Download - Case Onko 11 March
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Case Reportof
Oncologicdivision
MARCH 11th , 2013OBGYN
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Case1 : WAHIDIN SUDIROHUSODOHOSPITAL Mrs H, 48 y.o
P0A0
Menopause since 5 years ago
Abdominal enlargement since 2 months ago
Decreasing body weight (+) Losing appetite (+)
Married since 6 years ago
Hormonal usage (-)
Family history of cancer (-)
Micturition and defecation : normal Hypertension (-), DM (-), Asthma (-), Allergy (-)
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Physical exam :
Condition : sound, conscious
Vital signs : BP : 120/80
P : 92 x/I
R : 22 x/I
Temp. : 36.9 C
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Abdominal exam :
- Ascites (+) - Mass palpated , cystic, 40x97 cm,
immobile
Vaginal examination : - uterus : difficult to evaluate
- Mass palpated , cystic, immobile
Rectal examination : TSA,smooth mucous,
empty ampulla,
no adherence,
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Lab :
Hb : 13.3 gr/dl
Wbc : 7.5 x 103/ mm3
RBC : 4.46 x 106
/ mm3 PLT : 361 x 103/ mm3
HCT : 40,7%
Lab :
RBG : 94
Ur/Cr : 31/1.2 GOT/GPT : 19/18
Alb : 3.7
Na/Cl/K :141/3.6/101
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Gynecologic ultrasound : Complex large
mass, irregular border, septated, originseemed from adnexa. Free fluid inperitoneal cavity.
Conclusion : Right adnexa complex mass,
ascites
CEA : 47.71
CA-125 : 602.9 U/ml
RMI : 5,429.1 U/ml
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PA chest x-ray : left pleural effusion, bilateraldiaphragm elevated (intra abdominalprocess)
BNO-IVP : delayed function of right kidney +
hydronephrosis gr. IV + distal ureter pressure,calcified mass on left adnexa
MSCT-Scan without contrast : adnexal
complex mass, ascites, left pleural effusion
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USG
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D/ : Cystic ovarian Neoplasmsuspected malignancy
Planning : surgical staging on 11March 2013
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Case 2 : WAHIDIN SUDIROHUSODO
HOSPITAL Mrs M, 38 y.o
P2A3
Referred from labuang baji hospital with D/ Suspected malignant
trophoblastic disease
Blood discharge since December 2012. Changes of women pantyliners :3-5 x/day
History of menstruation : reguler/month before December 2012. 1-2x/day
of pantyliners changes, for 4 days in every months
3x abortion, never been curretaged.
History of curretage for mole diagnosis : 3x in December 2012, January
2013, February 2013. No pathology results History of blood tranfusion in labuang baji hospital about 9 hours before
admission
History of contact bleeding (-)
Micturition and defecation : normal
Hypertension (-), DM (-), Asthma (-), Allergy (-)
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Physical exam :
Condition : anemic, weak, conscious
Vital sign : T : 100/60
P : 94 x/I
R : 22 x/I
Tmp : 36.9 C
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Abdominal exam :
- Uterine fundal : 3 fingers (7 cm)above SOP - Palpatic pain : (-)
- Discharge : blood (+)
Vaginal examination : - portio : tender
- uterus : increase in size of 8-10 weeks pregnancy
- adnexa & Douglass cavity : normal
Rectal examination : TSA tightening, smooth
mucous,
empty ampulla, no adherence,
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Lab :
Hb : 7.8 gr/dl (Posttransfusion of 2 bagWB)
Wbc : 14.95 x 103/ mm3
RBC : 2.86 x 106/ mm3
PLT : 195 x 103/ mm3
HCT : 24.4%
Lab :
- HCG : 83,138
Ur/Cr : 13/0.6 GOT/GPT : 10/11
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D/ : Suspected malignant trophoblasticdisease
Th/ : IVFD RL : 28 dpm
Drips cocktail in RL 500cc/ iv/8hrly
Blood transfusion of WB 2 units
Plan of completing examination :
- Tumour marker : - HCG
- Abdominal Ultrasound
- Chest x-ray
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