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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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