Case Report

Patient’s ID

Name : Mrs. R
Age : 73 years old
Address : X Koto, Kabupaten Agam
MR No. : 01 02 10 70
Admission date : Nov 5th, 2018
Anamnesis

• A 73 years old patient admitted to the Gynecology Ward of Dr. M.

Djamil General Hospital Padang on Nov 5th, 2018 sent by Oncology
Clinics, with Ovarian Cyst Neoplasm with solid malignancy
suspected
Present Illness History

• There was enlargement of the abdomen since 4 month ago, as large as

term pregnancy, abdominal pain was (-)
• pelvic pain (-)
• Bleeding from vagina (-)
• The patient was married, have child 3 child, youngest 30 yo.
• No complain in urinary and bowel habits
• No history or weight loss in the short time, normal appetite
• Menstrual History : menacre at 13 years old, regular cycle, which last for 5
to 7 day each, cycle with amout of 2-3 times pad change/day without
menstrual pain. Last menstruation period forgotten
• Postcoital bleading (-)
Previous Illness History
• No history of the same illness
• History of any cardiac, lung, liver,hipertension or renal disease was unknown
• No history of allergy

Family Illness History

• No history of the same illness
• No history of any contagious, or psychological disorder run in the family
Physical Examination

Gen Conc BP HR RR T BH BW BMI

moderate CM 120/80 73 21 36.7° 155 50 20.8

Eyes : conjunctiva was not anemic, sclera was not icteric

Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Thorax : Heart / Lung – within normal limit
Extremity : physiological reflex +/+, pathological reflex -/-
Gynecological Records

Abdomen
• Inspection : Enlarge in accordance with 32 weeks of pregnancy, Cicatrix
(-)
• Palpation : a Cyst mass was palpable at 4 finger below processus
xyphoideus, mobile, slippery surface
• Percussion: Dull above the mass
• Auscultation : hard to determine
Genitalia
• Inspection : vulva and urethra – within normal limit
• Inspeculo : Vagina : Tumor (-), Laserasion (-), Fluxus (-)
MP, Size as adult toe, Tumor (-), Laseration (-), OUE was
closed, Fluksus (-), sondase 6 cm
• VT bimanual :
• Vagina : tumor (-) laseration (-) fluxus (-)
• Portio : MP, size as adult toe, tumor(-) laseration(-) OUE was closed
• CUT : hard to identify
• A/P : a tumor bottom pool was palpated
• CD : not protude
Ultrasounds
Uterus retrofleksi, size 5,33x2.56x4,16
- No myom or adenomiosis
- A large cyst mass mix a solid part whit size bigger than a monitor, RI : 0,52
- Adnexa kontralateral hard to determine

Impression : mixed solid Ovarian Cyst malignancy suspected

Laboratory Finding

Parameter Result Normal Value Unit

Haemoglobin 12,2 12.00-14.00 g/dl

Leucocyte 5.390 5.00-10.00 103/mm3

Thrombocyte 276.000 150.00-400.00 103/mm3

Hematocrit 39 37.00-43.00 %
 Parameter Result Normal Value Unit

Calsium 9,1 8.1-10.4 u/l

Potassium 3,1 3.5-5.1 mmol/L
Sodium 138 139-145 mmol/L
Random Blood Glucose 96 < 200.00 mg/dL
Total Protein 7,0 6.0-7.8 g/dL
Albumin 3,7 3.5-5.2 g/dL
Globulin 3,3 0.00-0.00 g/dL
SGOT 11 0.00-31.00 u/L
SGPT 10 0.00-34.00 u/L
Ureum 15 15.00-40.00 mg/dL
Creatinine 0,7 0.60-1.20 mg/dL
LDH 337 220- 480 u/L
Ca-125 19,4 <35 u/ml
AFP Reagen habis 0-5 Ng/ml
CT Scan

Impresion : intraperitoneal mass in the right abdomen, teratoma

suspected with dermoid cyst dd
Diagnosis

Mixes solid Ovarian Cyst malignancy suspected

Management :
• Controlling general condition, vital sign
• Consult to internist
• Report to OR
• Informed consent

Plan : Optimal debulking

Nov 08th, 2018, At 12.00 am :

• laparoromy was performed in general anesthesia

• After peritoneum opened  exploration  adhesive mass to ileum 
consult to digestif divison  adhesiolisis + anastomose resection 
Perfomed debulking optimal
• right ovary and tubes : within normal limit
• The specimen was sent to Pathological anatomy lab
• Blood loose during surgery : 1000 cc

Transfusion intra op 2 unit PRC

Diagnosis :
• Post optimal debulking on indication of mixed ovarian cyst malignancy
suspected

Plan :
• Closed post surgery monitoring
Thank You