ONCOLOGY OUTPATIENT

DAILY REPORT

Tuesday, October 16th 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
Ovarian ca std IV post - - - Chemotherapy BEP 1st
1 C56.1 - 183.0
suboptimal debulking course day 18th
Clinical staging
2 Cervical ca susp. Std IIIB C53.9 - - - - 180.9
Laboratory evaluation
BNO-IVP
Surgical staging
Laboratory evaluation
Consultation to interna
3 Endometrial ca + DM type II C54.9 - - - - 182.0
department
Consultation to anesthesi
department
chemotherapy Brexel-
Carbo 6 courses
4 Cervical ca std IVB C53.9 - - - - 180.9
Laboratory evaluation
Wound toilet
Endometrial ca inadequate Chemotherapy Carbo-Pac
5 C54.9 - - - - 182.0
staging il 6 courses
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Ovarian ca std IV
Ms. SAR/53/ Chemotherapy BEP
1 post suboptimal C56.1 183.0 AM RS
RA/P0A0 1st course day 18th
debulking
Clinical staging
Mrs.
Cervical ca susp. Std
2 NUR/53/UA/ C53.9 Laboratory evaluati 180.9 RS RS
IIIB
P3A0 on
BNO-IVP
Surgical staging
Laboratory
evaluation
Mrs. ESL/64/ Endometrial ca + Consultation to
3 C54.9 182.0 RS RS
RA/P5A0 DM type II interna department
Consultation to
anesthesi
department
chemotherapy
Brexel-Carbo 6
Mrs. SUR/50/ courses
4 Cervical ca std IVB C53.9 180.9 RS RS
RA/P4A0 Laboratory
evaluation
Wound toilet
Mrs. ESM/61/ Endometrial ca Chemotherapy Car
5 C54.9 182.0 AM RS
 1. Ms. SAR/53/RA/P0A0
S/ chemotherapy
Patient come with diagnose ovarian ca std IV post suboptimal debulking with PA result 3699/A/2018
metastase adult granulose cell tumor on omentum and peritoneum; no malignant cell were found on
peritoneal fluid cytology.
USG result (7-7-18): no new mass growth in the abdomen appears
h/ surgical staging 21-8-18
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (-) blood, 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/ Ovarian ca std IV post suboptimal debulking

P/ Chemotherapy BEP 1st course day 18th
 2. Mrs. NUR/53/UA/P3A0
S/ chemotherapy
Patient refferals from another Sp.OG with diagnsoe cervcial ca. Patient planned to be chemotherapy.
Patient complains vaginal bleeding and post coital bleeding (+).
h/ CKD on HD routinely.
USG Fetomaternal (27-9-18): Cervical malignancy mass invated OUI and vesica urinaria; lymph node
enlarged on parailiaca bilateral; hydronephrosis bilateral; hematometra
USG TUG result (5-10-18): Cervical malignacy mass infiltrated distal ureter bilateral cause
hydronephrosis bilateral grade III. Cyst mass adnexa dextra susp. Right ovarian cyst.
Cervical biopsy 3572/A/2018: papillary squamous cell carcinoma on cervical
O/
Abdominal palpation: convex, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Vaginal toucher: cervix unsmooth surface, friable, bleed easily, palpable exophytic mass size: 3x3 cm,
AP right/left tender, CD prominent, E/L/P (-)
Speculum examination: cervix friable, bleed easily, exophytic mass (+) size: 3x3x3 cm

A/ Cervical ca susp. Std IIIB

P/ Clinical staging
Laboratory evaluation
BNO-IVP
 3. Mrs. ESL/64/RA/P5A0
S/ PA result evaluation
Patient come with diagnose endometrial ca + DM t.II with PA result 4240/A/2018 susp. Endometrioid
carcinoma, FIGO grade III on endocervical and endometrium curettage.
USG result (10-9-18): endometrial hyperplasia
O/
Abdominal palpation: flat, supple, symmetric, tenderness (+), free fluid sign (-), mass (-)
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (+) blood, E/L/P (-), sondage 7
cm, CD not prominent
Vaginal toucher: portio not livide, closed OUE, CUT ~ 12 weeks pregnancy AP right/left tender, CD not
prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal

A/ Endometrial ca + DM type II
P/ Surgical staging
Laboratory evaluation
Consultation to interna department
Consultation to anesthesi department
 4. Mrs. SUR/50/RA/P4A0
S/ chemotherapy
Patient come with diagnose cervical ca std IVB with Cervical biopsy (5-7-18): Endocervical
adenocarcinoma usual type.
USG result (6-7-18): cervical mass malignancy; cyst mixed solid ovarian neoplasm susp malignancy;
mass susp. Abses from subfasia through cutis; intra abdomen organ adhesion.
O/
Abdominal palpation: convex, supple, symmetric, tenderness (-), free fluid sign (-), mass (+) subcutis,
ulcus (+)
Vaginal toucher: cervix unsmooth surface, friable, bleed easily, palpable exophytic mass size: 3x3 cm,
AP right/left tender, CD prominent, E/L/P (-)
Speculum examination: cervix friable, bleed easily, exophytic mass (+) size: 3x3x3 cm
RT: good sphincter tone, smooth mucosa, AP right/left normal

A/ cervical ca std IVB

P/ chemotherapy Brexel-Carbo 6 courses
Laboratory evaluation
Wound toilet
 5. Mrs. ESM/61/RA/P4A0
S/ chemotherapy
Patient come with diagnose endometrial ca inadequate staging with PA result 706/AS/2017 (FNAB):
Metastase adenocarcinoma posibility of metastase from endometrioid carcinoma can’t be replaced.
PA result PA/2017/007 (Charitas Hospital): Tunnel cluster cyst inflamatory chronic on cervical;
proliferation phase endometrium with endometrioid carcinoma area; carcinoma-moderately
differentiated can be supporeted; chronic inflamatory ovarian tissue; paratubal cyst on fallopian tube
O/
Abdominal palpation: flat, supple, symmetric, tenderness (+), free fluid sign (-), mass (-)
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (+) blood, E/L/P (-), sondage 7
cm, CD not prominent
Vaginal toucher: portio not livide, closed OUE, CUT ~ 12 weeks pregnancy AP right/left tender, CD not
prominent
RT: good sphincter tone, smooth mucosa, AP right/left normal

A/ Endometrial ca inadequate staging

P/ Chemotherapy Carbo-Pacil 6 courses