Case conference 4th jan 2012

04-Jan-2012, Divisi ginekologi onkologio RSCM

CASE CONFERENCE

JANUARY 4^th, 2012

1 OUTPATIENT

 

Mrs. S, 48yo, P3A1, 359-71-16

 

 

 

HISTORY

 

December 11^th, 2011

 

Patient came to RSCM with chief complain lower abdominal pain since 2 years before admission. (Refered to RSCM for sonographic examination)

 

Vaginal bleeding (+) and vaginal discharge since 2 years ago.

Postcoital bleeding (+).

Decreasing BW (+), 10 kgs in 2 years.

Difficulties in micturition and defecation (+).

 

Married 1x, 20 ys. P3A1, youngest child 15 ys

Housewife

 

PHYSICAL EXAMINATION on admission

 

General status, Compos mentis

BP 120/80 mmHg     Pulse 88x/min           RR 18x/min   T afebrile

Height 155 cm           BW 40 kg

Conjunctiva    : not anemic

Heart/lung     :wnl

Abdomen       :supel, bowel sound (+), tenderness (+) at lower abdominal

Extremities     : edema -/-

 

Gynecological status

Inspection      : wnl

Inspeculo       : portio endophytic,  necrotic tissue (+), fluor (-), fluxus (+)

VRE                 : portio enlarge 5x5x3 cm, cut wnl, parametrium rigid to the pelvic

                              Wall. Spingter ani tone wnl, rectal mucose smooth, no mass

 

Laboratory

(December 11^th, 2011)

CBC: 7.35/26.7/10300/425000/57/15/27   ur/cr: 22.5/0.5   RBG: 107

SGOT/PT: 32/17   uric acid: 3.0   Na/K/Cl: 135/4.03/98

(December 13^th, 2011) after blood transfussion PRC 737 cc

CBC: 10.6/34/22100/326000/66/20/31

 

US examination on December 9^th 2011

-          Anteflexed uterus, uterine corpus and fundus wnl, with enlargement size. Regular endometrium. Uterine cavum was opened, consist of echointernal substance size 75x35 mm, originated from hematometra.

-          Uterine cervix enlarge consist of echogenic mass with iregular and unclear border, inhomogen shape 44x23 mm, originated from cervix malignancy. Internal uterine ostium and both parametria were invated by mass.

-          Both ovaries wnl

-          No enlargement of para aorta and right para iliaca lymph nodes. Left para ilaca lymph nodes was enlarge 27x17 mm.

-          Liver, spleen and both kidney normal

-          No ascites

Conclusion :

Hematometra dd/ piometra ec carcinoma cervix. Mass invated to internal uterine ostium and parametria. Enlargement of left para iliaca lymph nodes.

 

December 19^th, 2011

Assessment by consultant : Dr. dr. Laila N, SpOG (K)

Endofitic mass at the uterine cervix size 5x5x3 cm

RVT :cut normal, mass at the left parametrium to the pelvic wall

 

December 20^th, 2011

Rectoscopy result was no metastatic tumor at the rectal mucose

 

December 21^st, 2011

Cystoscopy result was cystitis

 

December 22^nd, 2011

Patology result from biopsy was Positive. Adenocarcinoma mucinous cervix with villoglandular varian, good differentated.

 

Chest X-Ray: Multiple nodules ~ lung metastatic

 

BNO-IVP: Secretion and ecretion of both renal were normal.

 

ASSESMENT

Cervical cancer st IVB (lung metastatic)

 

PLAN

Palliative treatment à radiation palliative pelvic

Lung metastatic à Chemotherapy with cisplatin