GYNECOLOGY OUTPATIENT

REPORT

Friday, September 8th, 2016 until Thursday, September 15th, 2016

Chief on duty :
Dr. Rakhmat Akbar Dinur
Dr.Meidina Rahma A
Dr. Darlin Forbes
Dr. Ratih Sari Putri

Mrs.SUM/49/UA/P3A0
D/ Ovarian cancer stage III C
P/ Chemotherapy docetaxel-carboplatin 2nd course
PA 3258/A/2016:
Laboratory 15/09/2016
Hb
: 12.1 g/dL
Clear cell carcinoma on ovary
Wbc
: 5.500/mm3
Ovula nabothy cyst on endocervix
PLT
: 400.000/mL
Uterine adenomyosis
Ca-125 : 20.94
Endometriosis cyst on left ovary
Clear cell carcinoma on ovary II
Metastatic carcinoma on omentum
Sinus hystiocytosis on 11 right pelvic lymph nodes
Sinus hystiocytosis on 9 left pelvic lymph nodes
Sinus hystiocytosis on 12 paraaortic pelvic lymph nodes
Metastatic carcinoma with reactive mesothel on ascites fluid

Mrs.LIN/57/UA/P5A0
D/ Endometrial cancer stage III C complete response
P/ Paps smear evaluation
History of radical surgical staging (20/7/2012)
Chemotherapy 6 series paclitaxel-carboplatin
PAP SMEAR I (389/C/2016):
No active malignant cell
Degenerative malignant cell due to chemoradiation
Laboratory 15/09/2016
Hb
Wbc
PLT
Ca-125

: 13.2 g/dL
: 8.100/mm3
: 254.000/mL
: 16.96

Mrs.NUR/56/UA/P0A0
D/ Ovarian cancer stage I A
P/ Tumor marker evaluation
PA/2843/A/2016:
Atypical proliferative mucinous tumor (borderline mucinous
tumor) and endometriosis cyst on right ovary
No malignant cell on peritoneal fluid cytology
Non specified chronic cervicitis
No malignant cell on omentum
Reactive hyperplasia on 5 pelvic lymph nodes
Laboratory 15/09/2016
Hb
Wbc
PLT
Ca-125

: 12.5 g/dL
: 8.300/mm3
: 331.000/mL
: 7.92

Mrs.NYI/42/UA/P2A0
D/ Reccurent ovarian cancer
P/ Chemotherapy gemcitabine-oxaliplatin 6th course
PA/3615/A/2016:
Endocervical polyp
Uterine leiomyoma
Cystadenoma clear cell type on ovary II
Germinal centre reactive with sinus hystiocytocis on left
lymph nodes
Laboratory 15/09/2016
Hb
: 10.8 g/dL
Wbc
: 11.200/mm3
PLT
: 238.000/mL
SGOT : 29 U/L
SGPT
: 20 U/L
Ureum
: 28 mg/dL
Creatinin : 0,83 mg/dL
Ca-125
: 195.80

Mrs.YUN/51/UA/P5A0
D/ AUB e.c P1 + Non specified chronic cervicitis
P/ Plan for hysteroscopy D n C
PA/1084/2016: Chronic cervicitis with metaplasia ephitelial
+ endocervical polyp
Laboratory 16/09/2016
Hb
: 10.8 g/dL
Wbc : 8.300/mm3
PLT
: 331.000/mL
SGOT : 21 U/L
SGPT
: 20 U/L
Ureum : 16 mg/dL
Creatinin : 0,60 mg/dL

Mrs.SUN/51/RA/P3A0
D/ Ovarian cancer inadequate staging
P/ Chemotherapy BEP 1st course
History of salpingectomy (August 2016)
PA/693/MI/2016 : Metaplasia adult granulosa cell tumor
on left ovary
Laboratory 15/09/2016
Hb
: 10.6 g/dL
Wbc
: 6.500/mm3
PLT
: 355.000/mL
AFP : 2.90
CEA : 3.75
Ca-125: 24.95

Mrs.NUR/56/UA/P6A0
D/ Cervical cancer stage III B post chemotherapy 6 series partial
response
P/ Plan for radiation
History of chemotherapy paclitaxel-carboplatin 6 series
(complete)
PA/950/A/2016 : Well differentiated adenocarcinoma,
endocervical type on cervical biopsy
LABORATORY 16/09/2016
Hb
Wbc
PLT
Ureum :
Creat :

: 9.6 g/dL
: 11.200/mm3
: 343.000/mL
46
1.56

Mrs.TIR/25/UA/P0A1
D/ GTD stage 1 FIGO score 1
P/ Chemotherapy MR 5th course
History of curettage (June 2016)
PA/1056/PA/CH/2016 :
Hydatidiform mole, severe proliferation throphoblas and atypic cells
Wide invasion throphoblastic to endometrial tissue, necrotic,
haemorrhage and inflammation cell
LABORATORY 16/09/2016
Hb
: 12.0 g/dL
Wbc
: 9.000/mm3
PLT
: 214.000/mL
TSH : 1.03
FT4 : 6.99
BhCG : 0.54

Mrs.MAR/56/UA/P8A0
D/ Cervical cancer stage III B
P/ Chemotherapy paclitaxel-carboplatin 1st course
PA/218/BA/2016 : Well differentiated squamous cell
carcinoma cervix
Abdominal US : Left hidronefrosis
LABORATORY 16/09/2016
Hb
: 10.7 g/dL
Wbc
: 6.500/mm3
PLT
: 355.000/mL
Ureum : 33
Cre
: 0.54
Ca-125: 10.25

Mrs.KOM/42/UA/P2A0
D/ Endometrial cancer stage III C
P/ Chemotherapy paclitaxel-carboplatin 5th course
PA/247/A/2016 :
- Endometrioid adenocarcinoma grade II invasion to >
myometrium
- Simple cyst on right ovary
- Metastatic carcinoma on omentum and hyperplasia reactive on 4
pelvic lymph node
- Hyperplasia reactive on 16 right pelvic lymph nodes
- Hyperplasia reactive on 14 left pelvic lymph nodes
- Hyperplasia reactive on 4 paraaortic pelvic lymph nodes
LABORATORY 19/09/2016
- No malignant cell on tumor masses adhesion
Hb
: 11.5 g/dL
- Malignant cell were found in peritoneal washing
Wbc
: 4.300/mm3
PLT
: 167.000/mL
Ureum : 20
Cre
: 0.42
Ca-125: 14.23

Mrs.HOS/59/UA/P1A0
D/ Ovarian cancer stage III C
P/ Chemotherapy paclitaxel-carboplatin 6th course
PA/1567/A/2016 :
- Low grade micropapillary serous carcinoma on both ovaries
invade to fallopian tubes wall
- Metastatic on peritoneum and ascites cytology
-Cyst endometrial atrophic
LABORATORY 19/09/2016
Hb
: 10.8 g/dL
Wbc
: 6.800/mm3
PLT
: 153.000/mL
Ureum : 18
Cre
: 0.54
Ca-125: 44.23

Mrs.ROH/29/UA/P1A0
D/ Ovarian cancer stage III B
P/ Chemotherapy BEP 3rd course
PA/2907/A/2016 :
- Yolk sac tumor on left ovary
- No malignant cell on omentum
- No malignant cell on ligaments
- Sinus hystiocytosis on paraortic and bilateral pelvic lymph
nodes
LABORATORY 19/09/2016
Hb
: 11.3 g/dL
Wbc
: 10.900/mm3
PLT
: 516.000/mL
Ureum : 9
Cre
: 0.60
Ca-125: 18.10

Mrs.NUR/53/RA/P4A0
D/ Ovarian cancer stage IV A post chemotherapy 6 series
P/ General condition improvement
CT scan abdomen
Evaluation of Ca-125
PA/1523/A/2016 :
- Adenocarcinoma ovarium kearah suatu endometrioid carcinoma FIGO grade
III
metastatic to prevesical wall, ileum wall, paraaortic wall, omentum and
peritoneal washing
Reactive hyperplasia on 4 pelvic lymph node
Laboratory 20/09/2016
Hb
: 9.4 g/dL
Wbc
: 5.800/mm3
PLT
: 368.000/mL
AFP : 2.84
CEA : 1.36
Ca-125: 5000.00

Mrs.CIK/46/RA/P1A1
D/ Endometrial cancer stage I A
P/ Paps smear evaluation
PA/940/A/2016 :
- Non specified chronic cervicitis and microgladular
hyperplasia
- Polyp endometrial, uterine myomatosus
- Hyperplasia reactive on 12 bilateral pelvic lymph nodes
- Hyperplasia reactive on 4 paraaortic pelvic lymph nodes
LABORATORY 19/09/2016

PAP SMEAR I (773/C/2016) :

- Normal smear

Hb
Wbc
PLT
Ureum
Cre

: 11.3 g/dL
: 10.900/mm3
: 516.000/mL
:9
: 0.60

Mrs.TIT/48/RA/P3A0
D/ Cervical cancer stage II B
P/ NAC paclitaxel-carboplatin 2st course
Plan for radical hystrectomy after 3 course NAC
PA/813/B/VII/2016 :
- Moderately differentiated squamous cell carcinoma on
cervical biopsy
LABORATORY 19/09/2016
Hb
Wbc
PLT
Ureum
Cre

: 11.0 g/dL
: 7.100/mm3
: 258.000/mL
: 13
: 0.658

Mrs.RAR/48/RA/P3A0
D/ Reccurent ovarian cancer
P/ Chemotherapy gemcitabine-oxaliplatin 4th course
PA/2955/A/2014 :
- Endometrioid carcinoma on right ovary
- Endometrioid carcinoma on left ovary, metastatic to portio, uterine
and fallopian tubes
- Metastatic carcinoma endometrioid on omentum
- Metastatic carcinoma on ascites cytology
LABORATORY 19/09/2016
Hb
: 12.0 g/dL
Wbc
: 6.100/mm3
PLT
: 317.000/mL
Ureum : 13
Cre
: 0.68
Ca-125 : 400.7

PA/3952/A/2015 :
- Metastatic adenocarcinoma on peritoneum
- Metastatic carcinoma on omentum and omentums lymph node

Mrs.KAR/50/RA/P5A0
D/ Cervical cancer stage complete therapy
P/ Paps smear evaluation
Hi story : Chemotherapy paclitaxel-carboplatin 6 series
Radiation 35x
PA/518/A/XII/2015 :
- Moderately differentiated non ceratinizing squamous cell
carcinoma on cervical biopsy
Pap smear (1335/A/2016) :
- No active malignant cell

LABORATORY 19/09/2016
Hb
Wbc
PLT
Ureum
Cre

: 10.8 g/dL
: 7.300/mm3
: 317.000/mL
: 13
: 0.68

Mrs. BET/36/UA/P3A1
D/ Cervical cancer stage II B
P/ Neoadjuvant chemotherapy paclitaxel-carboplatin 1 st
course
PA/1176/P/2016 :
Adenosquamous carcinoma most likely glassy cell carcinoma
with lymphoplasmic infalmmation, angioinvasion (+)
Laboratory 20/09/2016
Hb
: 10.8 g/dL
Wbc
: 8.300/mm3
PLT
: 331.000/mL
SGOT : 21 U/L
SGPT : 20 U/L
Ureum : 16 mg/dL
Creatinin: 0,60 mg/dL