Identity Mrs.
25 YO/ 1286881/ Bangka Belitung/ P1A0/
Chief complain Shortness of breath
Recent illness Patient came with complained shortness of breath since 2 weeks ago and
history become worse since 2 days ago. Patient need to sleep with 2 pillows.
History of abdominal enlargement (+) since 2 months ago, history of
abdominal pain (+). History of vaginal bleeding (+). History of leucorrhea
(-). History of loss of apatite (+), history of weight loss (+). History of
fever (-), cough (-). Patient admitted has normal micturition and defecation
Past Illness Patient has done laparotomy surgical staging on September, 30th 2022 with
History PA result ( 4186/A/2022) :
I. There is no malignant cell in peritoneal wash
II. Adult granulose cell tumor at left ovary extended to fallopian tube,
vascular invasion (+)
III. Mature teratoma and follicle cyst in right ovary
IV. Reactive mesotheal at omentum
V. Metastases adult granulose cell tumor inside para-aortic lymph nodes
IHC result : adult granulose cell at left ovaries
Patient has been hospitalized at Bangka Hospital in February, 22nd 2023
caused of pleural effusion and has been underwent aspiration ( there was
fluid 900 cc)
Patient has done BEP Chemotherapy 1st course in December, 2022 but
patient didn’t continued chemotherapy.
Reproductive Menarche at 12 years old, irregular, LMP : February, 14th 2022
status
Married status Married 1x for 4 years
Obstetric status P1A0
Physical Sensorium compos mentis; BP: 120/70 mmHg Pulse: 99 bpm T:
Examination 36.8oC, RR: 24x/minute SPO2 94% room air VAS Score 2
BW 52 kg BH 170 cm
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
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 (-/-)
Obstetrical External examination
examination Abdomen : mediana incision (+) enlargement, supple, uterine fundal
height in 2 fingers below umbilical, mass (-), tenderness (+), free fluid sign
(+)
Genitalia
Speculum examination
Patient refused examination
Vaginal toucher
Patient refused examination
US examination
US examination - Anteflexed uterine with size 8.00 X 4,18 cm
04.03.2023
- Homogenous myometrium, regular basalis stratum; uterine cavity
opened
- Both ovaries non visualized ~ post bilateral salpingo-
oophorectomy
- Enlargement of Left calyx renal ~ left hydronephrosis
- Ascites (-)
C/
Left hydronephrosis
Laboratory Hb 10,4 g/dL RBC 5510/mm3 WBC 8790/mm3 Ht 33% PLT
examination 456.000/µL MCV 80,1 fL MCH 19 pg MCHC 31 g/dL Fibrinogen
04.05.2023
444,0 mg/dL D-dimer 3,22 µg/mL Ureum 34 mg/dL Creatinine 0,74
mg/dL BSS 95 mg/dL SGOT 33 U/L SGPT 29 U/L Albumin 4,4 g/dL
BSS 86 mg/dL Na 144 mEg/L K 4,0 mEg/L Cl 105 mmol/L
AFP 5,71 ng/mL ; CA-125 86,2 U/mL ; CEA 7,20 ng/ml
HBsAg non reactive; TPHA non reactive; VDRL non reactive; Anti HIV
non reactive
Abdominal US
examination
30.11.2023
Abdominal CT - Residual ovarian mass at pelvic cavity not clearly visualized,
Scan there is no infiltration at uterine, rectum and buli
30.11.2023
- Bilateral pleural effusion
- Nodes size 0,9x1,2 cm at liver ~ metastases process
- Ascites
Chest-X-Ray
04.03.2023
ECG
Diagnosis Ovarian cancer stage IIIA pleural metastases on chemotherapy
Left hydronephrosis
Management · Observation of vital sign
· O2 3L/minute
· Chest-X-Ray
· US confirmation
· Joint care with Internal medicine
Us result On ultrasound examination found:
An AF uterus with a size of 7.67 cm x 5.32 cm, homogeneous
myometrium is seen
Endometrial thickness 0.12 cm, stratum basalis regular
Normal endocervix and portio
Unvisual left ovary ~ post SOS
Right ovary 1.81 cm x 1.58 cm ~ within normal limits
There was a hypoechoic mass in the left adnexa without
vascularization with a size of 3 cm x 2.39
cm accompanied by adhesions ~ left pseudocyst
Hepar and spleen within normal limits
Right kidney within normal limits
You can see widening of the calyx of the left kidney, size 1.55 cm ~
left hydronephrosis
Looks ascites
Conclusion :
Left pseudocyst
Left hydronephrosis
Ascites
Suggestion :
MRIs
