Scribd
Upload
137 views4 pages

Tetek

This patient is a 42-year-old woman who presented with vaginal bleeding for 10 hours. She has a history of cervical cancer and underwent chemotherapy and radiation. On examination, an exophytic cervical mass was found invading the proximal vagina. Ultrasound showed a hyperechoic cervical mass, enlarged lymph nodes, and left hydronephrosis. Laboratory tests revealed severe anemia. She was diagnosed with stage IIIB cervical cancer and anemia, and was managed with observation, transfusion, and ultrasound confirmation.

Uploaded by

asoly giovano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
137 views4 pages

Tetek

This patient is a 42-year-old woman who presented with vaginal bleeding for 10 hours. She has a history of cervical cancer and underwent chemotherapy and radiation. On examination, an exophytic cervical mass was found invading the proximal vagina. Ultrasound showed a hyperechoic cervical mass, enlarged lymph nodes, and left hydronephrosis. Laboratory tests revealed severe anemia. She was diagnosed with stage IIIB cervical cancer and anemia, and was managed with observation, transfusion, and ultrasound confirmation.

Uploaded by

asoly giovano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

Identity Mrs.

PURNITA/42 YO/1220648/OGAN KOMERING/P4A0/FIF-IKY/ RS


Chief complaint Vaginal bleeding since 10 hours ago
Recent illness Chief complaint : vaginal bleeding since 10 hours ago
history Patient came with complaint there was vaginal bleeding since 10 hours ago, 2x
changing pad. History postcoital bleeding (+), body weakness (+), weight loss and
loss of apetite (+). Defecation and micturition was normal. Patient had complete
chemotherapy (Cysplatin), external (32x) and internal (3x) radiation at 15 September
2022.
Past Illness History Chemoterapy cysplatin
External radiation 32x
Internal radiation 3x

Marital status Married 20 years


Reproduction Menopause since 9 month ago
status
Obstetric history P4A0
Physical BP: 100/70 mmHg Pulse: 92 bpm T: 36.6oC, RR : 18x/m
Examination BW 53 kg BH 155 cm
Head: normocephalic, pallor conjunctiva (+/+), icteric sclera (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands
enlargement (-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Gynecology External examination :
examination Flat, supple, tenderness (-), mass (-), uterine fundal height unpalpable,
free fluid sign (-)

Speculum examination :
Exophytic mass at portio, bumpy surface, fragile, easy to bleed,
invade 1/3 proximal vagina

Vaginal toucher :
Exophytic mass at portio, bumpy surface, fragile, easy to bleed,
invade 1/3 proximal vagina, both AP was tensed

Rectal toucher :
Empty ampulla recti, intraluminal mass (-), CFS 0%-25%
US examination - Anteflexed uterus, size 7.70 x 4.31 cm, cavum uterine opened, myometrium
homogen.
- There was hyperechoic mass with neovascularization (+) at cervix size 2.42 x
2.89 cm invasive 1/3 proximal vagina ~ cervical malignancy mass was
suspected
- Right renal within normal limit
- Left hydronephrosis – hydroureter
- There was enlargement of parailiac and paraaortic lymph node
- Both ovary within normal limit
- Liver and spleen in normal limit

C/
Cervical malignancy mass
Left hydronephrosis – hydroureter
Enlargement of parailiac and paraaortic lymph node
Laboratory Hb 6.2 g/dL; RBC 2.22/mm3; WBC 12.050/mm3; Ht 17%; PLT 249.000/µL; MCV
examination
(6.11.22) 75.2 fL; MCH 28 pg; MCHC 37 g/dL; RDW-CV 14.40%; D/C 0/0/93/4/3
PT 16.0 second; INR 1.24; APTT 31.1 second; Ca 8.2; AST/ALT 12/8 U/L; Albumin
3.4 g/dL; BSS 113 mg/dL; U/C 28/0.47 mg/dL; Na 127 mg/dL; K 4.2 mg/dL
HBsAg non reactive; TPHA non reactive; VDRL non reactive; Anti HIV non
reactive
Anti SARS-CoV-2 : Ig M and IgG non reactive

Diagnosis • Cervical cancer stage IIIB complete therapy (C53.9)


• Severe anemia normocytic hipochrome (D64.9)

Management
• Observation vital sign and bleeding (V72.62)
• General condition improvement (V65.9)
• PRC transfusion (99.04)
• US confirmation (88.74)

You might also like