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SURAT RUJUKAN

Rujukan mestilah kepada Pegawai Perubatan/Pendaftar/Pakar/Pengarah Hospital


Kepada: ONCOLOGIST ONCALL DR. AZNAL X Segera
Jabatan/Unit: Oncology HKL Tidak segera, mengikut penetapan
Nama Pesakit: AHAM ANAK MAN
No. K/P: 560501106125 Umur: 61 Y 0 M
Tarikh: 30/05/2017 Jantina: MALE
Masa: No. rujukan:
History:
Dear Oncologist,

Thank you for seeing this patient, a 61-year-old Orang Asli gentleman, known case of Adenocarcinoma of
the hepatic flexure (T3N0M1) with possible lungs metastasis underwent right hemicolectomy on 6/6/2015.
He was refered to your centre in 2015 for chemotherapy however defaulted due to logistic issue.

He presented to us again on 7/5/2017 with the complaints of right-sided abdominal mass that was
progressively increasing in size for two months associated with abdominal pain as well as constitutional
symptoms. During initial assessment, patient was hemodynamically stable with tinge of jaundice.
Abdominal examination noted tenderness over right side of the abdomen and a vague mass palpable
5x5cm over right lumbar region. No hepatomegaly. Abdominal radiograph noted prominent large bowel
with opacity at the right lower quadrant. Bedside ultrasound noted heterogenous hypoechoeic lesion at
the right iliac fossa.

Proceed with CT-TAP on 12/5/2017, noted multiloculated collection of the right lumbar region with
involvement of the right ureter causing obstructive uropathy, multiple right paratracheal
lymphadenopathy, thin line right basal pneumothorax as well as cholelithiasis and right renal calculus.

Pigtail catheter was inserted to drain the psoas abscess on 16/5/2017.

In the ward, his abdominal pain worsening with deteriorating general condition. Repeated abdominal
radiograph noted dilated small bowel. Hence proceed with exploratory laparotomy.

Intra-operatively noted straw coloured peritoneal fluids upon entering the abdomen with adhesions of the
bowel to the right anterior abdominal wall, adhesionolosis done. Also noted tumour recurrence at the
anastomotic site with local invasion until retroperitoneum, unable to mobilise due to tumour invasion. The
right ureter appeared to be thinning. There was minimal faecal contamination of faeces within the
abdominal cavity. We performed jejuno-colostomy to bypass the tumour along with right ureteric
stenting. Impression was intestinal obstruction secondary to recurrent caecal carcinoma.

Post-operatively patient was admitted to ICU for 1 day for post-op stabilisation. Since then he remained
hemodynamically stable and afebrile in the ward, able to tolerate soft diet as well as passing flatus and
defecate.

We had counselled the patient and his family members for palliative chemotherapy and they are keen.
Diagnosis:
Recurrent Adenocarcinoma of the Caecum
Result of Investigations:

FBC: 25/5/17 RP: 28/5/17 Electrolytes 28/5/17 LFT 26/5/2017


Hb: 8.6 Urea: 3.3 Albumin: 30 AST: 15
Wcc: 22.4 Na: 131 Ca: 2.13 (corrected) ALP: 72
Plt: 574 K: 3.4 Mg: 0.69 ALT: 7
Hct 26.6 Creat: 71 PO: 0.66 Tbil: 21.9
Cultures History:
Blood Aerobes and Anaerobes:
7/5/2017: No growth
26/5/2017: SFNG

Sputum (7/5/2017): Acinetobacter baumannii


Urine (7/5/2017): SQCC
Pus (16/5/2017): Mix Growth (from pigtail)

Pending Investigations:
CEA (26/5/2017)
Blood Aerobes and Anaerobes (26/5/2017)
Treatment:
Antibiotic History:
IV Cefobid 1g BD: 18 days (8-25/5/2017)
IV Flagyl 500mg TDS: 18 days (8-25/5/2017)
IV Tazosin 4.5g TDS: 6 days (25-30/5/2017)

Ventilation History:
FM 5L/min: 2 days (23-25/5/2017)
NP 2L/min: 2 days (25-27/5/2017)

Total Parenteral Nutrition:


26-29/5/2017: 15kcal/kg/day

Central Venous Line:


22-29/5/2017 (7 days)

Transfusion History:
08/5/2017: 2 pints Packed Cells
16/5/2017: 4 units FFP
22/5/2017: 4 units FFP
23/5/2017: 1 pint Packed Cells
23/5/2017: 8 units FFP
Purpose of referral

For palliative chemotherapy.


Daripada Pegawai Perubatan/Pendaftar/Pakar/Pengarah Hospital
Nama: DR. MOHD FADHIL BIN AHMAD NAZLAN
Tandatangan:
Jabatan/Unit: Telefon:
CECT THORAX/ABDOMEN/PELVIS CT.03024/25/15 DONE ON 18/06/2015

Thorax-
Well-defined lung nodules are seen at bilateral upper lobes and left base (img 207).
Bilateral apical emphysema with subpleural blebs at the periphery of the upper lobes, largest
measuring 1.9 cm x 0.9 cm (AP x W).
Fibrotic strands at bilateral lung bases.
No pleural effusion.
Subcentimeter pretracheal lymph nodes, largest measuring 0.3 cm in short axis.
Thyroid gland is normal.

Abdomen/Pelvis-
The liver is enlarged but homogenously enhanced. Multiple foci of calcifications are seen at the
segment II, III, VII and VIII, which may represent previous infection or insult. No other focal lesion
seen. Portal vein is patent.
Spleen, pancreas, gallbladder and adrenals are normal.
Bilateral renal cysts seen.
Urinary bladder is distended.
Prostate is not enlarged.

Peritoneal fat streakiness is seen at the right upper abdomen, suggestive of post-operative changes.
Cicumferential mass with luminal narrowing at lower rectum aaproximately 3.7cm from anal verge.
Mild ascites noted.

Denegerative spinal changes. No suspicious lytic bony lesion.

====== [Conclusion] ======


Case of hepatic flexure tumour (HPE pending), post surgery status, current CT shows:
1) Possible lung metastasis.
2) Mulitple foci of calcifications seen within the liver may represent previous infection or insult.
3) Bilateral renal cysts.
4) Suspicious lower rectal lesion. Suggest proctoscopy/ HPE
CECT THORAX, ABDOMEN PELVIS NO. CT 01780/17 DONE ON 12.05.2017

Findings:
There is rim-enhancing multiseptated collection at the right lumbar region measuring approximately
13.2cm x 8.6cm x 10.1cm (AP x W x H).
Air pockets seen within. Marked fat streakiness surrounding the collection.
Poor dermacation with the undersurfaced of the liver, lateral abdominal wall muscles and adjacent
bowel loops.
Small collection seen just below the right renal pelvis, likely to involve the upper part of the ureter
causing moderate dilatation of the collecting system.
Right perinephric fat streakiness. Calculus is seen at lower pole of right kidney measuring 0.7cm x
0.7cm x 1.2cm (AP x W x H).

Multiple subcentimeter hypodensities seen at both kidneys may represent cysts.


Liver is homogenously enhanced. Multiple calcifications are seen at Segment II, III, IV and VIII of liver.
Common bile duct is dilated measuring 1.5cm. Intrahepatic biliary tree is normal. Normal portal vein.
Multiple calculi are seen within the gallbladder and cystic duct.
Spleen, pancreas and adrenal glands are normal.
No ascities.Degenerative changes of the spine.

Multiple enlarged right paratraches nodes. Multiple subcentimeter axillar nodes bilaterally.
Empysematous lung changes both lung apices. Multiple small blebs both upper lobe. No lung
nodules.
Thin line of lucency at the right lung base may represent thin pneumothorax

====== [Conclusion] ======


1- Multiloculated collection of the right lumbar region with involvement of the right ureter causing
obstructive uropathy.
2- Cholelithiasis and right renal calculus.
3- Multiple right paratracheal lymphadenopathy.
4- Thin line right basal pneumothorax.

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