DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

ONCOLOGY OUTPATIENT REPORT

Monday, 21st September 2020

Resident on Duty:
Dr. Aditya Rachman
Dr. Radinal Ys Prayitno

Doctor in charged :
Dr. H. Irawan Sastradinata, SpOG (K), MARS, SH

Supervisor :
Dr. H. Irawan Sastradinata, SpOG (K), MARS, SH
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

RECAPITULATION BASED ON DIAGNOSIS ONCOLOGY OUTPATIENT

REPORT
Monday, 21st September 2020

No Identity Diagnosis ICD Procedure ICD Cases

10 9
1 Mrs. RUN/ 69 Cervical Stage IIIB C53.9 Chemotherapy 99.25 1
YO/ 1171798/ cancer paclitaxel –
LAHAT/ P5A1/ carboplatin 4th course
NAL-IS
2 Mrs. MUR/ 46 Stage IIIB C53.9 Hospitalized 99.04 1
YO/ 1162745/ Moderate anemia D64.9 PRC transfusion 92.29
PALEMBANG/ Radiotherapy
P3A0/ NAL-RS
3 Miss. TIT/ 28 Ovarian Stage IC C56.9 Chemotherapy 99.25 1
YO/ 1175422/ cancer (complete paclitaxel –
PALEMBANG/ response) carboplatin 4th course
P0A0/ ARM-IS
4 Mrs. YUS/ 62 Stage IC Complete C56.9 Control 1 month later 89.7 1
YO/ 1166473/ therapy (complete (evaluation tumor
PALEMBANG/ response) marker)
P4A0/ NAL-RS
5 Mrs. NIN/ 46 Recurrent C56.9 US examination 88.7 1
YO/ 1181583/ Tumor marker V72.6
PALEMBANG/ evaluation 2
P2A0/ ARM-IS
6 Mrs. EMI/ 54 Inadequate staging C56.9 Laparotomy surgical 54.1 1
YO/ 1173523/ (post NAC staging
PALEMBANG/ Chemotherapy 3rd
P5A0/ NAL-IS course)
7 Mrs. ERL/ 52 Cystic ovarian neoplasm with N83.0 Laparotomy surgical 54.1 1
YO/ 1183529/ solid part malignancy was 2 staging
PALEMBANG/ suspected
P1A3/ NAL-RS
8 Mrs. HIL/ 57 Urethral caruncle (post N36.2 Control 2 weeks later 89.7 1
YO/ 1182027/ cryotherapy)
LAHAT/ P3A0/
ARM-RS
TOTAL 8
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Runa Binti Asih/ 69 YO/ 1177198/ LAHAT/ P3A1/ NAL-IS
Chief Complain Control for chemotherapy
Patient has diagnosed with cervical cancer stage IIIB. Patient had
underwent chemotherapy paclitaxel-carboplatin 3rd course on 31st August
2020.

History Right now patient didn’t had subjective complained. Patient come for
continued 4th course of chemotherapy paclitaxel-carboplatin

Laboratory result ( 21.09.2020)

Hb 10,6 g/dL WBC 8370/mm3 PLT 236000/µL Albumin 4,1 g/dL
Cervical biopsy result (2065/A/2020):
Moderately differentiated non keratinizing squamous cell carcinoma

Chest X-Rays (July 6th , 2020):

No cardiac enlargement, lungs within normal
Prior
Examination
BNO-IVP (July 14th,2020):
Left hydronephrosis grade I

US Result ( 08th July 2020) ;

Cervical malignancy mass was suspected with invasion to corpus uterine
Physical Examination
Sens: CM BP: 110/70 mmHg P: 82x/mnt RR: 20 x/mnt T: 36.5 C
General
Weight : 48 kg. Height : 156 cm
Flat abdomen, supple, symmetrical, uterine fundal height not palpable,
Abdominal
mass (-), tenderness (-), free fluid sign (-),
Bumpy portio, fragile, easy to bleed, exophitic mass size 2x3 cm,
Inspeculo
infiltrated to 1/3 proximal of vagina
Bumpy portio, fragile, easy to bleed, there is exophitic mass size 2x3 cm,
Vaginal Toucher infiltrated to 1/3 proximal of vagina, CUT ~ normal, AP was tense,
Douglas cavity not bulging
Rectal Toucher TSA normal, smooth mucous, empty ampula recti, CUT ~ normal, both
adnexa parametrium was tense, CFS : 50 % - 50 %
Diagnosis Cervical cancer stage IIIB
Planning Chemotherapy Paclitaxel-Carboplatin 4th course
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Mrs. Mursalia Binti Somidin / 46 YO/ 1162745/ PALEMBANG/ P3A0/

Identification
NAL-RS
Chief Complain Control for radiotherapy with anemia
Patient has been diagnosed with cervical cancer stage IIB. Patient had
finished 6 course of chemotherapy paclitaxel-carboplatin on 3rd July 2020.

Patient has planned for radiotherapy. Patient was checked for laboratory
History examination with result anemia, patient than consulted from radiotherapy
department.

Lab result (18.09.2020)

Hb 8,8 g/dL WBC 6890/mm3 PLT 213000/µL
PA result (474/04/2020) 10th February 2020
Cervical carcinoma dd/ cervical adenocarcinoma dd/ non ceratinizing
Prior squamous cell carcinoma
Examination
US result (11th May 2020)  post NAC Chemotherapy
Cervical malignancy mass with invasion to both of parametrium
Physical Examination
General Sens: CM BP: 110/70 mmHg P: 82x/mnt RR: 20 x/mnt T: 36.5 C
Flat abdomen, supple, symmetrical, uterine fundal height unpalpable,
Abdominal
tenderness (-), free fluid sign (-)
Bumpy portio, fragile, easy to bleed, there was exophilic mass size 3x4
Inspeculo
cm, fluor (-)
Bumpy portio, fragile, easy to bleed, there was exophilic mass size 4x5
Vaginal Toucher
cm, both AP was tensed, CUT ~ normal, Douglas cavity not bulging
Rectal Toucher Good tones of sphincter ani, smooth mucous, intraluminal mass (-), CFS
75%-50%
Cervical cancer stage IIB complete therapy
Diagnosis
Moderate anemia
Hospitalized
Planning PRC transfusion
Radiotherapy
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Miss. Titi Febriyanti / 26 YO/ 1175422/ PALEMBANG/ P0A0/ ARM-

Identification IS
Chief Complain Continued chemotherapy
Patient has diagnosed with ovarian cancer stage IC and has underwent
chemotherapy paclitaxel-carboplatin 3rd course on 31st August 2020

Patient right now didn’t had subjective complained and came for
History continued chemotherapy

Laboratory result (21.09.2020)

Hb 10,2 g/dL WBC 4200/mm3 PLT 97000/µL Albumin 4,0 g/dL
AFP 2,10 ng/mL CEA 1,80 ng/mL CA 125 8,7 U/mL
Patient has done conservative laparotomy surgical staging on 8 th July 2020
at Moh. Hoesin Hospital with
Prior PA result (2070/ A/ 2020):
Examination Seromucinous carcinoma at right ovary.
There wasn’t any sign of malignancy at omentum
Cytology of cyst’s liquid: atypic degenerative cell was seen
Physical Examination
General Sens: CM BP: 120/80 mmHg P: 88x/mnt RR: 20 x/mnt T: afebrile
Operation scar was seen, flat abdomen, supple, symmetrical, tenderness
Abdominal
(-), free fluid sign (-), mass (-)
Inspeculo Not performed
Vaginal Toucher Not performed
Diagnosis Ovarian cancer stage IC
Planning Chemotherapy paclitaxel-carboplatin 4th course
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Yusnaini Binti Paki Saki/ 62 YO/ 1166473/ PALEMBANG/ P4A0/
NAL-RS
Chief Complain Post 6 course of chemotherapy evaluation
History Patient has underwent laparotomy surgical staging and diagnosed with
ovarian cancer stage IC. Patient has finished 6 course of chemotherapy
paclitaxel-carboplatin on 28th August 2020.

Right now, patient didn’t had any subjective complained and come for
evaluation after complete 6 course of chemotherapy paclitaxel-carboplatin

Lab result (21.09.2020)

Hb 9,3 g/dL WBC 3930/mm3 PLT 143000/µL
AFP 2,16 ng/mL CEA 1,70 ng/mL CA 125 7,9 U/mL
Prior Examination Patient has done surgical staging in 21st April 2020 with
PA result ( 1577/A/2020) :
Low grade serous carcinoma in right ovary, cystadenoma serous in left ovary
: atypical cell in ascites fluid, hyperplasia reactive hyperplasia in 5 lymph no
des left parailliaca and 3 right parailliaca lymph nodes
Physical Examination
General Sens: CM BP: 120/70 mmHg P: 82x/mnt RR: 20 x/mnt T: 36.5C
Abdominal Flat abdomen, supple, symmetrical, uterine fundal height hard to assess, tend
erness (-), free fluid sign (-), mass (-)
Inspeculo Not performed
Vaginal Toucher Not performed
Diagnosis Ovarian cancer stage IC
Planning Control 1 month later (evaluation tumor marker)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Mrs. Nining Binti Sarman/ 46 YO/ 1181583/ PALEMBANG/ P2A0/

Identification NAL-IS

Chief Complain Abdominal CT Scan result has out.

History Patient first time come on 26th August 2020, referred from Hermina
Hospital and continued further treatment.

On 9th September 2020, patient come for done abdominal CT scan

examination. Patient came for abdominal CT scan result, and further
treatment

Abdominal CT Scan result

Multiple metastases nodes in liver
Cystic nodes size 1,2 cm in right posterior pelvic cavity
There is no pleura effusion

Prior On 25th August 2020, patient came to Hermina Hospital for tumor marker
examination evaluation. Patient has been planned for treated at Moh. Hoesin Hospital,
with CA 125 8,70 ng/ml.

Patient has done surgery in 17th May 2020 with

PA result (219/0434): high grade serous carcinoma ovary with invasion to
lymph vascular, colon and urinary vesical wall and endocervix; 1 lymph
nodes contain cystic mass (at Harapan Indah Hospital, Jakarta)

Patient has done abdominal CT san with result:

There is no infiltrate and nodes in both of pulmonary field.
There is no hilus and mediastinum lymph nodes enlargement

Patient than underwent 6 course of chemotherapy paclitaxel-carboplatin

and has done another CT Scan with result :
Loculated cyst collection subcapsular liver (compared with CT
30.08.2019)  smaller
There is no intraparenchymal nodes in liver
Ascites (+) perihepatic, same compared with before
Post TAH-BSO, there is no pathologic lesion in uterine bed
Colostomy in right abdomen

Patient has done TAH-BSO + colostomy in December 2019

Married status Married 1x for 14 years

Reproductive Menarche at 15 years old, regular, cycle of 28 days, for 5 days 

status menopause  post TAH-BSO

Obstetric history P2A0

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Physical Examination

General Sens: CM BP: 120/70 mmHg P: 86 x/mnt RR: 20 x/mnt T: 36,6

Abdominal Flat, Supple, symmetric, FUT not palpable, mass (-), tenderness (-), there
was mediana scar (+) 3 fingers below xyphoid process, there was stroma
in right abdomen

Inspeculo vaginal stump was normal, mass (-) flour (-) fluxus (-) E/L/P (-)

Vaginal Toucher Intact vaginal stump was normal, mass (-) Right -left parametrial was
supple, Douglas pouch not bulging

US examination
09.09.2020 ( PM)

There is no uterine and both ovaries ~ post TAH-BSO

Vaginal stump was calm
Non-homogenous consistency of liver, there was 5 nodes in liver, with
size 0,82-2,00 cm ~ metastases nodes in liver was suspected
Both renal in normal limit
There was solid mass size 1,20x1,35x1,40 cm in lateral vaginal stum ~
new growth mass
Ascites (-)

C/
Internal genital status ~ post TAH-BSO
Solid mass in lateral vaginal ~ new growth mass was suspected
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Multiple nodes in liver ~ liver metastases was suspected

Diagnosis Ovarian cancer stage recurrent (platinum sensitive)

Planning US examination (5th October 2020)

Tumor marker evaluation (5th October 2020)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Emilia Wahid Edy/ 54 YO/ 1173623/ PALEMBANG/

P5A0/NAL-RS
Chief Complain Post 3rd course of BEP Chemotherapy control
History Patient has been diagnosed with ovarian cancer inadequate staging.
Patient has been planned for 3 course of BEP Chemotherapy and followed
with surgical staging after than.

Patient has finished 3rd course of BEP Chemotherapy on 17th September

2020, and right now patient came for surgical staging preparation
Prior PA result (PA/2020/00553), March 2020/ Charitas Hospital:
Examination Macroscopic: A piece of uterus without portio with one adnexa
Conclusion: Malignant mixed mesodermal tumor at uterus and ovary

Imunohystochemistry (429/IM/2020)
AE 1/3 : Positive at tumor’s cell
Vimentine: Positive local at tumor’s cell
CD10: Postive local at tumor’s cell
Receptor of estrogen: positive at tumor’s cell
Receptor of progesteron: negative at tumor’s cell
C/ appropriate to malignant mixed mesodermal tumor (Carcinosarcoma,
WHO 2014) at uterus

US result ( 16.07.2020)
Malignancy mass was seen at vaginal stump, size 4,54 cm x 3,25 cm
Reproduction Menopause 9 years ago
Marrital 1x 25 years
Obstetric P5A0
Physical Examination
General Sens: CM BP: 110/70 mmHg P: 88 x/mnt RR: 20 x/mnt T: 36.5C
Abdominal Operation scar (mediana) was seen, flat abdomen, supple, symmetrical,
tenderness (-), free fluid sign (-), mass (-)
Inspeculo Not livide portio, closed EOU flour (-) fluxus (-) E/L/P (-)
Vaginal Toucher Portio firmed, closed OUE, both AP were no tense Douglas cavity not
bulging
Gynecological US
Examination
(Dr. H. Nuswil
Bernolian, SpOG
(K))
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

C/
Malignancy mass was seen at vaginal stump, size 4,54 cm x 3,25 cm
Diagnosis Ovarian cancer inadequate staging
Planning Laboratory examination
Chest-X-Ray
Internal medicine and anesthesia assessment
Surgical staging
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Mrs. Erlina Binti Ali Amin/ 52 YO/ 1183529/ PALEMBANG/ P1A3/

Identification NAL-RS

Chief Complain Abdominal enlargement

History Since 1 month before admission, patient admitted has abdominal

enlargement.

History of vaginal bleeding (-), history of post coital bleeding (-), history
of leucorrhea (+), white color, smell (-), itchy (-), history of weight loss
(-), history of loss of apatite (-)

History of past (-)

illness

Reproductive Menarche at 13 years old, regular, cycle of 28 days, LMP : 11th April 2020
status
Married 1x for 30 years
Married status

Obstetric history P1A3

Physical Examination

General Sens: CM BP: 110/70 mmHg P: 88 x/mnt RR: 20 x/mnt T: 36.5C

Abdominal Convex abdomen, asymmetrical, uterine fundal height unpalpable, solid

mass, immobile, with well defined border, size 15x16 cm, upper border in
3 fingers below xyphoid process, lower border in symphysis, right border
in right mid clavicular line, left border in left mid clavicular line,
tenderness (+), free fluid sign (-)

Inspeculo Unlivide portio, closed OUE, fluor (+) white color, smell (-), itchy (-),
fluxus (-), E/L/P (-)

Vaginal Toucher Firmed portio, closed OUE, both AP was supple, Douglas cavity not
bulging

US examination
18.09.2020
(AB)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

- Anteflexed uterine, size 8,71x3,92 cm

- Regular basalis stratum, homogenous myometrium, endometrial line (+)
5,83 mm
- There was solid mass size 12,62x13,66 cm, with active vascularization,
RI 0,31 originated from right ovary ~ right solid ovarian neoplasm with
malignancy was suspected dd/ solid abdominal mass
- There was cystic mass with solid part size 9,72 cm in left ovary ~ left
cystic ovarian neoplasm with solid part malignancy was suspected
- Liver in normal limit
Both renal in normal limit
- Ascites (+)

C/
Ascites
Right solid ovarian neoplasm with malignancy was suspected dd/ solid
abdominal mass
Left cystic ovarian neoplasm with solid part malignancy was suspected

Chest-X-Ray Cardiomegaly
18.09.2020

Laboratory result Hb 10,9 g/dL RBC 4160/mm4 WBC 32400/m4m Ht 35% PLT 662000/µL
18.09.2020 Ca 9,1 mg/dL SGOT 58 U/L SGPT 29 U/L Albumin 3,9 g/dLBSS 89
mg/dL Ureum 21 mg/dL Creatinine 0,70 mg/dL Na 138 mEg/L K 5,3
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

mEg/L

AFP 2,74 ng/mL CEA 1,40 ng/mL CA 125 610,7 U/mL

Diagnosis Cystic ovarian neoplasm with malignancy was suspected

Laparotomy surgical staging
Planning
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Hilta Sirawati/ 57 YO/ 1182027/ LAHAT/P3A0/ ARM- RS

Chief Complain Post cryotherapy
History Patient came with complained there was lumps in her vaginal since 10 days
ago. After done several examination, patient diagnosed with Urethra
caruncle and planed for cryotherapy

Patient has done cryotherapy on 14th September 2020, and come for control.

Physical Examination
General Sens: CM BP: 120/90 mmHg P: 82 x/mnt RR: 20 x/mnt T: afebrile
Abdominal Flat abdomen, supple, symmetrical, tenderness (-), mass (-)
Inspeculo There was mass in urethra, size 2x3 cm, tenderness (+), active bleeding (-),
fluor (-), fluxus (-), E/L/P (-)
Vaginal Toucher Firmed portio, closed OUE, CUT ~ normal, both AP was supple, Douglas
cavity not bulging
Rectal toucher Smooth mucous, good tones of sphincter ani, empty ampulla recti
US examination
(09.09.2020) - NS
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Anteflexed uterine, shape and size ~ post menopause ( 4,34x2,12 cm),

homogenous myometrium
Regular basalis stratum, endometrial thickness 0,06 cm
Both ovaries ~ post menopause, right ovary size 1,65x1,14 cm, left ovary
size 1,60x1,35 cm

C/ right now there is no abnormality in internal genital organ

Lab result Hb 13,2 g/dL RBC 4780/mm3 WBC 7680/mm3 HT 41% PLT 360000/µL
( 04.09.2020) RDW-CV 12,80%
BSS 58 mg/dL
AFP 3,31 ng/mL CEA 2,80 ng/mL CA 125 19,1 U/mL
Chest-X-Ray Cardiomegaly
04.09.2020 Arcus aorta elongation
Diagnosis Urethra caruncle (post cryotherapy)
Planning Control 2 week later