Professional Documents
Culture Documents
DAILY REPORT
Consultant incharge:
dr. H. Irawan Sastradinata, SpoG (K), MARS
ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
Cervical cancer stage II post Planning for radiotherapy
1 radical hysterectomy + post C53.9 - - - - Consult to radiotherapy 180.9
NAC 3 series department
Planning for Laparotomy
FS
adenocarcinoma recti stage Consult to digestive
IIIB + ovarian solid
- - - surgery department for
2 neoplasm sinstra suspected C56.9 - 183.0
joining operation
malignancy DD/
Consult to anesthesi and
intraabdomen mass
interna department
Laboratory examination
Continue radiotherapy on
cervical cancer stage IB2 March 5th, 2019
3 C53.9 - - - - 180.9
post radical hysterectomy Laboratory examination
on March 4th, 2019
Pap smear examination
cervical cancer stage IIA
4 C53.9 - - - - Pap smear examination 3 180.9
complete therapy
months later (5-2-19)
ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD 10 New case Old case Procedure ICD 9
H A H A
Cervical cancer stage IIIB - - -
5 C53.9 - -
complete therapy
Pap smear
examination
Ovarian cyst neoplasm - - - Pap smear 3 months later
6 C56.9 - 180.9
suspected malignancy Planning for CT scan pelix
post radiotherapy 3 mont
hs later
Planning for Laparotomy
Cervical cancer stage IIIB
FS
7 post NAC + radical C53.9 - - - - 1830
Laboratory examination
hysterectomy
Thorax rontgen
chemotherapy Paclitaxel-
recurrent ovarian Carboplatin 5th seri
8 C56.9 - - - - 180.9
endometrioid cancer Simulator schedule Feb
26th, 2019
Cervical cancer stage IIIB +
Chemotherapy Pacilitaxel-
9 moderate anemia + C53.9 - - - - 183.0
carboplatin 6th seri
leukopenia
ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Planning for
Cervical cancer
radiotherapy
Mrs. NUR/51 stage II post radical
1 C53.9 Consult to 180.9 IS IS
/RA/P4A0 hysterectomy + post
radiotherapy
NAC 3 series
department
Planning for
Laparotomy FS
adenocarcinoma Consult to digestive
recti stage IIIB + surgery department
ovarian solid
Mrs. KRI/41/ for joining operation
2 neoplasm sinstra C56.9 183.0 AT IS
UA/P3A0 Consult to anesthesi
suspected
and interna
malignancy DD/
intraabdomen mass department
Laboratory
examination
Continue
cervical cancer radiotherapy on
Mrs. MUL/40 stage IB2 post March 5th, 2019
3 C53.9 180.9 IS IS
/RA/P3A1 radical Laboratory
hysterectomy examination on
March 4th, 2019
Pap smear examinati
cervical cancer on
Mrs. HAJ/61
ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
CIAN incharge
Pap smear
examination
Cervical cancer Pap smear 3 months
Mrs. NUR/42
5 stage IIIB complete C53.9 later 180.9 AT IS
/RA/P0A0
therapy Planning for CT scan
pelix post radiothera
py 3 months later
Planning for Laparot
Ovarian cyst omy FS
Mrs. ARM/35
6 neoplasm suspected C56.9 Laboratory examinati 1830 AM IS
/UA/P2A0
malignancy on
Thorax rontgen
chemotherapy
Cervical cancer
Paclitaxel-
Mrs. WIR/29/ stage IIIB post NAC
7 C53.9 Carboplatin 5th seri 180.9 RS IS
UA/P2A1 + radical
Simulator schedule
hysterectomy
Feb 26th, 2019
recurrent ovarian Chemotherapy Pacilit
Mrs. CIK/52/
8 endometrioid C56.9 axel-carboplatin 6th 183.0 RS IS
UA/P4A1
cancer seri
Hospital admission
Cervical cancer PRC transfusion
Mrs. LIS/38/ stage IIIB + Inj. Leucogen
9 C53.9 180.9 RS IS
RA/P4A0 moderate anemia + Chemotherapy
1. Mrs. NUR/51/RA/P4A0
S/ post chemotherapy
Patient come with diagnose cervical ca stage IIB post radical hysterectomy. Patient complained vaginal
bleeding since 2 months ago, colour: red-black amount: 1 time dressing, post coital bleeding (+),
urination and defecation normal, weight loss (-) appetite loss (-). Patient did cervical biopsy with PA
rsult PA 214/PA/2018 adenocarcinoma cervix, endometrioid type DD/ endomterical type
adenocarcinoma cervix.
US result (24-5-18) Hematometra in the uterine cavum
PA result 2508/A/2018: - endocervical carcinoma, usual type of cervix, with an invasion of> 1/2
myocervical thickness, vaginal cuff and 1/3 lower uterine body hinga <1/2 myometrial thickness and 2
pieces of left pelvic lymph nodes
- parametric I & II is free of tumor mass
- the ovary and fallopian tubes I & II are free of tumor mass
- reactive hyperplasia in 2 right pelvic lymph nodes and 3 left pelvic lymph nodes
- chronic non-specific inflammation in the cytology of fluid in the uterus
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-)
Lab rsult (25-07-18) Hb9,6; Leu 5400; Trombo 163000; SGOT 25; SGPT 32; Ur26
O/
Abdominal palpation: convex supple, symmetric, tenderness (-), free fluid sign (-), mass (+)
Speculum examination: portio not livide, closed OUE, fluor (-), fluxus (+), E/L/P (-), CD prominent
Vaginal toucher: portio not livide, closed OUE, AP right/left tender, CD prominent
RT: good sphincter tone, smooth mucosa, MIL (-), AP right/left tender
A/ adenocarcinoma recti stage IIIB + ovarian solid neoplasm sinstra suspected malignancy DD/ intraab
domen mass
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-), opeartion scar (+) calm
P/ Pap smear examination PA result 1668/C/2018: smear atrophic; no malignant cells were found
Pap smear examination 3 months later (5-2-19)
5. Mrs. NUR/42/RA/P0A0
S/ control post chemotherapy and radiotherapy
Patient come with diagnose Cervical cancer stage IIIB complete therapy with PA result endometrial
intraepithelial carcinoma; US result cervical malignancy mass;
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), fundal height not
palpabled, mass (-)
Speculum examination: cervix unsmooth surface, friable and bleed easily, OUE closed, mass (+) 1/3
proximal right vagina wall size 4x3 cm, fluxus (-), fluor (-)
Vaginal toucher: cervix unsmooth surface, friable and bleed easily, OUE closed, mass (+) 1/3 proximal
right vagina wall size 4x3x4 cm, CUT ~ normal, AP right/left tender, CD not prominent
RT: good sphincter tone, smooth mucosa, AP right/left tender, CFS 100%-75%
Laboratory result (25-10-18): Hb 9,2; Leu 3700; Trombo 197000; AFP 3,67; CEA 1,50; CA 125 11,0
P/ Hospital admission
PRC transfusion
Inj. Leucogen
Chemotherapy Paclitaxel Carboplatin 6th seri