Case Conference March 6th 2013
06-Mar-2013, Divisi Ginekologi Onkologi RSCMClinical conference
March 6th 2013
Mrs Y
(Colposcopy clinic Jan 7th 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 07th 13):
Squamous cell neoplastic with tumor diatesis
à Biopsy of suspected lesion
Colposcopy (Jan 07th 13)
Unsatisfied
Biopsy punch
LEEP
Colposopy clinic
PA Biopsy (result: Jan 10th 13)
Squamous cell carcinoma
Poor differentiated
Lymphosit reaction
Mild necrotic
(Oncology clinic Jan 21st 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
,Berita Lainnya
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