DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

ONCOLOGY OUTPATIENT REPORT

Monday, 28th September 2020

Resident on Duty:
Dr. Octaria Saputra
Dr. M. Ath. Thaariq

Doctor in charged :
Dr. H. Patiyus Agustiansyah, OB/GYN ( C), MARS

Supervisor :
Dr. H. Irawan Sastradinata, OB/GYN ( C), MARS, SH
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

RECAPITULATION BASED ON DIAGNOSIS ONCOLOGY OUTPATIENT

REPORT
Monday, 28th September 2020

No Identity Diagnosis ICD Procedure ICD Cases

10 9
1 Mrs. JEL/ 44 Cervical Stage IIIB C53.9 Hospitalized 89.7 1
YO/ 1180314/ cancer Leucopenia D72.8 Leucogen injection 99.2
JAMBI/ P4A0/ 19 Chemotherapy 99.25
THR-IS paclitaxel-carboplatin 92.29
3rd course
Plan for radiotherapy (
4th November 2020)
2 Mrs. JUA/ 76 Stage IIIB ( post C53.9 Hospitalized 89.7 1
YO/ 1164997/ chemotherapy N18.2 PRC Transfusion 99.04
OGAN paclitaxel- D64.9 Internal medicine 92.29
KOMERING carboplatin 6th consult
ULU/ P8A0/ course) Plan for radiotherapy (
OSP-IS Aki stage I 5th October 2020)
Moderate anemia
3 Mrs. MAI/ 57 Stage IIB C53.9 Chemotherapy 99.25 1
YO/ 1179083/ paclitaxel-carboplatin
LUBUK 3rd course
LINGGAU/
P3A0/ OSP-AT
4 Mrs. NAR/ 56 Stage IIIB ( on C53.9 Hospitalized 89.7 1
YO/ 1172720/ radiotherapy) N18 PRC transfusion 99.04
BANYUASIN/ CKD stage V Z90.5 Antibiotic 99.2
P8A0/ THR-IS Post left D64.9 Albumin flash 92.29
nephrostomy D72.8 Analgesic
Moderate anemia 29 Dermato-venerology
Leukocytosis E88.0 assessment
Hypoalbuminemia E87.6 Internal medicine
Hypokalemia L89 assessment
Decubital ulcer Plan for radiotherapy
grade II (27th October 2020)
5 Mrs. NUR/ 53 Ovarian Stage IIIC C56.9 Hospitalized 89.7 1
YO/ 1173179/ cancer Leucopenia D72.8 Leucogen injection 99.2
MUSI 19 BEP Chemotherapy 99.25
BANYUASIN/ 4th course
P5A0/ OSP-RS
6 Mrs. SAA/ 63 Multilocular cystic ovarian N83.0 Laparotomy surgical 54.1 1
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

YO/ 1180352/ neoplasm with solid part 2 staging

PALEMBANG/ malignancy was suspected
P8A0/ THR-IS
TOTAL 6
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Jelita Binti Tohir/ 44 YO/ 1180314/ JAMBI/ P4A0/ THR-IS
Chief Complain Continued chemotherapy
History Patient has been diagnosed with cervical cancer stage IIIB by Dr. Rudy
Gunawan, OB/GYN ( C), Onc, and referred to Moh. Hoesin Hospital on
14th August 2020.

Patient has underwent chemotherapy paclitaxel-carboplatin 2nd course on

04th September 2020

Patient didn’t had subjective complained. Patient come for continued

chemotherapy paclitaxel-carboplatin 3rd course

Lab result ( 23.09.2020)

Hb 12,4 g/dL WBC 2460/mm3 PLT 271000/µL Albumin 4,1 g/dL
Prior PA Result ( AL.20.330/3) 20.07.2020
Examination Cervical non ceratinizing cell carcinoma, moderate differentiated

Chest-X-Ray ( 11.08.2020)
Dilatation and elongation of aorta
Normal pulmonary
There is no metastases process in lung

BNO-IVP ( 13.08.2020)
Good secretion and excretion of both renal
There is no hydronephrosis and hydroureter
There is no mass infiltration to buli

US Examination ( 14.08.2020)
Cervical malignancy mass size 3,46x3,67 cm
Left cystic ovarian neoplasm size 1,23x0,84 cm
Physical Examination
General Sens: CM BP: 110/70 mmHg P: 88 x/mnt RR: 20 x/mnt T: 36.5C
Abdominal Flat abdomen, supple, symmetrical, uterine fundal height hard to assess,
tenderness (-), free fluid sign (-)
Inspeculo Bumpy portio, fragile, easy to bleed, there is exophilic mass size 3x3 cm,
fluor (-)
Vaginal Toucher Bumpy portio fragile, easy to bleed, there is exophilic mass size 3x3 cm,
CUT hard to assess
Diagnosis Cervical cancer stage IIIB
Leucopenia
Planning Hospitalized
Leucogen injection
Chemotherapy paclitaxel-carboplatin 3rd course
Plan for radiotherapy ( 4th November 2020)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Juariah bt H. Ismail/ 76 YO/ 1164997/ OGAN KOMERING ULU/

P8A0/ OSP-IS
Chief Complain General condition improvement for radiotherapy
History Patient diagnosed with Cervical cancer stage IIIB,. Patient has nderwent
chemotherapy paclitaxel-carboplatin 6th course on 21st July 2020.

Right now patient came for continued radiotherapy, with

Laboratory result 28.09.2020
Hb 8,0 g/dL WBC 7130/mm3 PLT 31000/µL SGOT 35 U/L SGPT 38 U/L
Albumin 4,1 g/dL Ureum 60 mg/dL Creatinine 1,22 mg/dL
Prior Examination BNO-IVP (3/3/20):
Hydronephrosis bilateral grade I-II

PA result ( 611/DH/2020)
Non keratinizing squamous cell carcinoma cervix

Chest-X-Ray result ( 05.03.2020)

Cardiomegaly with aorta elongation
There is no metastases nodes in lung
Physical Examination
General Sens: CM BP: 110/80 mmHg P: 89 x/mnt RR: 20 x/mnt T: afebrile
Abdominal Flat, Supple, symmetric, FUT not palpable, mass (-), tenderness (-)
Inspeculo Not performed
Vaginal Toucher Not performed
Diagnosis Cervical carcinoma stage IIIB ( post chemotherapy paclitaxel-carboplatin 6th
course)
Aki stage I

Moderate anemia
Planning Hospitalized
PRC Transfusion
Internal medicine consult

Plan for radiotherapy ( 5th October 2020)

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Mrs. Maimunah Binti Mahat Saleh/ 57 YO/ 1179083/ LUBUK

Identification
LINGGAU/ P3A0/ OSP-AT
Chief Complain Continued chemotherapy
Patient has been diagnosed with cervical cancer stage IIIB. Patient has
underwent chemotherapy paclitaxel-carboplatin 2nd course on 01st
September 2020.

History Right now patient didn’t had subjective complained and come for
continued 3rd course chemotherapy paclitaxel-carboplatin

Lab result ( 22.09.2020)

Hb 10,0 g/dL WBC 4280/mm3 Ht 211000/µL
BNO-IVP ( 03.08.2020)
Good function of both renal excretion

Chest-X-Ray ( 27.07.2020)
There is no abnormality in this thorax photo
Prior
examination PA 1812/DH/2020
Non ceratinizing squamous cell carcinoma in cervix

US examination 28.08.2020
Cervical malignancy mass
Multiple uterine myoma
Physical Examination
General Sens: CM BP: 130/70 mmHg P: 82x/mnt RR: 20 x/mnt T: afebrile
Abdominal Flat abdomen, supple, symmetrical, uterine fundal height unpalpabe
Inspeculo Not performed
Vaginal Toucher Not performed
Diagnosis Cervical cancer stage IIIB
Planning Chemotherapy paclitaxel-carboplatin 3rd course
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Narmik Binti Sahidin / 56 YO/ 1172720/ BANYUASIN/ P8A0/

THR-IS
Chief Complain Weakness of body and abdominal enlargement
History Patient came with complained abdominal enlargement since 3 months ago.
History of vaginal discharged (+) white yellow-ish color, continues, smelly
(+), followed with weakness of body. History of loss of apatite (-), history of
nausea (-), history of vomit (-)

Patient ahs been diagnosed with cervical cancer stage IIIB. Patient has
underwent 10x radiotherapy ( 27th July 2020), and done routinely
hemodialysis ( last time Saturday, 26th September 2020)

On 27th August 2020, patient has underwent left nephrostomy at Moh.

Hoesin Hospital
Prior BNO-IVO ( 19.05.2020)
examination Non visualized left renal and ureter until 120th minute
Right hydronpehrosis grade III-IV
Right hydroureter
Decreased of buli function

PA result ( 1681/A/2020) 19.05.2020

Squamous cell carcinoma cervix, more like squamotransitional carcinoma

Chest-X-Ray (19.05.2020)
There is no abnormality in this thorax photo

US result ( 14.05.2020)
Cervical cancer stage IIIB was suspected
Right hydronephrosis
Left cystic ovarian neoplasm
Physical Examination
General TD: 120/80 mmHg N: 90 x/mnt RR: 24 x/mnt T: afebrile
Abdominal Convex abdomen, tensed, there was mass size 15x15 cm, with upper border
in 1 fingers below umbilical, lower border in 1 fingers below symphysis, rigt
border in right LMC, left border in left LMC, there was nephrostomy pipe
( no. 22f)
Inspeculo Portio has atrophied, fluor (+), white-yellowish color, smell (+), fluxus (-),
Vaginal Toucher Hardened portio, easy to bleed
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Lab result Hb 8,6 g/dL WBC 48350/mm3 PLT 84000/µL Albumin 1,9 g/dL Ureum
28.09.2020 77 mg/dL Creatinine 2,05 mg/dL Na 131 mEg/L Na 131 mEg/L K 3,2
mEg/L Cl 99 mmol/L
Diagnosis Cervical cancer stage IIIB ( on radiotherapy)
CKD stage V
Post left nephrostomy
Moderate anemia
Leukocytosis
Hypoalbuminemia
Hypokalemia
Decubital ulcer grade II
Planning Hospitalized
PRC transfusion
Antibiotic
Albumin flash
Analgesic
Dermato-venerology assessment
Internal medicine assessment
Plan for radiotherapy (27th October 2020)
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Nuriya Binti Abdul/ 53 YYO/ 1173179/ BANYUASIN / P5A0/

OSP-RS
Chief Complain Continued chemotherapy
History Patient has been diagnosed with ovarian cancer stage IIIC. Patient has
underwent chemotherapy BEP 3rd course on 18th September 2020

Right now patient didn’t have any subjective complained. Patient come for
continued BEP Chemotherapy 4th course

Laboratory result ( 25.09.2020)

Hb 10,0 g/dL WBC 1890/mm3 PLT 154000/µL Albumin 4,1 g/dL Ureum
11 mg/dL Creatinine 0,69 mg/dL
History of past Patient has done operation at Moh. Hoeisn Hosptial on 15th July 2020, with
illness PA Result ( 2144/A/2020) :
- Adult granulosa cell tumor in right ovaries
- Adult granulosa cell tumor metastases in omentum
- Adult granulosa cell tumor in abdominal wash cytology

Tumor marker evaluation

17.09.2020  AFP 3,86 ng/mL CEA 1,20 ng/mL CA 125 10,3 U/mL
25.09.2020  AFP 2,83 ng/mL CEA 1,10 ng/mL CA 125 8,5 U/mL
Physical Examination
General Sens: CM BP: 120/70 mmHg P: 82x/mnt RR: 20 x/mnt T: afebrile
Abdominal Flat abdomen, supple, symmetrical, mediana incision scar, uterine fundal
height unpalpable, mass (-), free fluid sign (-)
Inspeculo
Vaginal stump within normal
Vaginal Toucher
Vaginal stump within normal
Diagnosis Ovarian cancer stage IIIC
Leucopenia
Planning Hospitalized
Leucogen Injection
BEP Chemotherapy 4th course
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identification Mrs. Sa;adah Binti Mansali/ 63 YO/ 1180352/ PALEMBANG/ P8A0/

THR-IS
Chief Complain Abdominal enlargement
History Since 2 years ago, patient complained has abdominal enlargement
followed with shortness of breath. History of abdominal pain (-), nausea
(-) vomit (-), weight loss (+), loss of apatite (-). Patient admitted has
normal micturition and defecation. History of vaginal bleeding (-)

Patient went to OB/GYN(C), Onc and was suspected with cystic ovarian
neoplasm. Patient than referred to Moh. Hoesin Hospital
Reproductive Menopause since 8 years ago
status
Married status Married 1x for 37 years
Obstetric history P8A0
Physical Examination
General TD: 120/80 mmHg N: 90 x/mnt RR: 24 x/mnt T: afebrile
Abdominal Convex abdomen, supple, tenderness (-), there was mass, mobile, cystic,
size 30x20 cm, with upper border in 2 fingers below xyphoid process,
lower border in symphysis, right border in right LAA, left border in left
LAA, free fluid sign (+)
Inspeculo Unlivide portio, closed OUE, fluor (-), fluxus (-), E/LP (-)
Vaginal Toucher Firmed portio, closed OUE slinger pain (-), both AP was supple, douglas
pouch didn’t protrude
Rectal toucher Good tones of sphincter ani, smooth mucous, intraluminal mass (-), CUT
~ normal, CFS 100%-100%
US result
13.08.2020 - NS
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Retroflexed uterine, with shape and size according to post menopause

( 4,31x2,87 cm)
Regular basals stratum, endometrial line (+) 0,29 cm
Portio and endocervix in normal limit
There was cystic mass, multilocular, septa (+), RI 0,29 ~ multilocular
cystic ovarian neoplasm malignancy was suspected
Contralateral ovary hard to assess
Liver and lien in normal limit
Both renal in normal limit

C/ Cystic ovarian neoplasm malignancy was suspected

Laboratory Hb 12,6 g/dL RBC 3840/mm3 WBC 6140/mm4 Ht 37% PLT 190000/µL
result MCV 95,1 fL MCH 33 pg MCHC 35 g/dL RDW-CV 12,40% D/C
12.08.20220 0/3/58/33/6 Ca 9,1 mg/dL SGOT 21 U/L SGPT 20 U/L Albumin 4,3 g/dL
Ureum 86 mg/dL Creatinine 3,1 mg/dL Na 142 mEg/L K 4,1 mEg/L Cl
111 mmol/L

AFP 1,30 ng/mL CEA 1,80 ng/mL CA 125 21,2 U/mL

Chest-X-Ray Mild cardiomegaly was suspected, with arcus aorta elongation
12.08.2020 Fibrosis line in right upper pulmonary field
Diagnosis Multilocular cystic ovarian neoplasm with solid part malignancy was
suspected
Planning Laparotomy surgical staging