1. Mrs. SAM/69 y.o/12.92.79.68/dr.

SET, SpOG

(S) The patient was consulted by an internist colleague with obstructive uropathy + mass
in the cervix + hyperkalemia + metabolic acidosis, the patient complained of weakness
and no appetite for 4 days; P2002; Married 2x  I. 5 years (divorced/death), II. 1980-
now; Contraception: (-); LMP: Menopause since 15 years ago; Menarche: 13 y.o.; Cycle :
28-30 days; duration 5-7 days (O) General Status: GCS 456 A(+)/I(-)/C(-)/D(-); BP:
113/778, HR: 102, RR: 24-26; Trect: 36,7oC, Sp.O2: 96% (free air); Cor: WNL; Pulmo:
WNL; Abdomen Soefl, BU (+) N: Weight: 37 kg, Height: 144 cm, BMI: 17,3;
Gynecologi status: Vaginal exam: v/v fluxus (-) fluor (-), infiltration upper third vagina,
Portio: exophitic, friable; CU: AF ~ WNL, AP D/S: mass palpable size ± 30 cm, fixed,
CD: WNL; RT: TSA (+), smooth mucosa CFS 25%/ 25%; Peripheral blood smear:
normochromic normochromic anemia anisopoikilocytosis. Leukocytes with immature
granulocytes (+); US: Solid mass, in the cervix uteri, size +/- 6.95 x 6.97 x 6.93 cm, mass
extends to the right and left parametrium, lower uterine segment, 1/3 proximal vagina.
Partial border is not clear to the bladder impression infiltrates the bladder. Bilateral
moderate hydronephrosis (grade III equivalent) with bilateral hydroureter. Currently
Liver/GB/Pancreas/Lien does not appear abnormal; BOF: Shadows of gas in the intestine
mixed with prominent fecal material with distribution up to the pelvic cavity, Shadow
radioopaque, oval shape in the pelvic cavity suggesting phlebolith, Ground glass opacity
in the pelvic cavity gives the impression of a full bladder, Lumbar spondylosis; Swab ID
Now : Negative ; CXR : Pulmonary inflammation (please clinical and laboratory
correlation), Cardiomegaly with aortosclerosis; Laboratory : Hb 6,4; WBC 9.090; Alb
3,2; pH 7,07; pO2 149; pCO2 13; HCO3 3,8; BE -20,3; So2 : 98%, BUN/SK 127/14,93;
(A) Susp. Clinical IIIB Cervical Cancer + History of loss of consciousness ec
Hypoglycemia + Hyperkalemia (K 7.7) + Anemia (Hb 6.2) + AKI dd ACKD (BUN/SK
127/14.93) + Moderate HN + Hypoalbumin (Alb 3,2) (P) Cervical Biopsy  Observation
and Follou up