Case Confrence 28 April 2010

28-Apr-2010, Oncology Gynecology Division RSCM

1. woman/ 40 yo / P2

Chief complain : abdominal enlargement since 1,5 years ago.

Defecation and mixturition still normal. There is no symptom of loss body weight and appetite as well.

She had been married for 2 times. P3, age of the youngest child is 3 yo.
Menarche in 15 yo, regular period, dismenorrhea (-). No history of contraception.

March  24th  2010; CXR      : wnl.
March  24th 2010; BNO/IVP   : normal secretion and exretion on both kidney

March 31th 2010; CT Abdomen : solid mass with contras uptake heterogen in pelvic cavity until
                              lower abdomen, clear margin, measuring 13,36x16,81x16,91 cm.
                              vesica urinaria was pushed to postero-inferior, No calcification.
                              Mass  was protrude to m.rectus abdominis.
                              Other organ : wnl 
                              Conc. Malignancy Ovarian mass protrude to m.rectus abdominis
                                    No lymphnode enlargement
               
April 8th 2010; US :Uterus was pushed to caudal, measuring 5,5x1,7x2,1 cm, AF, echo structure        
                    homogen, mass (-), endometrial line 2,4 mm.
                    Adnexa solid mass, clear border, measuring 17x13x16 cm vol. 1900 cm3 with
                    vascularization RI 0,23.
                    Conc: Solid ovarian tumor (vol >1900 cm3) suspected malignancy process.

April 13th 2010; Ca-125 : 34,8 u/ml

Consultted to Digestive Dept. : acc joint operation
 
Consulted to Urology  Dept : acc joint operation
DD :  Solid abdominal mass originated from : 1. Ovarian mass
                                             2.Vesica urinaria mass
                                             3. M. Rectus Abdominis          

Problem :  Fixed solid pelvic mass protrude to m. rectus abdominis.
          1.Primary origin of the tumor
          2.Management for this patient

Should we do :  - Laparatomy (joint op with digestive and urology dept)?
                - Lapataromy biopsy or NAC?

2.Woman, 49 YO. P4-8YO. MR 338 41 32, SKTM

Chief complaint: consciousness deteriorating

History of complaint:
12/04/10 : S : Came with main complaint failed to urinate for 13 days. She also complaint scanty vaginal bleeding for 1 year following coitus. She has just admited before at Budi Asih hospital 1 week ago and reffered to RSCm due to Ca Cx. She also complain about, nausea and sick.
 
    O : Physical exam : Somnolen, BP 180/100mmHg. P 100x/m
        On gynaecologic exam no mass in the abdomen.
        Inspekulo : mass exophytic, 5x4x3 cm, VT: infiltration to left and right pelvic wall. Rectal mucose is normal.

14/04/07 :thorax PA : cardiomegali and congestion.  BNO no abnormality, cystoscopy, rectoscopy not yet done.
          US X Hospital : Hidronephrosis-hidroureter  bilateral. 
          PA : not sent to PA Dept. (biopsy has been done in ER)
 
   Lab: Hb 4,2g%, Hct 12, WBC 14,4K/uL, MCV/MCH/MCHC 78/27/34, U/Cr 185/23, Uric acid 12,5, OT/PT 26/16, Alb 2,6, BSR 131, NaK/Cl 129/5,9/105

   A : Ca Cx IIIB + Acute kidney injury
    P : Radiation

   C:
             Urologi : 12/4/10 hidronephrosis bilateral planned for bilateral nephrostomy.
             Cardiology : 12/4/10 Hipertension St II Acute kidney Injury ec Uropathy obstructive. Hipoalbumin, hiperkalemia, hiperuricemia and leukocytosis
             Renal-Hypertension : 12/4/10 Acute kidney Injury ec nephropaty obstructive, acidosis metabolic, hyperkalemia, HT st II, anemia due to blood lost.

          P : Amlodipin 1x10 mg
              Haemodialisis cito + blood transfusion
              Ca glukonas 1 amp
              Captopril 3x25mg

F Up :
                             27/4        25/4        22/4         21/4          18/4          17/4
            U/Cr 143/12,3   176/15,6  184/12,7    178/12,1    151/10,3    156/-

Post transfusion Hb 9,6g%

Problem : Diagnostic not complete
Problem solving : should this case followed by complete diagnostic plan?