ONCOLOGY OUTPATIENT

DAILY REPORT

Friday, December 7th 2018

Consultant incharge:
dr. H. Rizal Sanif, SpoG (K), MARS
 ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
Post hydatidiform mole Beta HCG evaluation 7
1 O01.9 - - - - 630
evacuate days later
US confirmation
Thorax rontgen
Cervical cancer suspected - - - BNO IVP
2 C53.9 - 180.9
stage IIB Laboratory examination
Planning for
chemotherapy
- - - Chemotherapy BEP 1st
3 Ovarian cancer stage IIA C56.9 - 183.0
seri
Abdominal CT Scan with c
ontrast
ascites massive et cause
- - - Laboratory
4 malignancy + DM type II + R87.612 - 795.03
examination
HHD
Consult to interna depart
ment
Chemotherapy paclitaxel-
- - - carboplatin 6th seri
5 cervical cancer stage IIIB C53.9 - 180.9
Radiotherapy Dec 11,
2018
 ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
US confirmation
Ovarian cancer stage IA
6 C56.9 - - - - Tumor marker evaluation 183.0
post clinical staging
every 3 months
Chemotherapy Docetaxel-
Carboplatin 2nd seri
Ovarian cancer advace - - -
7 C56.9 - Planning for Laparotomy 183.0
staging
FS (surgical staging post
NAC)
P/ Chemotherapy Doceta
Ovarian cancer stage IIIA + - - - xel-Carboplatin
8 C56.9 - 183.0
moderate anemia 1st seri
Control 1 week later
Tumor trophoblast
- - - P/ MR Chemotherapy 2nd
9 gestational std I FIGO score O01.9 - 630
seri
4
US confirmation
Laboratory
Endometrial atypical - - -
10 C54.1 - examination 182.0
hyperplasia
Planning for hysterectom
y
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Mrs. ARI/26/ Post hydatidiform Beta HCG evaluation
1 O01.9 630 RS RS
RA/P2A1 mole evacuate 7 days later
US confirmation
Thorax rontgen
BNO IVP
Mrs. RIY/39/ Cervical cancer
2 C53.9 Laboratory 180.9 IS RS
RA/P4A0 suspected stage IIB
examination
Planning for
chemotherapy
Mrs. NUR/30 Ovarian cancer Chemotherapy BEP
3 C56.9 183.0 AM RS
/UA/P1A0 stage IIA 1st seri
Abdominal CT Scan w
ith contrast
ascites massive et
Mrs. FAR/37/ R87.61 Laboratory 795.0
4 cause malignancy + IS RS
RA/P3A0 2 examination 3
DM type II + HHD
Consult to interna de
partment
Chemotherapy
paclitaxel-carboplatin
Mrs. KOS/39 cervical cancer
5 C53.9 6th seri 180.9 AT RS
/RA/P2A0 stage IIIB
Radiotherapy Dec 11,
2018
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
US confirmation
Ovarian cancer
Ms. DWY/14/ Tumor marker
6 stage IA post clinical C56.9 183.0 AT RS
RA/P0A0 evaluation every 3
staging
months
Chemotherapy
Docetaxel-
Carboplatin 2nd seri
Mrs. SRI/55/ Ovarian cancer
7 C56.9 Planning for 183.0 AM RS
UA/P2A1 advace staging
Laparotomy FS
(surgical staging post
NAC)
P/ Chemotherapy Do
Ovarian cancer
Ms. WON/50 cetaxel-Carboplatin
8 stage IIIA + C56.9 183.0 AM RS
/UA/P0A0 1st seri
moderate anemia
Control 1 week later
Tumor trophoblast
Mrs. YUS/22 P/ MR Chemotherapy
9 gestational std I O01.9 630 RS RS
/RA/P2A0 2nd seri
FIGO score 4
US confirmation
Laboratory
Mrs. DES/36/ Endometrial atypical
10 C54.1 examination 182.0 RS RS
RA/P2A0 hyperplasia
Planning for hysterec
tomy
 1. Mrs. ARI/26/RA/P2A1
S/ control post hydatidiform mole evacuation
Patient come with diagnosis post hydatidiform mole with US result: suspected hydatidiform mole. Patient
was scheduled to do Beta HCG evaluation.
Laboratory evaluation:
NO DATE T3 fT3 fT4 TSHs B-HCG
1 23-10-18 4,54 19,66 3,19 0,0080 1250285,90
2 5-11-18 5,50 1,82 0,0081 10095,44
3 13-11-18 0,88 2,20 0,76 0,0091 920,44
4 21-11-18 246,15
5 28-11-18 87,25
6 6-12-18 36,66

O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height difficult to
meassure, mass (-)
Laboratory result (13-11-18): Hb 9,1; Leu 7100; Trombo 304000; T3 0,88;

A/ Post hydatidiform mole evacuate

P/ Beta HCG evaluation 7 days later

 2. Mrs. RIY/39/RA/P4A0
S/ vaginal bleeding
Patient complains vaginal bleeding since 7 months ago, history of post coital bleeding (+), history of
vaginal discharge (+), weight loss (=), appetite loss (+). She went to Obstetrician and did surgical staging
and vaginal biopsy with result cervical cancer stage IIB then she was planned to do chemotherapy NAC
for 3 series continued by laparotomy radical hysterectomy.
h/ cervical biospy on September 13th, 2018 with PA result: adenocarcinoma differentiated
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-).
Speculum examination: cervix friable, bleed easily, exophytic mass (+) size: 3x3 cm, fluor (-), fluxus (-),
E/L/P (-)
Vaginal toucher: cervix unsmooth surface, friable, bleed easily, palpable exophytic mass size: 3x3 cm,
AP right/left tender, CD prominent
RT: good sphincter tone, smooth mucosa, MIL (-), AP right/left normal, CFS 100%:100%

A/ Cervical cancer suspected stage IIB

P/ US confirmation
Thorax rontgen
BNO IVP
Laboratory examination
Planning for chemotherapy
 3. Mrs. NUR/30/UA/P1A0
S/ control post operation in another hospital
Patient control post operation HTSOB on October 28th, 2018 at Charitas Hospital with PA result
(PA/2018/02416) endodermal sinus tumor; right and left parailiac lymphatic glands with sinus
histiocytosis; omentum with hyperplasia mesothel
Abdominal US result (28-10-18): ascites and suspected large ovarian tumors are not measurable
possible malignancies
O/
Abdominal palpation: convex tense, symmetric, tenderness (-), free fluid sign (-), mass (-)
Speculum examination: normal vaginal stump
Vaginal toucher: normal vaginal stump
RT: good sphincter tone, smooth mucosa, AP right/left tender
Laboratory result: AFP 135,92

A/ Ovarian cancer stage IIA

P/ Chemotherapy BEP 1st seri

 4. Mrs. FAR/37/RA/P3A0
S/ Abdominal enlarged
Patient complains right abdominal enlarged since 3 months ago. Patient has hospitalized with diagnosis
ascites et cause malignancy + DM type II + HHD. Complaining of vaginal bleeding (-), vaginal discharge (-),
post coital bleeding (-).
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (+), mass can’t be evaluate
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (-), E/L/P (-), CD not prominent
Vaginal toucher: portio not livide, closed OUE, AP right/left not tender, CD not prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal

A/ ascites massive et cause malignancy + DM type II + HHD

P/ Abdominal CT Scan with contrast

Laboratory examination
Consult to interna department
 5. Mrs. KOS/39/RA/P2A0
S/ vaginal bleeding
Patient complains vaginal bleeding since 1 month ago, appetite loss (+) weight loss (+) urination and
defecation normal. Patient has done clinical staging with diagnosed cervical ca stg IIIb and did
chemtherapy BEP for 1 seri. PA result 2750/A/2018 endocervical adenocarcinoma usual type in the
uterine cervix.
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Speculum examination: cervix friable, bleed easily, exophytic mass (+) size: 4x4 cm, fluor (-), fluxus (-),
E/L/P (-)
Vaginal toucher: cervix unsmooth surface, friable, bleed easily, palpable exophytic mass size: 4x4 cm,
AP right/left tender, CD prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal, CFS 25%:0%
Laboratory result (5-11-2018): Hb 11,3; Leu 3900; Trombo 135000; SGOT 71; SGPT 87; Alb 4,5; BSS 85

A/ cervical cancer stage IIIB

P/ Chemotherapy paclitaxel-carboplatin 6th seri

Radiotherapy Dec 11, 2018
 6. Ms. DWY/14/RA/P0A0
S/ Post op, bring PA result
Patient come with diagnose ovarian cancer stageIII complete therapy with PA result 266/HL/2016 (02-
12-2016): ovarian dysgerminoma.
MSCT Abdomen (20-9-18): excretion function and right kidney secretion decrease. Right kidney
atrophy; Lymphadenopathy in L1-2 height of the right abdominal paraaorta measuring 4.7 x 2.29 cm is
urgent causing right hydronephrosis (severe).
h/ SOD surgical 02-12-2016
h/ chemotherapy NAC BEP 4 seri
h/ lapartomy conservative surgical staging on Nov 29th, 2018 with PA result 5035/A/2018: no
malignant signs were found in the omentum and peritoneal rinses
NO DATE AFP CEA CA 125
Tumor
1 markerevaluation:
19-09-17 - 3,05 -
2 04-07-18 0,67 0,80 19,50
3 30-07-18 1,56 1,40 23,2
4 27-09-18 1,94 - 15,0
5 6-12-18 2,40
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-) supra pubic, free fluid sign (-), mass (-),
operation scar (+) calm

A/ Ovarian cancer stage IA post clinical staging

P/US confirmation
Tumor marker evaluation every 3 months
 7. Mrs. SRI/55/UA/P2A1
S/ bring FNAC result
Patient come with complain of abdominal enlargement, since 1 month, pain (+) diagnose ovarian
cancer advance stage was suspected (suspected metastatic to umbilical) + right ovarian solid neoplasm
+ cyst mixed solid ovarian neoplasm suspected malignancy with PA result 767/AS/2018 carcinoma in
the FNAC cytology umbilical region. US result (31-10-18) ascites in the solid ovarian neoplasm dextra +
cyst mixed solid ovarian neoplasm suspected malignancy
O/
Abdominal palpation: convex tense, symmetric, tenderness (-), free fluid sign (-), mass (+) 20x10 cm,
cyst, mobile, upper border 4 fingers below proc. xipoid; lower border symphisis pubic; left border
LMCS; rght border LMCD
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (+), E/L/P (-), CD prominent
Vaginal toucher: portio not livide, closed OUE, AP right/left tender, CD prominent
RT: good sphincter tone, smooth mucosa, AP right/left tender
Lab result (29-10-18): Hb 12,7; Leu 8000; Trombo 444000; AFP 3,39; CEA 2,10; CA 125 2436,5
CT scan result: Mass with a necrotic component not calcified in the pelvic cavity, possibly a result of an
ovary infiltrating the sigmoid colon and causing right hydronephrosis accompanied by massive ascites
from pleural effusion.

A/ Ovarian cancer advace staging

P/ Chemotherapy Docetaxel-Carboplatin 2nd seri

Planning for Laparotomy FS (surgical staging post NAC)
 8. Ms. WON/50/UA/P0A0
S/ post op, bring PA result
Patient post Laparotomy FS on November 13th, 2018 with PA result 4992/A/2018 I & II. - FIGO grade III
endometrioid carcinoma of the right and left ovaries; III. Metastatic carcinoma in the cytology of ascites
fluid
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-), operation scar
(+)
RT: good sphincter tone, smooth mucosa, AP right tender, AP left not tender, mass (+) 6x4 cm inferior
adnexa, CD not prominent
USG result (2-10-18)= endometrial thickening susp. Endometrial hyperplasia + uterine adenomyoma;
NOP multiloculare with katik bilateral
Lab resut: Hb 9,5; Leu 5600; Trombo 603000; AFP 2,10; CEA 6,70; CA 125 88,4

A/Ovarian cancer stage IIIA + moderate anemia

P/ Chemotherapy Docetaxel-Carboplatin 1st seri

Control 1 week later
 9. Mrs. YUS/22/RA/P2A0
S/ control
Patient come with diagnose tumor trophoblast gestational and scheduled to evaluate beta HCG
periodically and chemothearpy, Complaining of abdominal pain (-), vaginal discharge (-), vaginal
bleeding (-), urination and defecation normal.
NO DATE BETA HCG
1 5-11-18 3,08
2 21-11-18 1,73
3 7-12-18 1,20

O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

A/ Tumor trophoblast gestational std I FIGO score 4

P/ MR Chemotherapy 2nd seri

 9. Mrs. HIK/49/UA/P3A0
S/ post op on another hospital
Patient refferals from Bunda Palembang Hospital post HTSOB indicated by uterus chronic inflamation
with PA result 2890/MI/2018 moderate differentiated non-keratinizing squamous cell cervical
carcinoma; Lymphovascular invasive (+) has been invasived through myometrium; luteal cyst bleeding
on ovarian I; endometriosis on fallopian tube I;
h/ HTSOB 28-9-18
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-), scarring
operation
Vaginal toucher: normal vaginal stump
Speculum examination: hyperemis on vaginal stump, blood (+)
RT: good sphincter tone, smooth mucosa, AP right/left normal, bloody stool at right side
Lab result: Hb 11,4; Leu 9700; Trombo 340000; SGOT 39; SGPT11; BSS 127; Ur 17; Cr 0,71

A/ cervical ca inadequate therapy

P/ Chemotherapy Pacli-Carbo 2nd seri

Chemoradiation  25 times start on February 12, 2019 after chemotherapy
 10. Mrs. DES/36/RA/P2A0
S/vaginal bleeding
Patient come complain vaginal bleeding (+), vaginal discharge (-), abdominal pain (-), abdominal
enlarged (-) post coital bleeding (-), patient went to Obstetrician and did curettage with PA result
2365/DH/2018 endometrial hyperplasia atypical, malignancy can’t be eliminate.
h/ 2014, curettage at Moh Hoesin Hospital  endometrial polyp
h/ 2018 (Nov 15th), curettage at Bunda Hospital
O/
Abdominal palpation: flat, supple, symmetric, tenderness (+), free fluid sign (-), mass (-)
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (-), E/L/P (-), CD not prominent
Vaginal toucher: portio not livide, closed OUE, AP right/left not tender, CD not prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal

A/ Endometrial atypical hyperplasia

P/ US confirmation
Laboratory examination
Planning for hysterectomy