Case Conference March 6th 2013

06-Mar-2013, Divisi Ginekologi Onkologi RSCM

Clinical conference                         

Mrs Y

(Colposcopy clinic Jan 7^th 13)

Cc: post coital bleeding

(reffered from ps rebo hosp due to ca cx susp IIA)

 

•      Blood spotting since 3 mos, post coital bleeding (+).

•      Pap smear at Pasar Rebo hosp (25/12/13): cervical infection

•      Biopsy: cervix uteri CIN 3 – insitu carsinoma, stroma invasion

•      Married 1x (25yo),  husband 1x

•      A2: 1. 2mos à curretage (-)

      2. 4 mos à curretage

 

Physical exam:

•      Gen st: within normal limit

•      Gyn st:

 I: no active bleeding

Io: bulging mass and easily bleed size d2x2cm

RVT: bulging mass palpated size d2x2cm, mass spread to 1/3 prox vagina. Smooth parametrium.

 

Lab : 22-1-2013

CBC : 12.5 /36.9/ 7880 / 322.000

OT/PT : 17/13  Albumin :4.5   Ur/Cr : 20/0,7 

GDP / 2JPP: 83/85

Na/K/Cl : 136 / 3.6 / 105

 

 

 

A: Carsinoma Invasif

 

Pap smear RSCM (Jan 07^th 13):

Squamous cell neoplastic with tumor diatesis

à Biopsy of suspected lesion

 

Colposcopy (Jan 07^th 13)

Unsatisfied

Biopsy punch

LEEP

Colposopy clinic

 

 

PA Biopsy (result: Jan 10^th 13)

Squamous cell carcinoma

Poor differentiated

Lymphosit reaction

Mild necrotic

 

(Oncology clinic Jan 21^st 2013)

 

Gyn st: no active bleeding

RVT: mass from cervix palpated, size d4x4x3.6cm. Smooth vaginal wall, fornix anterior and parametrium. No mass on pelvic wall.

Rectal mucose smooth

 

 

A : Ca cervix stad IIA2

 

P: Histerektomi + Neoadjuvant Chemotherapy

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