Case conference October 19th 2011

19-Oct-2011, Divisi ginekologi onkologi RSCM

Mrs. S/50 th/P4A1

 

 

HISTORY

 

October 10th 2011

She was referred to gynecological clinic with genitalia interna abses.

September 2011 : She came to Hospital with chief complain right quadrant abdominal pain. She diagnosed first as appendicitis. Then she was referred to Fetomaternal ultrasound RSCM and diagnosed as genitalia interna abcess.

Body weight decreasing 4 kg in 2 weeks. Normal micturition and defecation.

Hypertension (+)

Operation History : post subtotal hysterectomy in year 2005due to myoma uteri.

PA : adenomiosis and adenomyoma.

 

Physical examination :

Gen st :

Abdomen: palpated mass in hypogastrica dextra, cystic, fixed.No defence muscular.

 

Gyn status :

I        : vulva, uretra wnl

Io      : portio and vagina smooth

RVT : CUT no palpable, adnexa hard   to identify, palpated mass on Mcburney size 5 cm.

 

USG examination October 5th 2011 : Cervix wnl. No abnormal mass. Both ovarian no identified. Cystic mass at the regio hipogastrica dx, on Mcburney.  Adhere with the surrounding tissues, wth echointernal non homogen, size 100 x 50 mm, no vascularisation. Suspected abcess mass in the area hypogastrica dx. Primary organ hard to identify. Hepar,lien, kidney wnl. Both adnexa (-).

 

 

Consult to Digestif division:

First performing the CT scan Abomen.

 

CT scan Abdomen pelvis : Solid cystic mass in the area right adnexa size 4,5 and 6,3 cm possibility from right ovarium.

 

Reconsult to digestif division:

Due to suspected adnexal mass, patient was sent back to gynecology clinic.

 

Laboratory finding :

CBC : 13,8/ 42,2%/ T 323.000/ L 8770, Ur 28/ Cr 0,90/ Ca 125: 96,3 U/ml/ Ca 19-9: 20,4 U/ml

 

Discussion with Dr dr Eka SpOG (k):

Ovarian cyst with solid part suspected malignancy  with RMI 288,9/ malignant score 6.

Referred to oncology policlinic.

 

Assesment by oncology consultant (Prof Dr dr Andrijono SpOGk):

Suspected abcess.

           

Assessment :

•      Suspected intraabdominal abcess  dd/ ovarian neoplasm suspected malignancy.

 

Management

•      Second opinion CT scan abdominal pelvis.