Case conference feb 1st 2012

01-Feb-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

February 1^st   2012

1 OUTPATIENT

 

MsF/ 18 yo, ,3660201, Jamkesda

 

 

HISTORY

 

January 5th, 2011

 

Patient came to RSCM with chief complain enlarging lower abdominal mass of 2 months .Lost apetite and there was decreased of body weight since 1 month ago No problem on micturition and defecation

Last menstrual period 2011 september. Before that time, the patient had regular menstrual period .

Menarche 12 yo, regular menstrual period, 28-30 days, duration 7 days, change pads 3x/day..

 

 

History :

 

No hypertension and DM history

 

Family history:

 

Hipertension (-), DM (-), heart/lung diseases (-), tumor/malignancy (-)

 

PHYSICAL EXAMINATION

 

General status,

Compos mentis

BP 120/80 mmHg     Pulse88 x/min           RR 24x/min   T afebrile

TB 150 BB 40kg

Conjunctiva    : not anemic

Heart/lung     :wnl

Abdomen       :enlarged until xp, with shifting dullness , pain-

Extremities     : edema -/-

 

Gynecological status (staging)

 

Inspection      :wnl

RE                   : cystic with solid part mass palpable with unclear marginat  

adnexa,Tonus sphincter anigood, mucous rectum smooth

 

Laboratory result (30/1/2012)

CBC: 13/39,5/7000/617.000

OT/PT:26/18  Ur/Cr:13/0,6 , Na/K/Cl : 132/5,4/99, alb 2,28 ,D dimer : 400 , CCT 51,92

 

 

Tumor marker :

            Ca125 : 213               AFP : 0,6                     hCG : 5,4

            LDH    : 540               CA    : 31,54

 

Cytology  result:

Ascites Cytology        : adenocarcinoma

yolk sac tumor

 

Ultrasound (06/1/2012) :

 Massive ascites and cystic multiloculerneoplasma with solid part suspect malignancy with unclear malignancy organ origin , suspect left ovarian dd non gynecology tumor . Left kidney congenital anomaly ( pelvic kidney ?)

 

 

Chest x ray: 4/1/2012:

Normal heart with minimal infiltrate at right parakardial

 

CT Scan :

Cystic mass multiloculer at pelvic cavity suspected from left adnexa

Massive ascites

Right pleural effusion

Left ectopic kidney shift to right side as high as vertebrae L5

 

 

 

Problem:

 

Neoplasma cystic with solid part suspect malignancydd Non gynecologic tumor

 

 

PLAN

Consult to digestive surgery division

NAC or laparotomy