ONCOLOGY OUTPATIENT

DAILY REPORT

Thursday, September 27th 2018

Consultant incharge:
dr. Amirah Novaliani, SpoG (K)
 ONCOLOGY OUTPATIENT RECAPITULATION
No. Diagnosis ICD New case Old case Procedure ICD 9
10
H A H A
Cervical Ca std III post HT r
1 C53.9 - - - - Pap smear evaluation 180.9
adical complete therapy
Pap smear evaluation
Endometrial ca std IVA com - - -
2 C54.1 - every 6 months (1st) (27- 182.0
plete therapy
3-2019)
Cervical Ca std IIIB post che - - -
3 C53.9 - Pap smear evaluation 180.9
motherapy
Endometrial ca std IIIC com - - - Pap smear evaluation 6
4 C54.1 - 182.0
plete therapy months later (27-3-19)
Hospital admission
PRC Transfusion
TC Transfusion
5 Vaginal ca + Pancytopenia C57.9 - - - - 184.0
Inj. Leucogen
Chemotherapy brexel-
carboplatin 3rd course
 ONCOLOGY PATIENT’S RECAPITULATION\
No. IDENTITY DIAGNOSIS ICD 1 PROCEDURE ICD 9 PHYSI Consultant
0 CIAN incharge
Cervical Ca std III po
Mrs. ESY/46/
1 st HT radical comple C53.9 Pap smear evaluation 180.9 IS AM
UR/P3A0
te therapy
Endometrial ca std I Pap smear evaluation
Ms. SUT/37/R
2 VA complete therap C54.1 every 6 months (1st) 182.0 AM AM
A/
y (27-3-2019)
Mrs. ROH/58 Cervical Ca std IIIB
3 C53.9 Pap smear evaluation 180.9 AT AM
/UA/P5A0 post chemotherapy
Pap smear evaluation
Mrs. LIN/63/ Endometrial ca std II
4 C54.1 6 months later (27-3- 182.0 AT AM
UA/P5A0 IC complete therapy
19)
Hospital admission
PRC Transfusion
TC Transfusion
Mrs. PAR/61/ Vaginal ca + Pancyto
5 C57.9 Inj. Leucogen 184.0 IS AM
RA/P4A0 penia
Chemotherapy
brexel-carboplatin 3rd
course
 1. Mrs. ESY/46/UR/P3A0
S/ control pro Pap Smear once a year
Patient come with diagosis Cervix Ca std IIb post ht radical complete therapy
With PA result 1247/C/2017 = chronic servicitis non specific; no malignant cells.
h/ ht radical (15-7-2014)

O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Speculum examination: normal vaginal stump
Vaginal toucher: normal vaginal stump

A/ Cervical Ca std III post HT radical complete therapy

P/ Pap smear every year for second times.
Pap smear evaluation 1 year later (26-9-2019)
 2. Ms. SUT/37/RA/
S/ control Pap Smear evaluation (4th) and laboratorium result.
Patient come with diagnosis Endometrial Ca std IVA complete therapy. She did her routinely Pap Smear
evaluation every 3 months for forth times with Pap smear last result 846/C/2018= no viable malignant
cells.
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Lab result (26-9-2018): AFP 4,40; CEA 1,40; Ca 125 7,6

A/ Endometrial ca std IVA complete therapy

P/ Pap smear evaluation every 6 months (1st) (27-3-2019)
 3. Mrs. ROH/58/UA/P5A0
S/ control post chemotherapy
Patient come with diagnosis Cervix Ca std IIIB post chemotherapy with PA result 1292/A/2018=
Poorly differentiated squamous cell carcinoma on cervix biopsy DD/: Large cell neuroendocrine
carcinoma.
USG result (28-03-2018)= cervix malignancy mass size: 2,48 x 1,8 cm
h/ chemotherapy paclitaxel-carboplatin 6 courses
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

Lab: (25-9-18) Hb 9.0 WBC 13.6 PLT 386 SGOT 18 SGPT 12 Ur 54 Cr 2.97 Ca 9.0 Na 146 K 4.6 Cl 114

A/ Cervical Ca std IIIB complete therapy

P/ Pap smear evaluation
 4. Mrs. LIN/63/UA/P5A0
S/ Pap smear evaluation
Patient come with diagnosis Endometrial ca std IIIC complete therapy. Patient brings her Pap smear
result 1318/C/2017 (26-9-18)= No active malignant cells.
h/ Radical surgical staging (20-7-12)
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)

A/ Endometrial ca std IIIC complete therapy

P/ Pap smear evaluation 6 months later (27-3-19)
 5. Mrs. PAR/61/RA/P4A0
S/ chemotherapy
Patient come with diagnosis Vaginal ca urethra metastase + Pancytopenia With PA result 267/P/2018=
moderated non keratinizing squamous cell carcinoma on vaginal and mouth of urethra
h/surgical staging 18-07-2018
O/
Abdominal palpation: flat, supple, symmetric, tenderness (-), free fluid sign (-), mass (-)
Lab: Hb 9,1; Leu 4200; trombo 18.000

A/ Vaginal ca + Pancytopenia
P/ Hospital admission
PRC Transfusion
TC Transfusion
Inj. Leucogen
Chemotherapy brexel-carboplatin 3rd course