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Onchology Case Report

Onchology Surgery dr. Sardjito MedicalCenter of Yogyakarta

2014

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IDENTITY

Name : Trd

Birth Date : 10th  of September 1985

Sex : Female

MR Number : 1670246

Hospitalized Date : 4th of April 2014

Ward : 2

nd

 of Cendana

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Admission

Primary Survey

A : Clear speaking, no snorring , no gurgling

B : no dyspneu, RR 26 x/mntC : 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

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Secondary Survey :

Chief complain : Fatigue History : about 1,5 year ago the patient

undergo operation in Boyolali State Hospitalfor tumour removal of the left

femur.Pathological anatomy result wasFibrosarcoma . Three months after, thetumour is regrow. Again she was operated inSalatiga Stated Hospital with the

histopathologic result for the same reslult.Then the patient was referred to MoewardiMedical Center for further teratment.

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  Operation has been done with thehistopathological result for fibrosarcoma.FTSG procedure has been done for closingthe operation defect. Chemotherapy wasplanned for the patient. She refused theprocedure. A month before hospitalization

she came to Sardjito Hospital EmergencyRoom for dizzines,lethargic complain. TheHemoglobin is 4 gr%

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During hospitalization she was tranfused with 6bag of PRC. She was sent home.Radiotherapy was planned in 15th of April2014. In the day, she come to RadiotherapyCenter, but suggested for hospitalizationbecause of the general weakness. The

Hemoglobin was 6,9 gram%, white bloodcount is 31.400. The radiotherapy wasreplanned after optimalization condition.

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PHYSICAL EXAMINATION

General Appearance : Weak , Compos Mentis

Vital Sign :

BP = 90/60 mmHg P = 92 x/mnt,RR = 24 x/mnt t = 36º

VAS = 8

Head : Anemia of the Conjuntivae (+/+),Scleral Icteric (-/-)

Neck : No JVP uprise, No lnn palpable

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Thorax :I : Simetric, no motion lag of the chestP : The same vokal fremitus for both side

P : The sonoric sound for both sideA : The same vesicular sound for both side

Abdomen:

I : FlatA : normal bowel soundP : SupelP: Timpani

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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

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Medial Side of the left

femur

Lateral side of the left

femur

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Result for Thorax Exam

(12/3/2014) Normal

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Result for Femur Radiologic

Exam (12/3/2014) Soft tissue mass of

the left poteromedialaspect without bonedestruction

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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

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ASSESSMENT

Fibrosarcoma of the left Femur regionAnemiaLeucocitosis

HipoalbuminHipoNatremiaHipoChloremia

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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

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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

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration above 10 gram%

IVFD Natrium Chloride 0,9% 30 dpm

Ceftriaxone injection 1 gram/12 hoursMetronidazole injection 500 mg/8 hours

Ketorolac injection 30 mg/hours

Ranitidin injection 50 mg/12 hoursParacetamol tablet 500 g/8 hours

Albumin 20 % tranfusion/day

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbumin

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration 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

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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 2,6WBC 15,46 Chloride 97

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbuminDiarhea

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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 hoursKetorolac 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

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19/4/2014

WBC 14,9 RBC 2,40

HGB 6,8 PLT 305

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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: painA: Fibrosarcoma of the left Femur regionAnemiaHipoalbumin

Diarhea

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P: IVFD kaen 3B : Novamil : RL = 30 dpm

New diatab 3x1

Imodium 1 tab (extra)

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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: painA: Fibrosarcoma of the left Femur regionAnemiaHipoalbumin

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration above 10 gram%

IVFD Natrium Chloride 0,9% 30 dpm

Ceftriaxone injection 1 gram/12 hoursMetronidazole injection 500 mg/8 hours

Ketorolac injection 30 mg/hours

Ranitidin injection 50 mg/12 hoursParacetamol tablet 500 g/8 hours

Albumin 20 % tranfusion/day

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23/4/2014

WBC 17,85 AST 11

RBC 3,02 ALT 10

HGB 8,7 BUN 2,9HCT 23 CREAT 0,23

PLT 332 NATRIUM 123

ALB 1,15 KALIUM 2,4RANDOMBLOOD

GLUCOSE

107 CHLORIDE 102

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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: painA: Fibrosarcoma of the left Femur regionAnemiaHipoalbumin

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration 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

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Blood Culture/sensitivity

Result (24/4/2014) Negatif

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbumindiarhea

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration 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)

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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: painA: Fibrosarcoma of the left Femur regionAnemiaHipoalbumin

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration 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

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Urine Culture/Sensitivity

(28/4/2014) Source of infection : Candida albicans

Sensitive to Fluconazole and Nystatin

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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, oozeout.

P: painA: Fibrosarcoma of the left Femur region

Anemia

Hipoalbumin

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P: Clindamicin => STOP

Fluconazole infus 200mg/12hour

Ciprofloxacin infus 400mg/12hour

Metronidazole infus 500g/8jam

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29/4/2014

WBC 24,7 RBC 2,61

HGB 7,9 PLT 297

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbuminUTI

Pleural efusion

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration above 10 gram%

IVFD Kaen mg3 : kalbamin = 22dpm

Ciprofloxacin 400mg/12hourFluconazole 200g/24hour

Metronidazole 500mg/8hour

Ondancentron injection 4mg/12hourKetorolac injection 30 mg/8hours

Ranitidin injection 50 mg/12 hours

Albumin 20 % tranfusion/day

U i E i ti R lt

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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/µL Leukocyte 59/µLEpithel 68/µL Cylinder 4/µL

Bacteria 22.37,5/µL Yeast Like

Cell

228/µL

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Result for USG (2/5/2014)

Right Pleural Effusion

No metastasis toInternal abdominalorgan

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbuminUTI

Pleural efusion

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration above 10 gram%

IVFD Kaen mg3 : kalbamin = 22dpm

Ciprofloxacin 400mg/12hourFluconazole 200g/24hour

Metronidazole 500mg/8hour

Ondancentron injection 4mg/12hourKetorolac injection 30 mg/8hours

Ranitidin injection 50 mg/12 hours

Albumin 20 % tranfusion/day

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5/5/2014

WBC 18,3 GDS 89

RBC 2,69 Na 120

HGB 7,9 K 2,14HCT 21,9 Cl 98

PLT 22 GDS 89

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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, oozeout.

P: pain

A: Fibrosarcoma of the left Femur regionAnemiaHipoalbuminUTI

Pleural efusion

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P: General Condition Correction

Blood Tranfusion untill HemoglobinConcentration above 10 gram%

IVFD Kaen mg3 : kalbamin = 22dpm

Ciprofloxacin 400mg/12hourFluconazole 200g/24hour

Metronidazole 500mg/8hour

Ondancentron injection 4mg/12hourKetorolac injection 30 mg/8hours

Ranitidin injection 50 mg/12 hours

Albumin 20 % tranfusion/day

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