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    Oncology Outpatient Daily Report: Tuesday, October 2 2018

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    Rebeka Anastasia Marpaung
    flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-) RT: smooth mucosa, AP right tender, AP left not tender, mass (-), CD not prominent A/ Cervical Ca std IB complete therapy P/ Pap smear evaluation 6 months later

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    Oncology Outpatient Daily Report: Tuesday, October 2 2018

    Uploaded by

    Rebeka Anastasia Marpaung
    27 views12 pages
    flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-) RT: smooth mucosa, AP right tender, AP left not tender, mass (-), CD not prominent A/ Cervical Ca std IB complete therapy P/ Pap smear evaluation 6 months later

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    flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-) RT: smooth mucosa, AP right tender, AP left not tender, mass (-), CD not prominent A/ Cervical Ca std IB complete therapy P/ Pap smear evaluation 6 months later

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views12 pages

    Oncology Outpatient Daily Report: Tuesday, October 2 2018

    Uploaded by

    Rebeka Anastasia Marpaung
    flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-) RT: smooth mucosa, AP right tender, AP left not tender, mass (-), CD not prominent A/ Cervical Ca std IB complete therapy P/ Pap smear evaluation 6 months later

    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 12

    ONCOLOGY OUTPATIENT

    DAILY REPORT

    Tuesday, October 2nd 2018

    Consultant incharge:
    dr. H. Rizal Sanif, SpoG (K), MARS
    ONCOLOGY OUTPATIENT RECAPITULATION
    No. Diagnosis ICD 10 New case Old case Procedure ICD 9
    H A H A
    Continue radiotherapy
    Cervical ca std IV B (pulmon - - -
    1 C53.9 - Consultation to 180.9
    ary metastase)
    radiotherapy
    Ovarian ca std IC complete t - - -
    2 C56.1 - Tumor marker evaluation 184.0
    herapy
    Endometrial ca std IIIC com
    3 C54.1 - - - - Pap smear 182.0
    plete therapy
    Pap smear
    Endometrial ca std IIIC com
    4 C54.1 - - - - Consultation to interna 182.0
    plete therapy + DM t.II
    department
    pro VC Laparotomy
    NOP multiloculare with kati
    Consultation to interna d
    k bilateral+ Endometrial hyp
    5 D27.9 - - - - epartment 220.0
    erplasia DD/ Endometrial
    Consultation to anesthesi
    malignancy
    department
    Ovarian ca advanced stage c
    6 omplete C561 - - - - CT Scan Abdomen Pelvic 184.0
    therapy
    Ovarian ca std IIIC + mild an Pro chemotherapy brexel-
    7 C561 - - - - 184.0
    emia + leukopenia carboplatin 2nd course
    Cervical Ca std IB complete Pap smear evaluation 6 m
    8 C53.9 - - - - 180.9
    therapy onths later
    ONCOLOGY PATIENT’S RECAPITULATION\
    No. IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSI Consultant
    CIAN incharge
    Continue
    Cervical ca std IV B (
    Mrs. IND/44/ radiotherapy
    1 pulmonary metastas C53.9 180.9 AM RS
    UA/P5A0 Consultation to
    e)
    radiotherapy
    Mrs. ROS/46/
    Ovarian ca std IC co Tumor marker
    2 RA/P0A0 C56.1 184.0 IS RS
    mplete therapy evaluation
    Mrs. DAR/56/ Endometrial ca std II
    3 C54.1 Pap smear 182.0 IS RS
    RA/P2A1 IC complete therapy
    Endometrial ca std II Pap smear
    Mrs. BOI/R52
    4 IC complete therapy C54.1 Consultation to 182.0 RS RS
    /UA/P7A0
    + DM t.II interna department
    NOP multiloculare pro VC Laparotomy
    with katik bilateral+ Consultation to inte
    Ms. WON/50
    5 Endometrial hyperpl D27.9 rna department 220.0 RS RS
    /UA/P0A0
    asia DD/ Endometri Consultation to ane
    al malignancy sthesi department
    Ovarian ca advance
    Ms. YUL/21/R CT Scan Abdomen P
    6 d stage complete C561 184.0 IS RS
    A/P0A0 elvic
    therapy
    Ovarian ca std IIIC + Pro chemotherapy
    Mrs. SUN/56/
    7 mild anemia + leuko C561 brexel-carboplatin 184.0 IS RS
    RA/P6A0
    penia 2nd course
    Mrs. PAR/53/ Cervical Ca std IB Pap smear evaluati
    1. Mrs. IND/44/UA/P5A0
    S/ chemotherapy control
    Patient come with diagnose cervical ca std IVB (pulmonary metastase). Patient has finished
    chemotherapy pacli-carbo 6th series (30-8-18). PA result 1803/A/2018: non keratinizing squamous cell
    carcinoma on vaginal biopsy.

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

    A/ Cervical ca std IV B (pulmonary metastase)


    P/ Continue radiotherapy
    consultation to radiotherapy  scheduled: November 6, 2018 (25x)
    2. Mrs. ROS/46/RA/P0A0
    S/ control
    Patient come with diagnose ovarian ca std IC with PA result 5440/A/2017= LSIL (low grade squamous
    intraepithelial lesion) on cervical; uterine leiomyoma; clear cell carcinoma on ovary II; chronic
    salphyingits non specific on fallopian tube I and II.
    Lab result (15-8-18)= AFP 2,8; CEA 1,60; CA125 11,70

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
    Lab result (10-1-18)= AFP 1,71; CEA (result follow); CA125 25,95

    A/ Ovarian ca std IC complete therapy


    P/ tumor marker evaluation
    3. Mrs. DAR/56/RA/P2A1
    S/ Pap smear evaluation
    Patient come with diagnosis ovarian ca std IIB complete therapy. 7th pap smear result 875/C/2018 (25-
    6-18)= No active malignant cells; Degenerative cells caused by chemo radiation effects (+)

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

    A/ Endometrial ca std IIIC complete therapy


    P/ Pap smear (8th)
    4. Mrs. BOI/R52/UA/P7A0
    S/ Pap smear evaluation
    Patient come with diagnosis ovarian ca std IIB complete therapy. Pap smear result 902/C/2018 (2-7-
    18)= No active malignant cells; Degenerative cells caused by chemo radiation effects (+); atrophic
    smear
    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

    A/ Endometrial ca std IIIC complete therapy + DM t.II


    P/ Pap smear
    Consultation to interna department
    5. Ms. WON/50/UA/P0A0
    S/ USG result evaluation
    Patient come with diagnose abnormal uterine bleeding.
    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (+) 15X10 cm
    RT: good sphincter tone, smooth mucosa, AP right tender, AP left not tender, mass (+) 6x4 cm inferior
    adnexa, CD not prominent
    USG result (2-10-18)= endometrial thickening susp. Endometrial hyperplasia + uterine adenomyoma;
    NOP multiloculare with katik bilateral

    A/ NOP multiloculare with katik bilateral+ Endometrial hyperplasia DD/ Endometrial malignancy

    P/ pro VC Laparotomy
    Consultation to interna department
    Consultation to anesthesi department
    6. Ms. YUL/21/RA/P0A0
    S/ control tumor marker
    Patient come with diagnose ovarian ca advanced stage complete therapy
    h/ suboptimal debulking laparotomy (3-9-17)  PA result 3794/A/2017= left ovary, infundibulo
    pelvicum ligament, right fallopian tube, KGB, omentum + peritoneal fluid not found malignancy cells
    h/ tumor removal surgery (Muara Enim, 2-4-17) with PA result 566/DH/2017= yolk sac ovarian tumor.
    Tumor marker evaluation:
    NO DATE AFP CEA CA 125
    1 2-2-18 1,88 1,84 10,66
    2 3-5-18 1,90 15,1
    3 6-8-18 2,10 81,5

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

    A/ ovarian ca advanced stage complete therapy

    P/ CT Scan Abdomen Pelvic


    7. Mrs. SUN/56/RA/P6A0
    S/ continue chemotherapy
    Patient come with diagnose ovarian ca std IV with PA result 3073/A/2018:
    A. VC tissue
    - low grade serous carcinoma in the right ovary
    - non-specific chronic salphingitis in the right fallopian tube
    B. I. - ovule cyst nabothy in the endocervix
    - uterine adenomyosis
    II. Low grade serous carcinoma in the left ovary
    - non-specific chronic salphingitis in the left fallopian tubes
    III. Sinus histiocytosis in the right inguinal lymph node
    IV. - VII. metastase low grade serous carcinoma in ascites, peritoneal, colon and omentum fluid cytology

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
    Lab result (1-10-18): Hb 9,9; Leu 4100; trombo 196000;

    A/ ovarian ca std IIIC + mild anemia + leukopenia

    P/ Pro chemotherapy brexel-carboplatin 2nd course


    8. Mrs. PAR/53/RA/P1A0
    S/ vaginal bleeding
    Patient come with cervical ca std IB complete therapy (2015). Currently, patient complains of vaginal bl
    eeding (+) since 2 weeks ago, post coital bleeding (+)
    h/ ht radical (27-4-2015)
    h/ chemotherapy finished 20-12-2015; chemoradiation (35X) 28-12-2015

    O/
    Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
    Speculum examination: normal vaginal stump
    Vaginal toucher: normal vaginal stump
    Pap smear result (24-9-18)= no malignant cells were found on the preparation; degenerative cells cause
    d by chemoradiation

    A/ Cervical Ca std IB complete therapy

    P/ Pap smear evaluation 6 months later (19-3-2019)

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