ Tr 539.000

Rontgen Thorax : cor and pulmo normal, no metastatic lesion

BNO-IVP : left contracted kidney, excretion and secretion normal, no sign of obstruction

 

ANALYSIS : High Grade SIL

Plan for conization on September 30, 2011