Summary of Database

Mr. B / 40.y.o/Ward 24A Bed 3A

Autoanamnesa
Chief Complaint:
Swelling of stomach
History of Present Illness:
The patient was admitted to the hospital from the HOM clinic for chemotherapy. Currently, the
patient complained swelling of stomach since 1 year ago, nausea (+), pain (+). The appetite was normal,
decreased of body weight 6 kg in 1 year.
The defecation was difficult, with the concistency were rugged and small, yellowish, blood (-),
mucus (-), urination was normal limit.
History of surgery for biopsy of tissue in abdomen 5 months ago at Ishak Tuluagung Hospital. Fever
was denied, history of liver disease was denied.
He was diagnosed with myelofibrosarcoma with differential diagnosis myxoid GIST since March
2021.
 Summary of Database
Past Medical History:
No past medical history
Family History:
None of his family had a history of malignancy, chronic disease, such as DM and
hypertension.
Social History:
Patient is an unemployee, the daily activities mostly spent in his home, married, and has
2 children.
Review of System:
General: fatigue (+) weight loss (+) 6 kg for the last 1 year
 Physical Examination
General appearance looked moderately ill VAS 0/10
GCS 456 Compos Mentis, KS 90% BW 50 kg; BH 160 cm; BMI 19,5 kg/m2
BP 106/70 mmHg PR 84 bpm regular strong RR 20 tpm Tax 36,4 oC Sat O2 99% RA
Head Anemic Conjuctiva (-)
Neck JVP R+ 2 cmH20 30 degrees, enlargement lymph nodes (-)
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular| Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular| Vesicular
-| - -|-
Sonor | Sonor Vesicular| Vesicular
-| - - |-
Cardio Ictus invisible, palpable at ICS V MCL (S)
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Abdomen rounded, soefl, Bowel Sound (+) normal, abdomen mass (+)11 x15 cm, immobile,
pain (-)
Liver/ liver span 12 cm, epigastrium tenderness (-)
Lien unpalpable
Extremities Warm and dry acral, edema (-), CRT < 2” , MMT 5 | 5
5|5
 Laboratory Findings (06/05/2021)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 7.180 4.700 – 11.300 /µL Ureum 26,8 20-40 mg/dL

Hemoglobine 11,70 11,4 - 15,1 g/dl Creatinine 0,98 <1,2 mg/dL

PCV 35,40 38 - 42% GDS

Thrombocyte 369.000 142.000 – 424.000 /µL Natrium 136-145 mmol/L

MCV 73,30 80-93 fl Kalium 3,5-5,0 mmol/L

MCH 24,20 27-31 pg Chlorida 98-106 mmol/L

Eo/Bas/Neu/ 0,1/0,7/64/24, 0-4/0-1/51-67/ SGOT 0-32 U/L

Limf/Mon 7/8,9 25-33/2-5
SGPT 0-38 U/L
PPT 10,90 Bilirubin Total <1 mg/dL

APTT 25,60 Bilirubin Direk <0,25 mg/dL

INR <1,5 Bilirubin Indirek <0,75 mg/dL
Procalcitonin <0,5 ng/mL Albumin 3,5-5,5 g/dL
CRP Fibrinogen
Eclia D-Dimer
Chest X-Ray
 Chest X-Ray
• PA position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal, infiltrat
(-)
• Cor: site was normal, size CTR 55%, shape was normal,
aorta calcification (-), cardiac waist (+)

Conclusion:
- Cor dan pulmo are within normal limit
Electrocardiography (07/07/2020)
 ECG
• Rhythm : Sinus
• Rate : 105 x/min
• Frontal axis : normal
• Horizontal axis : CCWR
• P wave : 0,08 s
• PR interval : 0,16 s
• QRS complex : 0,10 s
• QT interval : 360 s

Conclusion : Sinus Tachycardia 105 bpm

MSCT abdomen 27/07/2020
MSCT abdomen 27/07/2020

KESIMPULAN :

-Susp. Liposarcoma dengan multiple omental cake

Tak campak nodul basal paru & hepar maupun bone
metastase
-Simple cyst middle pole ren sinistra
Biopsi PA 17/03/2021
• KESIMPULAN :
• Menyingkirkan Myxoid Liposarcoma, belum dapat menyingkirkan
Myxofibrosarcoma.
• DD: Myxoid GIST.
• Mohon dilanjutkan pemoriksaan IHK : CD34, Desmin, CD117, DOG1.
IHK 17/03/2021

• CD34 : Positif diffus pada membran sel tumor

• Desmin : Negatif pada sitoplasma sel tumor
• CD117 : Negatif pada sitoplasma dan membranous sel tumor
• DOG-1 : Negatif pada sitoplasma dan membranous sel tumor
• KESIMPULAN :
• Immunofenotype dapat merupakan bagian dari Differentiated Liposarcoma
dengan komponen Myxofibrosarcoma.
• N.B.: Mohon konfirmasi ukuran tumor dan bagaimana gambaran radiologi?
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. B/ 40 yo/ Ward 24A 1. Abdominal 1.1 - Non Pharmacology PMo
Subjective mass + Change Myxofibrosarcoma ● Bed rest S, VS, UOP
- Mass on his stomach since 1 of bowel habit 1.2 Myxoid GIST ● Soft diet HCHP 1800 Sign of
year ago, nausea (+), difficulty in + Decrease of kcal/day chemotherapy
defecating body weight ● IVFD NS : Fluid 2:1 = 1500 (slide
- Decrease of BW around 6 kgs in cc/ 24 h sebelumnya
1 year (-))
Pharmacology
Objective ● Chemotherapy with PEd
- Abd: Mass (+) 11x15 cm regimen • Educate the
cyclophosphamide- patient
Laboratory: vincristine-doxorubicine- about his
- dacarbazine current
condition
PA Biopsy: and planning
Belum dapat menyingkirkan to do
myxofibrosarcoma DD myxoid chemoterpay
GIST

IHK:
Differentiated liposarcoma with
myxofibrosarcoma component
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. B/ 40 yo/ Ward 24A 2. Mild cancer - - Non Pharmacology PMo
Subjective pain ● Bed rest S, VS, VAS
- Mass on his stomach since 1
year ago, nausea (+), difficulty in Pharmacology PEd
defecating  Pain (+) ● PO Paracetamol 3x1000 • Educate the
mg patient
Objective about his
- VAS 2/10 current
- Abd: Mass (+) 20x10 cm condition

Laboratory:
-

PA Biopsy:
Belum dapat menyingkirkan
myxofibrosarcoma DD myxoid
GIST

IHK:
Differentiated liposarcoma with
myxofibrosarcoma component
 Problem Analysis

myxofibrosarcoma

Mild Cancer Pain

 Risk Factors Analysis

Problem Theory Patient

GISTs are equally common in -Male
male and female patients
(1:1 ratio). However,
succinate dehydrogenase
(SDH) deficient tumors,
most frequently seen in
pediatric patients, are
twice as common in
females than males.

Osteosarcoma guidelines : Indonesian

ministry of health
Distribution  Symptoms depend on the site and size of the
tumor Include: 
• Stomach 50-60% 
-Abdominal pain 
• Small bowel 20-30% 
-Dysphagia 
• Large bowel 10% 
- Gastrointestinal bleeding 
• Esophagus 5% 
-Symptoms of bowel obstruction
• Else where in abdomen 5% 
-Small tumors may be asymptomatic
• Most common site of metastasis:
Liver/Dissemination within abdominal cavity 
 Management Analysis

Problem Theory Patient

myxofibrosarcoma - wide excision (surgical) Chemotherapy
- Radiotherapy
- Chemotherapy
 Key Message Social

• Good emotional support from the family, health

care provider, and spiritual support must be
given to the patient