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Yusuf Zulkarnaen

12100116204

Supervisor :
dr. Ismu Setyo Djatmiko, Sp.OG, M.Kes

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY


MEDICINE FACULTY OF BANDUNG ISLAMIC
UNVERSITY
RSUD R SYAMSUDIN, SH SUKABUMI
2017
INTRODUCTION
Gynecological disease that have a high level of
malignancy and become the leading cause of
death in women in developing countries

WHO : Risk group : 80% in the


490.000 female with developing
women/year aged over country
in the world 30 yo Indonesia

Transmitted
Main cause : Human through
Papilloma Virus (HPV) sexual
intercours

Pap Smear
Prevention is done by early
detection Visual inspection
with acetic acid
(VIA)
CASE
PRESENTATION
PATIENTS IDENTITY

Name : Mrs. M
Age : 52 yo
Address : Hegarmanah
Cantayon-Sukabumi
Ethnic : Sundanese
Religion : Moslem
Graduate : Elementary School
Marital Status : Married
Occupation : House wife
Date of Examination: Augus 16th, 2017
CHIEF COMPLAINT
History of present illnes Others
complaints :

Patient come to the hospital with Fatigue


complaints of bleeding out from the Dizziness
vagina since 11 months ago.
Lower
abdominal
pain
Firstly, the bleeding just stop, and Loss of
then 1 last month the bleeding out appetite
more often and hard to stop.
Loss of body
weight
difficulty
Patient admitted using 1-2 pads/day urinating and
but the blood doesnt clot. The
patient has not been in contact with pain during
her husband since 5 months ago. urination
HISTORY OF PASS
ILLNESS
History of surgery : denied
History of curettage :
denied
History of chronic
hypertension :
denied
History of kidney disease :
denied
History of diabetes mellitus
: denied
History of auto immune
diseas : denied
History of asthma : denied
History of allergy : denied
History of cancer : denied
FAMILY HISTORY

History of hypertension : denied


History of kidney disease : denied
History of diabetes mellitus : denied
History of auto immune disease :
denied
History of cancer : Mothers histoy ca
cervix and sister history breast
cancer
MENSTRUAL HISTORY

Menarche : at 13 years old


Menstrual cycle : regularly every 28-31 days, 5-7 days
duration and with history of pain during menstruation
Last menstrual period : 2 years ago

Marriage history

Married once, she has been


married for 17 years
Contraception history

Pill contraceptive for 5 years old


since 2000-2005
Gestational history

Gestational Labor Birth


No Date Helper/Place Sex
Age History Weight

1. 1983 Traditional birth Aterm Vaginal Male 3200 g


attendants delivery

2. 1994 Midwife/Puskesmas Aterm Vaginal female 3300 g


delivery

3. 1999 Abortus
PHISYCAL EXAMINATION
General condition : mildly ill appearance
Consciousness : compos mentis
Blood pressure : 120/80 mmHg
Heart rate : 89 bpm
Respiratory rate : 22x/minute
Temperature : 36,8C
Weight : 40 kg
Height : 150 cm
BMI : 17,77 kg/m2
GENERAL EXAMINATION
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosa membrane
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing
-/-
Abdomen
Inspection : Flat, mass (-)
Palpation : mass (-), tenderness lower abdomen (+)
Auscultation : bowel sound (+)
Percussiom : timpani in all region
Extremities : warm, edema -/-/-/-, CRT < 2 seconds
GYNECOLOGICAL EXAMINATION
External Examination :
pelvic mass not palpable
lymph node not palpable
normal vulvovaginal, bloody discharge (+)
Inspeculo :
Vestibulum : Bloody discharge
2/3 proximal vagina : Mass, irregular,
multiple
1/3 distal vagina : Normal
Portio :Visible pus,
carcinomatous mass exophytic outside of
the cervix, size of 2x2x2 5x5x4 cm
Vaginal toucher:
Vestibulum : Normal

Vagina

2/3 proximal vagina : Mass palpable,


multiple, irregular, soft, fragile and bleed easily
1/3 distal vagina : Normal
Portio : Mass palpable,
multiple, irregular, soft, fragile and bleed easily
Uterus

Size & Shape : Normal

Position : Anteflexion
Surface : No mass palpable
Adnexa
Right : Mass palpable, multiple, irregular, soft,
fragile
Left : No mass palpable, within normal limit
Douglas Pouch : Normal

Rectal toucher
Strong anal sphincter tone

Ampulla of recti is not collaps

Mass (-), tenderness (-), bleeding (-), FCS dextra


50% and FCS sinistra 100%
ADMISSION DIAGNOSIS

Mrs. M , 52 years old, P2A1 with


(suspect) Carcinoma Cervix stage
IIB
MANAGEMENT AND THERAPY

Complete laboratory examination


Biopsy
Drug administration Tranexamic Acid
3x500 mg IV
Planning of chemoradiation
PROGNOSIS

Quo ad vitam : dubia ad bonam


Quo ad functionam: dubia ad malam

Quo ad sanationam: dubia ad malam


CASE ANALYSIS
1. How to diagnosis Ca Cervix?
2. What is the risk factor of this
case?
3. How to manage the Ca
Cervix?
Theory Case
Anamnesis Symptoms ca cervix Symptoms ca cervix
Irregular or continued vaginal Continued vaginal bleeding
bleeding Fatigue
Offensive vaginal discharge Dizziness
Pelvic pain Lower abdominal pain
Leg edema Loss of appetite
Bladder symptoms : Loss of body weight
frequemcy of micturition, difficulty urinating and pain
dysuria, hematuria during urination
Menstrual abnormalities in
the form of contact bleeding
or bleeding on straining
(during defecation)
Intermenstrual bleeding are
very much suspicious,
specially over the age 35
Theory Case
Anamnesis Carcinoma cervix Carcinoma cervix
Risk Factor/Etiology Risk Factor/Etiology
patient infection of HPV, HIV Early sexual intercourse
and Chlamydia Early age of first pregnancy
Early sexual intercourse ( <17 She admitted usage of Pill
years) hormonal contraception for 5
history of sexually transmitted years
diseases Mother was diagnosed with ca
early age of first pregnancy cervix and sister was
too many and too frequent diagnosed with breast cancer
births Low socioeconomic status
low socioeconomic status
multiple sexual partner
imunosuppresed (HIV
positive) individuals
Husband whose previous wife
dead of cervical malignancy
Oral pill users
smoking habit and history of
malignancy in family
Theory Case
Physical Speculum examination : either a Speculum examination : 2/3
examination red granular which looks like an proximal vagina visible mass,
ectopy (erosion) extending from irregular, multiple. Portio visible
the external os or nodular growth pus, carcinomatous mass
or on ulcer. The lesion bleed on exophytic outside of the cervix,
friction. It should be done prior to size of 2x2x2 5x5x4 cm
bimanual examination. The Vaginal toucher : 2/3 proximal
vagina visible mass palpable,
cervical lesion may not be visible
multiple, irregular, soft, fragile and
due to bleeding from the friable
bleed easily. Portio visible mass
lesion caused by digital palpable, multiple, irregular, soft,
examination. fragile and bleed easily. Adnexa
Bimanual examination : the lesion examination visible mass
is indurated, friable and bleeds to palpable, multiple, irregular, soft,
touch. Cervix is freely mobile fragile
Rectal examination : the Rectal toucher FCS dextra 50%
parametrium absolutely free and FCS sinistra 100%
Theory Case
Confirmation of Biopsy Complete laboratory examination
diagnosis Cytoscopy
X-ray chest Biopsy
Intravenous pyelography
Protoscopy
Theory Case
Management In general therapy of Drug administration
cervix is divided into 2, Tranexamic Acid 3x500
namely prevention and mg IV
curative. Prevention is Planning of
divided into 2 namely chemoradiation
primary and secondary.
Stage IIB :
Chemoradiation/Palliat
ive suregry
(Nephrostomy/colosto
my). Chemoradiation +
palliative radiotherapy