ONCOLOGY OUTPATIENT

DAILY REPORT

Monday, November 12th 2018

Consultant incharge:
dr. H. Irawan Sastradinata, SpoG (K), MARS
 ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
Cervical cancer stage II post Planning for radiotherapy
1 radical hysterectomy + post C53.9 - - - - Consult to radiotherapy 180.9
NAC 3 series department
Planning for Laparotomy
FS
adenocarcinoma recti stage Consult to digestive
IIIB + ovarian solid
- - - surgery department for
2 neoplasm sinstra suspected C56.9 - 183.0
joining operation
malignancy DD/
Consult to anesthesi and
intraabdomen mass
interna department
Laboratory examination
Continue radiotherapy on
cervical cancer stage IB2 March 5th, 2019
3 C53.9 - - - - 180.9
post radical hysterectomy Laboratory examination
on March 4th, 2019
Pap smear examination
cervical cancer stage IIA
4 C53.9 - - - - Pap smear examination 3 180.9
complete therapy
months later (5-2-19)
 ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
Cervical cancer stage IIIB - - -
5 C53.9 - -
complete therapy
Pap smear
examination
Ovarian cyst neoplasm - - - Pap smear 3 months later
6 C56.9 - 180.9
suspected malignancy Planning for CT scan pelix
post radiotherapy 3 mont
hs later
Planning for Laparotomy
Cervical cancer stage IIIB
FS
7 post NAC + radical C53.9 - - - - 1830
Laboratory examination
hysterectomy
Thorax rontgen
chemotherapy Paclitaxel-
recurrent ovarian Carboplatin 5th seri
8 C56.9 - - - - 180.9
endometrioid cancer Simulator schedule Feb
26th, 2019
Cervical cancer stage IIIB +
Chemotherapy Pacilitaxel-
9 moderate anemia + C53.9 - - - - 183.0
carboplatin 6th seri
leukopenia
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Planning for
Cervical cancer
radiotherapy
Mrs. NUR/51 stage II post radical
1 C53.9 Consult to 180.9 IS IS
/RA/P4A0 hysterectomy + post
radiotherapy
NAC 3 series
department
Planning for
Laparotomy FS
adenocarcinoma Consult to digestive
recti stage IIIB + surgery department
ovarian solid
Mrs. KRI/41/ for joining operation
2 neoplasm sinstra C56.9 183.0 AT IS
UA/P3A0 Consult to anesthesi
suspected
and interna
malignancy DD/
intraabdomen mass department
Laboratory
examination
Continue
cervical cancer radiotherapy on
Mrs. MUL/40 stage IB2 post March 5th, 2019
3 C53.9 180.9 IS IS
/RA/P3A1 radical Laboratory
hysterectomy examination on
March 4th, 2019
Pap smear examinati
cervical cancer on
Mrs. HAJ/61
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Pap smear
examination
Cervical cancer Pap smear 3 months
Mrs. NUR/42
5 stage IIIB complete C53.9 later 180.9 AT IS
/RA/P0A0
therapy Planning for CT scan
pelix post radiothera
py 3 months later
Planning for Laparot
Ovarian cyst omy FS
Mrs. ARM/35
6 neoplasm suspected C56.9 Laboratory examinati 1830 AM IS
/UA/P2A0
malignancy on
Thorax rontgen
chemotherapy
Cervical cancer
Paclitaxel-
Mrs. WIR/29/ stage IIIB post NAC
7 C53.9 Carboplatin 5th seri 180.9 RS IS
UA/P2A1 + radical
Simulator schedule
hysterectomy
Feb 26th, 2019
recurrent ovarian Chemotherapy Pacilit
Mrs. CIK/52/
8 endometrioid C56.9 axel-carboplatin 6th 183.0 RS IS
UA/P4A1
cancer seri
Hospital admission
Cervical cancer PRC transfusion
Mrs. LIS/38/ stage IIIB + Inj. Leucogen
9 C53.9 180.9 RS IS
RA/P4A0 moderate anemia + Chemotherapy
 1. Mrs. NUR/51/RA/P4A0
S/ post chemotherapy
Patient come with diagnose cervical ca stage IIB post radical hysterectomy. Patient complained vaginal
bleeding since 2 months ago, colour: red-black amount: 1 time dressing, post coital bleeding (+),
urination and defecation normal, weight loss (-) appetite loss (-). Patient did cervical biopsy with PA
rsult PA 214/PA/2018 adenocarcinoma cervix, endometrioid type DD/ endomterical type
adenocarcinoma cervix.
US result (24-5-18) Hematometra in the uterine cavum
PA result 2508/A/2018: - endocervical carcinoma, usual type of cervix, with an invasion of> 1/2
myocervical thickness, vaginal cuff and 1/3 lower uterine body hinga <1/2 myometrial thickness and 2
pieces of left pelvic lymph nodes
- parametric I & II is free of tumor mass
- the ovary and fallopian tubes I & II are free of tumor mass
- reactive hyperplasia in 2 right pelvic lymph nodes and 3 left pelvic lymph nodes
- chronic non-specific inflammation in the cytology of fluid in the uterus

O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-)
Lab rsult (25-07-18) Hb9,6; Leu 5400; Trombo 163000; SGOT 25; SGPT 32; Ur26

A/ Cervical cancer stage II post radical hysterectomy + post NAC 3 series

P/ Planning for radiotherapy
Consult to radiotherapy department
 2. Mrs. KRI/41/UA/P3A0
S/ bring US result
Patient come with adenocarcinoma recti stage IIIB + ovarian solid neoplasm with US result (7-11-18)
ovarian soli neoplasm sinistra suspected malignancy DD/ intraabdomen mass
PA result 1025/MI/2017 moderately differentiated adenocarcinoma in the rectum 1/3 mid with one
of part slice full of tumor mass.
MSCT Scan whole abdomen (19-10-18): solid-cyst mass in the left side of pelvic cavity DD/ ovarian
mass, lymphadenopaty, free fluid in the cavum pelvic; simple cyst left renal.

O/
Abdominal palpation: convex supple, symmetric, tenderness (-), free fluid sign (-), mass (+)
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, MIL (-), AP right/left tender

A/ adenocarcinoma recti stage IIIB + ovarian solid neoplasm sinstra suspected malignancy DD/ intraab
domen mass

P/ Planning for Laparotomy FS

Consult to digestive surgery department for joining operation
Consult to anesthesi and interna department
Laboratory examination
 3. Mrs. MUL/40/RA/P3A1
S/ control post op
Patient come with diagnose cervical cancer stage IB2, patient did radical hysterectomy on Oct 23th,
2018 with PA result 4515/A/2018: I. - Keratinizing squamous cell carcinoma of the cervix has invaded
vaginal cuff, myoservix, uterine body, parametrium 1 and 2, 3 pieces of left pelvic cervical gland (2 cm
in diameter).
- follicular cysts in ovaries 1 and 2
- fallopian tubes 1 and 2 without real abnormalities
II. reactive hyperplasia in 6 lymph nodes from 9 left pelvic pelvic lymph nodes found
III. reactive hyperplasia in 13 right pelvical lymph nodes found

O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-), opeartion scar (+) calm

A/ cervical cancer stage IB2 post radical hysterectomy

P/ Continue radiotherapy on March 5th, 2019

Laboratory examination on March 4th, 2019
 4. Mrs. HAJ/61/RA/P0A1
S/ PAP smear result
Patient come with diagnose cervical cancer stage IIA complete therapy with PA result 3323/A/2017
moderated differentiated keratinizing squamous cell carcinoma in the uterine cervical.
Pap smear PA result 1478/C/2018 (10-10-18) no malignant cells; degenerative cells caused by
chemoradiation effects
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-)

A/ cervical cancer stage IIA complete therapy

P/ Pap smear examination  PA result 1668/C/2018: smear atrophic; no malignant cells were found
Pap smear examination 3 months later (5-2-19)
 5. Mrs. NUR/42/RA/P0A0
S/ control post chemotherapy and radiotherapy
Patient come with diagnose Cervical cancer stage IIIB complete therapy with PA result endometrial
intraepithelial carcinoma; US result cervical malignancy mass;
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-)
Speculum examination: cervix unsmooth surface, friable and bleed easily, OUE closed, mass (+) 1/3
proximal right vagina wall size 4x3 cm, fluxus (-), fluor (-)
Vaginal toucher: cervix unsmooth surface, friable and bleed easily, OUE closed, mass (+) 1/3 proximal
right vagina wall size 4x3x4 cm, CUT ~ normal, AP right/left tender, CD not prominent
RT: good sphincter tone, smooth mucosa, AP right/left tender, CFS 100%-75%

A/ Cervical cancer stage IIIB complete therapy

P/ Pap smear examination

Pap smear 3 months later
Planning for CT scan pelix post radiotherapy 3 months later
 6. Mrs. ARM/35/UA/P2A0
S/ abdominal enlarged
Patient complains abdominal enlarged since 2 months ago, pain (-) urination and defacation normal,
weight loss (-), patient went SpOG and told she got cyst and then refferals to RSMH
US result (12-11-18): multiloculare papiloferum ovarian cyst neoplasm suspected malignancy
O/
Abdominal palpation: convex, supple, asymmetric, free fluid sign (-), mass (+) 13 x 10 cm upper border:
2 fingers below proc. Xypoideus; lower border: simphysis pubic; right border: LMCD; left border: LMCS
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, bloody stool at right side

A/ ovarian cyst neoplasm suspected malignancy

P/ Planning for Laparotomy FS

Laboratory examination
Thorax rontgen
 7. Mrs. WIR/29/UA/P2A1
S/ chemotherapy
Patient come with diagnose Cervical cancer stage IIIB post NAC + radical hysterectomy with PA result
(16-10-18) low grade vaginal intraepithelial in the cuff vaginal; adenosquamous carcinoma cervix; low
grade squamous intraepithelial lesion cervix.
h/ radical hysterectomy 15-10-18
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Lab result (10-11-18): Hb 9,8; Leu 5300; Trombo 478000; SGOT 25; SGPT 37; Ur 32; Cr 21

A/ Cervical cancer stage IIIB post NAC + radical hysterectomy

P/chemotherapy Paclitaxel-Carboplatin 5th seri

Simulator schedule Feb 26th, 2019
 8. Mrs. CIK/52/UA/P4A1
S/ Chemotherapy
Patient come with diagnose recurrent ovarian endometrioid cancer with PA result 1197/PA-HR/16
endometrioid carcinoma grade III in the ovary 1 & 2, tube fallopian 1&2 metatatic, colon wall
translusent and mesocolon
h/ surgical at Hermina hospital, november
O/
Abdominal palpation: Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-),
mass (-)

Laboratory result (25-10-18): Hb 9,2; Leu 3700; Trombo 197000; AFP 3,67; CEA 1,50; CA 125 11,0

A/ recurrent ovarian endometrioid cancer

P/ Chemotherapy Pacilitaxel-carboplatin 6th seri

 9. Mrs. LIS/38/RA/P4A0
S/Continue chemotherapy
Patient come with diagnose cervical cancer stage IIIB with PA result (12-4-18) high grade cervical
glandular intraepithelial neoplasia, she has taken for 5 series of chemotherapy Paclitaxel-Carboplatin.
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Speculum examination: cervix unsmooth surface, OUE closed, friable and bleed easily, exophilic mass
3x3x4 cm, fluor (-), fluxus (+) CD prominent
Vaginal toucher: cervix unsmooth surface, OUE closed, friable and bleed easily, exophilic mass (+)
3x3x4 cm, CUT ~ normal, AP right/left tender, CD prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal, CUT not palpabled, CFS 50%-50%
Laboratory result (1-11-18): Hb 9,7; Leu 3200; Trombo 234000

A/ Cervical cancer stage IIIB + moderate anemia + leukopenia

P/ Hospital admission
PRC transfusion
Inj. Leucogen
Chemotherapy Paclitaxel Carboplatin 6th seri