Onchology Case Report

Onchology Surgery dr. Sardjito Medical

Center of Yogyakarta
2014
IDENTITY
Name : Trd
Birth Date : 10
th
of September 1985
Sex : Female
MR Number : 1670246
Hospitalized Date : 4
th
of April 2014
Ward : 2
nd
of Cendana
Admission
Primary Survey
A : Clear speaking, no snorring , no gurgling
B : no dyspneu, RR 26 x/mnt
C : Warm feet and hands, Blood Pressure 100/60
Pulse 98 x/mnt RCT < 1 second
D : GCS E4V5M6, isokor of pupil 3mm/3mm, Light
Reflex +/+

Initial Asesment : No life threatening

Secondary Survey :
Chief complain : Fatigue
History : about 1,5 year ago the patient
undergo operation in Boyolali State Hospital
for tumour removal of the left
femur.Pathological anatomy result was
Fibrosarcoma . Three months after, the
tumour is regrow. Again she was operated in
Salatiga Stated Hospital with the
histopathologic result for the same reslult.
Then the patient was referred to Moewardi
Medical Center for further teratment.
Operation has been done with the
histopathological result for fibrosarcoma.
FTSG procedure has been done for closing
the operation defect. Chemotherapy was
planned for the patient. She refused the
procedure. A month before hospitalization
she came to Sardjito Hospital Emergency
Room for dizzines,lethargic complain. The
Hemoglobin is 4 gr%

During hospitalization she was tranfused with 6
bag of PRC. She was sent home.
Radiotherapy was planned in 15
th
of April
2014. In the day, she come to Radiotherapy
Center, but suggested for hospitalization
because of the general weakness. The
Hemoglobin was 6,9 gram%, white blood
count is 31.400. The radiotherapy was
replanned after optimalization condition.

PHYSICAL EXAMINATION
General Appearance : Weak , Compos Mentis
Vital Sign :
BP = 90/60 mmHg P = 92 x/mnt,
RR = 24 x/mnt t = 36
VAS = 8
Head : Anemia of the Conjuntivae (+/+),
Scleral Icteric (-/-)
Neck : No JVP uprise, No lnn palpable

Thorax :
I : Simetric, no motion lag of the chest
P : The same vokal fremitus for both side
P : The sonoric sound for both side
A : The same vesicular sound for both side
Abdomen:
I : Flat
A : normal bowel sound
P : Supel
P: Timpani

Local status of the left femur
region
I : mass on the medial
side of the left femur,
15x 2o cm in size
,with ulkus
P : Pain

Medial Side of the left
femur
Lateral side of the left
femur
Result for Thorax Exam
(12/3/2014)
Normal
Result for Femur Radiologic
Exam (12/3/2014)
Soft tissue mass of
the left poteromedial
aspect without bone
destruction
Blood examination
resut(15/4/2014)
WBC 31,4 RBC 2,46
Hb 6,9 Ht 20
AT 286 Alb 0,88
SGOT 16 SGPT 16
BUN 4,5 Creat 0,26
GDS 109 Natrium 109
Kalium 3,79 Cl 74,7

ASSESSMENT
Fibrosarcoma of the left Femur region
Anemia
Leucocitosis
Hipoalbumin
HipoNatremia
HipoChloremia

Plan
Complete Blood Count examination,
BUN/Creatitin, ALT/AST,Albumin, Eletrolite
General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Plan
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Paracetamol tablet 500 g/8 hours
Albumin 20 % tranfusion/day
Elektrolite Corection
Consult to Internal Medicine Departement :
Sugested for NaCl 3% 8 dpm



Follow up 15/4/2014
S: fatigue, pain
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Leucocitosis
Hipoalbumin
HipoNatremia
HipoChloremia


P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Paracetamol tablet 500 g/8 hours
Albumin 20 % tranfusion/day



Follow up 18/4/2014
S: fatigue, pain,
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin


P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Paracetamol tablet 500 g/8 hours
Albumin 20 % tranfusion/day



Blood exams Result
(18/4/2014)
WBC 15,46 Total
protein
2,69
RBC 2,37 Albumin 0,79
HGB 6,6 Natrium 118
PLT 327 Kalium 2,6
WBC 15,46 Chloride 97
Follow up 19/4/2014
S: fatigue, pain,diarhea
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
Diarhea


P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Paracetamol tablet 500 g/8 hours
Albumin 20 % tranfusion/day
New Diatab 2 tablet/ diarhea
Consul Internist for diarhea



19/4/2014
WBC 14,9 RBC 2,40
HGB 6,8 PLT 305
Follow up 20/4/2014
internist
S: diarhea >10x/day
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
Diarhea


P: IVFD kaen 3B : Novamil : RL = 30 dpm
New diatab 3x1
Imodium 1 tab (extra)


Follow up 23/4/2014
S: fatigue, pain,
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Paracetamol tablet 500 g/8 hours
Albumin 20 % tranfusion/day



23/4/2014
WBC 17,85 AST 11
RBC 3,02 ALT 10
HGB 8,7 BUN 2,9
HCT 23 CREAT 0,23
PLT 332 NATRIUM 123
ALB 1,15 KALIUM 2,4
RANDOM
BLOOD
GLUCOSE
107 CHLORIDE 102
Follow up 24/4/2014
S: fatigue, pain,
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day



Blood Culture/sensitivity
Result (24/4/2014)
Negatif
Follow up 25/4/2014
S: fatigue, pain, Diarhea
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
diarhea


P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Ceftriaxone injection 1 gram/12 hours
Metronidazole injection 500 mg/8 hours
Ketorolac injection 30 mg/hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day
Imodium 1 tablet (extra)



Follow up 28/4/2014
S: fatigue, pain,
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Natrium Chloride 0,9% 30 dpm
Clindamycin 300mg/6hour
Aspar K2x1
Ondancentron injection 4mg/12hour
Ketorolac injection 30 mg/8hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day



Urine Culture/Sensitivity
(28/4/2014)
Source of infection : Candida albicans
Sensitive to Fluconazole and Nystatin
Follow up 29/4/2014
Internist
S: fatigue, diarhea
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin



P: Clindamicin => STOP
Fluconazole infus 200mg/12hour
Ciprofloxacin infus 400mg/12hour
Metronidazole infus 500g/8jam




29/4/2014
WBC 24,7 RBC 2,61
HGB 7,9 PLT 297
Follow up 2/5/2014
S: fatigue, pain, dyspneu
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
UTI
Pleural efusion



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Kaen mg3 : kalbamin = 22dpm
Ciprofloxacin 400mg/12hour
Fluconazole 200g/24hour
Metronidazole 500mg/8hour
Ondancentron injection 4mg/12hour
Ketorolac injection 30 mg/8hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day



Urine Examination Result
2/5/2014
pH 6,0 Colour Yellow
Glucose - Blood -
Urobilinoge
n
- Keton -
Bilirubin - Leucocyte 500 /U
Nitrit +1 Protein +-
Eritrocyte 14/L Leukocyte 59/L
Epithel 68/L Cylinder 4/L
Bacteria 22.37,5/L Yeast Like
Cell
228/L
Result for USG (2/5/2014)
Right Pleural Effusion
No metastasis to
Internal abdominal
organ
Follow up 5/5/2014
S: fatigue, pain, dyspneu
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
UTI
Pleural efusion



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Kaen mg3 : kalbamin = 22dpm
Ciprofloxacin 400mg/12hour
Fluconazole 200g/24hour
Metronidazole 500mg/8hour
Ondancentron injection 4mg/12hour
Ketorolac injection 30 mg/8hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day



5/5/2014
WBC 18,3 GDS 89
RBC 2,69 Na 120
HGB 7,9 K 2,14
HCT 21,9 Cl 98
PLT 22 GDS 89
Follow up 6/5/2014
S: fatigue, pain, dyspneu
O: General apperance, week, VAS: 3
Local status of the left femur
I:tumour mass covered by gauze, ooze
out.
P: pain
A: Fibrosarcoma of the left Femur region
Anemia
Hipoalbumin
UTI
Pleural efusion



P: General Condition Correction
Blood Tranfusion untill Hemoglobin
Concentration above 10 gram%
IVFD Kaen mg3 : kalbamin = 22dpm
Ciprofloxacin 400mg/12hour
Fluconazole 200g/24hour
Metronidazole 500mg/8hour
Ondancentron injection 4mg/12hour
Ketorolac injection 30 mg/8hours
Ranitidin injection 50 mg/12 hours
Albumin 20 % tranfusion/day



Blood Gas Analysis
pH 7,427 S02 97%
pO2 94,1
mmHg
cHCO3 7,7
pCO2 11,9
mmHg
BE -12,9
a/AO2 70% FIO2 70,1%
Temp 37 0 C