IDENTITY

• Name : Astri Nilawati Rahayu

• Sex :F
• Age : 37 yo
• CM : 20030686
• Insurance : BPJS
• Phone :
• Admitted : 14/08/20
• Ward : Angsoka 304.1
 History
Chief Complain
• Pain on her left thigh since 3 months ago.

Mechanism of Injury
• Patient came with complaint of weakness and pain on her left thigh since 3 months ago, and
worsen since 2 days ago.
• Patient slipped on her bathroom was not able to walk since 3 months ago. Patient routinely
went to bonesetter for the past 3 months with her complaint getting worse.
• Patient also experienced weight loss

Past History
• There are solid mass on both of her breast for the past 2 months, but patient did not seek any
medical help or consume any medicine.
• Patient is referred with Tumor Left Mammae susp Bone Metastasis + Pathological Fracture
Left Column Femur by a Surgeon at Surya Husada Hospital for further treatment.

Family History
• Patient’s mother had cervical cancer and passed away
Left Thigh Region
L : Deformitas (+) internal rotation, swelling (-), bruist (-) , mass (-)
F : Tenderness (+) at proximal region, dorsalis pedis artery (+) palpable, CRT <2" , normal sensation
M : Active ROM Hip limitted due to pain
Active ROM Knee limitted due to pain
 Chest X-ray AP View
Surya Husada Hospital (24/07/2020)
 Lumbosacral X-ray AP/Lateral View
Surya Husada Hospital (24/07/2020)
 Pelvic X-ray AP View
Surya Husada Hospital (24/07/2020)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey
Sanglah Hospital (18/08/20)
 Bone Survey Expertise
Sanglah Hospital (18/08/20)
 Laboratory Result
Sanglah Hospital (15/08/2020)

Normal
Examination Result Range
Examination Result Normal AST/SGOT 300,5 11.00 - 33.00
Range
WBC 10,61 4.1 - 11.0 ALT/SGPT 280,60 11.00 - 50.00

PLT 427 150 - 440 BUN 12,70 8.00 - 23.00

HGB 5,88 13.5 - 17.5 SC 1,11 0.70 - 1.20

Na 135 136-145
K 3,6 3.5-5.1
Diagnosis:
Tumor Left Mammae T4bNxM1 suspect contralateral metastasis, suspect bone
metastasis, suspect liver metastasis Cancer Pain (VAS 2)
Moderate Anemia (6.5)
Transminitis ec susp liver metastasis
Pathological Fracture Left Neck Femur ec susp MBD/ dd MM

Treatment:
Work up diagnostic
Bone survey
Laboratory test: infection marker LDH, Ca, ALP
Tumor Marker Test
Immobilization with Skin Traction load 5kg
Clinical Picture Post Skin Traction