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CLINICAL PATHOLOGICAL CONFERENCE

Agust, th 2018

No Name Anamnesis Physical Examination PA + Lab Radiology Assessment Plan


1 Budy Iryawan Chief Complaint : General condition: Good FNAB( 4-4-2018): X ray : Pathological Pathological fracture of
38 y.o Pain on the left upper arm Karnofsky score : 70 Atipic cell suspect fracture left humerus, the left humerus ec
319436 Recent History : Head : no abnormality malignancy litic lesion, suspect peripheral nerve sheath
Magelang - Appeared since 3 month before admission, Neck : no abnormality primary bone tumor. tumor
after playing volley ball. Eyes : no abnormality PA (19-7-2018):
- 6 month before admission pasien felt pain on Nose : no abnormality Borderline peripheral MRI :
his left upper arm Ears : no abnormality nerve sheath tumor Massa intramedullary
- No history of trauma before. Mouth : no abnormality diafisis, susp Ewing
- History of weight loss (+), night pain (+), Loss Chest : no abnormality Lab : 20-6-2018 sarcoma dd lymphoma of
of appetite (-). Shoulder: no abnormality Hb : 15,5 g/d bone
- history of chronic illness (-) Abdominal: no abnormality Ht : 45 %
Past History: Extermities: look at local Leu : 6300 rb/ul CT scan
• Significant or repetitive trauma (+) examination Tro : 245 rb/ul Osteomyelitis, with
• Steroid use (-) Gluco : 80 mg/dL pathological fracture of
• Chronic illness (-) Left Upper Arm region: ALP : 86 u/L diaphysis humerus
• Cancer history L : Skin intact, swelling (-), LDH : 318
Family: venectation (-), color of the skin still
• Cancer History (-) normal, deformity unclear.
F : Tenderness (-),
Neurovascular disturbance (-)
M : ROM Shoulder and elbow
limited due to pain
2. Syahdin Aulia Chief Complaint : General condition: Average FNAB (11-10-2017) X ray Closed pathological
16 y.o Pain on the right knee Karnoffsky Score : 70 Osteosarcoma Mass on metadiaphysis fracture of right distal
309728 Recent History : Head : no abnormality PA (19-7-2018) distal femur, blastic femur due to
Tegal Three days before admission, patient was Eyes : no abnormality Osteosarcoma (residif) lesion , with pathological osteosarcoma
slipped down in the bathroom, with position her right Nose : no abnormality fracture
knee hit the floor first. After the accident, patient felt Ears : no abnormality Lab (9-9-2017)
pain over her right knee that aggravated by movement Mouth : no abnormality Hb : 12.6 g/dl MRI (28-6-2018)
and unable to bear weight Neck : no abnormality Ht : 39 % Malignant bone tumor
Night pain (+), loss of body weight (+), loss of appetite Shoulder : no abnormality Leu : 5200 rb/ul tumor metadiafisis distal
(+), dyspnea (-), headache (-), chronic fever (-), Chest : no abnormality Tro : 330 rb/ul femur dextra, feeding
mixturition and defecation still normal. Abdominal : no abnormality LED 1 : 52 mm/jam artery from arteri
Extermities : look at local LED 2 : 71 mm/jam femoralis and popliteal
Past History: examination CRP : (-) dextra, pathological
Chemotherapy : 6x in Moewardi Hospital ALP : 387 u/L fracture diafisis distal
Significant or repetitive trauma (-) Right thigh region femur dextra
Steroid use (-) L : mass over the knee with 42 Lab (06-06-2018)
Chronic illness (-) x 17 cm, shiny skin (+), swelling Hb : 10.6 g/dl
Cancer history (-) distal (-), ulcer(-) Ht : 32 %
F : solid mass, fixated, unclear Leu : 7500 /ul
Family: margin, warmer than adjacent skin, Tro: 163 rb/ul
Cancer History (-) tenderness (+) knee LED 1 : 35 mm/jam
M : ROM knee hard to evaluate LED 2 : 60 mm/jam
due to pain CRP : (-)
ALP : 159 u/L
LDH : 212