ppt case 2
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CASE REPORTCervical cancer stadium IB2 with anemia
Preseptor : dr Hesty Duhita, SpOG
Arranged by : Annisa Kartika (2011730007)
Introduction Cervical cancer is malignancies strike
cervix or cervix , that is the lowest part of the uterus prominent to the top of the copulation.
Cervical cancer is the second most common cancer in women in the world.
prevalence of cervical cancer in indonesia is 28,66 %.
Patient’s identity Name : Mrs. A Age : 45 years old Nationality : Indonesian Education : Junior High school Marital status: Married Occupation : Housewife Religion : Moslem Date of admission : 12 June 2015
Husband’s identity Name : Mr L Age : 45 years old Nationality : Indonesian Education : Senior High school Marital status : Married Occupation : Private employees Religion : Moslem
Anamnesis Chief complaint Patient complained of bleeding from her
genital organ since 3 months ago
History of present illnessBleeding with clots, fresh red, and accompanied by abdominal pain
Patients also complained of weakness (+) and dizziness (+).
History of past illnessHave history of hipertention No history of DM No history of urinary or kidney
disease No history of allergic No history of hematologic disease No history of trauma No history of operation
History of family Sister of patients suffering from diabetes
mellitus and heart disease. Younger brother of patients died because
of glands cancer. No history of allergic No history of hematologic disease No history of epilepsy
Habits Smoking habits :
Denied Drinking alcohol :
Denied Taking any medication or “jamu” :
Denied
Contraceptive history Contraceptive use is 3-month injectable
contraceptives and pills
Menstrual history
Menarche : 13 years
Cycle :28 days
Duration : 5 days
Dysmenorrhea : (-)
Obstetric historyNumber of pregnant
Gender Age of children
Mode of delivery
Place of birth
helper Weight of birth
1 Abortus
2 abortus
3 M 21 years old
Spontaneus vaginal
Midwives practice
Midwives
3100 gr
4 M 14 years old
Spontaneus vaginal
Midwives practice
Midwives
3100 gr
Marriage history Patients were married two times. Married with current husband now 15
years old
Physical examination
Generalis status
•General condition: Moderate ill•Conciusness: composmentis
Vital signs
•blood pressure: 130/90 mmHg•Heart rate: 68x/minute•Respiratory rate: 20x/minute•Temperature : 36.5 ° C•Body weight : 48 kg•Body height : 155 cm•BMI: 19,97
•Head : normocephal, deformity (-)•Faces : symmetric•Eyes : anemic conjungtiva (+/+), icteric sclera (-/-)•Mouth : the oral mucosa moist•Neck : not palpable mass, lymphadenopathy (-)
General physical
examination
•Heart : Heart sounds regular I & II, gallops (-), murmur (-) •Pulmo : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -•Mammae : within normal limits
Thorax •Inspection: flat •Auscultation: bowel (+) sounds, 4-5/minutes•Palpation: mass(-), pressure pain (+), ascites (-)• Percussion: Timpani
Abdomen
•Superior: Edema (- / -), Akral warm (+ / +), RCT <2 seconds (+ / +)•Inferior: Edema (- / -), Akral warm (+ / +), RCT <2 seconds (+ / +)
Extremities
Gynecology examination
External examination• Vulva : no
abnormality• Vagina : no
abnormality
Inspekulo • Vulva: no
abnormality• Vagina: no
abnormality• Portio: smelling
discharge (+), irregular portio
Vaginal toucher• Vulva: no
abnormality• Vagina: no
abnormality• Portio: Palpable
mass bumpy, rough surface, iMobile, tenderness (+), ± 2-3 cm in size, fragile, easily bleed
• Parametrial left-right: infiltration (-)
• Rectal Touche: CFS 100%
Laboratory examination(12th August 2015) Examination Value Units Normal Routine bloodHemoglobin 7,3 g/Dl 12 – 14
leukocytes 5.300 /μl 4.000 – 10.000
hematocrit 23 % 37 – 47
erythrocyte 3,0 Juta/μL 3,8 – 5,2
Platelet
Erythrocyte index
432.000 /μL 150.000 – 45.000
MCV 77 fL 80 – 100
MCH 24 Pg 26 – 34
MCHC 32 g/dL 32 – 36
Laboratory examination(14th August 2015)
Examination Value Units Normal Routine bloodHemoglobin 10,6 g/dL 12-14leukocytes 6.600 /ml 4.000-10.000hematocrit 33 % 37-47erythrocyte 4,3 Juta/Ml 3,8-5,2Platelet 307.000 /ml 150.000-
450.000Erythrocyte indexMCV 75 Fl 80-100MCH 24 Pg 26-34MCHC 33 g/dL 32-36
Laboratory examination(15th August 2015)
Examination Value Units Normal Routine bloodHemoglobin 11,3 g/dL 12-14leukocytes 5.400 /ml 4.000-10.000hematocrit 35 % 37-47erythrocyte 4,6 Juta/Ml 3,8-5,2Platelet 256.000 /ml 150.000-
450.000Erythrocyte index
MCV 76 Fl 80-100MCH 25 Pg 26-34MCHC 33 g/dL 32-36
Anatomical Pathology Biopsy Results
Macroscopica network size of 3 cm x 2 cm x 1 cm, brownish white color rather
fragile. Padalam elasi appear brownish white solid masses
Microscopic biopsy dosage form of the tumor
mass is composed of oval cells that grow between the solidified hyperplastic stroma. Pleomorfi core, hiperchromatis, mitosis
found. Bersebukan stromal PMN cells, partially fibrotic. On the
outside is covered with stratified squamous epithelium which has
the form of a tumor mass as above
Conclusion: Non keratinizing epidermoid carcinoma A / r cervix
uteri
Resume Women 45 years P2A2
present with vaginal bleeding since 3 months SMRs. Bleeding as much as ± 10x replace the pads
in the day, fresh red bleeding, clots and
accompanied by abdominal pain. Bleeding
occurs outside the menstrual cycle
Patients also experience vaginal discharge,
yellowish, itching (+), smell (+). In addition to
the above complaints, the patient felt a weight loss
of 56 kg to 48 kg within 1 month, weak (+) and
dizziness (+)
general condition seemed ill being,
awareness compos mentis, blood pressure: 130 /
90mmHg, conjunctival pallor (+ / +),
+), inspection inspekulo portio: discharge smells (+),
bleeding (+), portio looks bumpy, fragile, checks in the lower portion: Palpable mass
bumpy, rough surface, iMobile, tenderness (+), ± 2-3
cm in size, fragile, easily bleeding, adnexal: pain (-),
left-right parametrium: infiltration (-) , RVT: CFS
100%
Working diagnosis Mrs A, 45 years P2A2 stage IB2 cervical
cancer with anemia
Planning Correct the patient's general condition Blood transfusion indication if Hb <11 g /
dL Refer patient to the Hasan Sadikin
Hospital Radical hysterectomy
Prognosis Quo ad vitam : dubia ad
bonam Quo ad functionam : dubia ad
bonam Quo ad sanationam : dubia ad
bonam
Follow Up
13th August 2015 14th August 2015 15th August 2015S :• Bleeding (+)• Abdominal pain (+)
S :• Itching in the whole body• Bleeding• Dizziness (+)
S :Itching in the whole body
O :-Moderate ill-ComposmentisVital signs :Blood pressure: 130/70 mmHgTemperature : 37,0 ℃Heart rate: 65 x/mRespiratory rate: 21 x/m
abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani
O :- Moderate ill- Composmentis Vital Signs:Blood Pressure: 140/80 mmHgRespiratory rate : 20 x / mTemperature: 37.0 ℃Heart rate: 76 x / m
abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani
O :- Moderate ill- Composmentis Vital signs :Blood Pressure: 140/90 mmHgRespiratory Rate: 20 x / mTemperature: 36.5 ℃Heart rate: 80 x / m
abdomen:Inspection: flatAuscultation: BU (+) normalPalpation: tenderness (+)Percussion: timpani
13th August 2015 14th August 2015 15th August 2015
Obstetrics status:Vaginal toucher:V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra
Obstetrics status:Vaginal touche :V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra
Obstetrics status:Vaginal touche :V / v: normalPortio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), size 2-3 cm ±Bleeding: (+) rubra
A :P2A2 stage IB2 cervical cancer with anemia
A :P2A2 stage IB2 cervical cancer with anemia
A :P2A2 stage IB2 cervical cancer with anemia
P :Blood transfusion if Hb >11Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o
P :Blood transfusion if Hb >11Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o
P :Asam mefenamat 3x1 p.oPlasminex 3x1 p.oAmoxiline 3x1 p.o
Case analysis1. How to diagnosis of cervical cancer ?2. How management of the patient in this
case?3. What is prognosis of this patient in this
case?
1. The diagnosis steps from anamnesis to additional examinations compare to theoris was made into a table as follow :
Theory PatientAnamnesa
Vaginal bleeding after intercourseBleeding outside the menstrual cyclewhitishpelvic painBleeding after menopausespontaneous bleeding
Risk Factors :Age Marriage status and sexual activity in the younger ageAmount of parityHPV infectionSmoking Socio economic history
Patient complained of bleeding from her genital organ. Spontaneous bleeding, accompanied by abdominal pain. Patients also experienced a whitish, yellowish color, itch (+), smell (+),
patient were married for two times. Patient have given birth for two times.
Physical examinationExternal examinationDepends on staging, the mass could spread to 1/3 distal or proximal vagina.
Vulva and vagina : no abnormality.
Theory Patient
InspekuloPortio looks irregular with bleeding
Portio: smelling discharge (+), irregular portio
Vaginal touchePalpable mass depends on staging.
Portio: Palpable mass bumpy, rough surface, iMobile, tenderness (+), ± 2-3 cm in size, fragile, easily bleedParametrial left-right: infiltration (-)
Rectal toucheCancer free space
CFS 100%
Biopsy Non keratinizing epidermoid carcinoma A / r cervix uteri
Theory Case
Colposcopy Not performed on patient
Radiology Not performed on patient
2. Management patient in this case
Theory Case
Staging IB2
Radical Histerectomylymphadenectomy + neoadjuvan Radiation
Patients only received blood transfusion because Hb < 11 g/dl and simptomatic drugs such as: plasminex, asam mefenamat. Patient was referred to Hasan Sadikin Hospital to the further treatment
3. What is prognosis of this patient in this case ?
Theory Case Prognosis of cervical cancer depends on multi factors such as :
age, general state of physical,the level of clinical, histological characteristics of the tumor cells, the ability of experts who handleand the availability of adequate treatment.
According to the staging IB2, so prognosis for this patient : 88%Dubia ad bonam
5 years survival rate Stadium 5 years survival
I A
I B
100%
88%
II A
II B
68%
44%
III 18-39%
IV A 18-34%
Source: UICC / Clinical Oncology; Springer-Verlag, New York, Hiedelberg, Berlin; 1973, p: 218
TINGKAT AKH-5 tahun
T1S Hampir 100 %
T1 70-85%
T2 40-60%
T3 30-40%
T4 < 10 %
Conclusion In this case, it can be seen that in patients with
clinical manifestations and physical examination were found to support the diagnosis of cervical cancer grade IB2. In addition, this patients have anemia due to blood loss. Therefore the first management is The first management that can be done is to improve the patient's general condition
In its own cervical cancer prevention can be done for cervical cancer include primary prevention, secondary, and tertiary.
Thank You
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