dr.

Putu Anda Tusta Adiputra,

Sp.B(K)Onk

As a general practitioner, mostly surgery

cases come to polyclinic or emergency
department
General practitioners as a first line health
services, must know how to managed the
cases before referred to surgeon
All the aspect of diagnosis such as: history
taking, physical examination, adjunct
examination ( laboratory/ radiology ,etc)
and differential diagnosis must be well
conducted by general practitioners.

Breast cancer is the one of most surgery

polyclinic cases
The physician plays the important rule in
finding, diagnosing, and educating the
patient before referral to the surgeon
Mastery of knowledge and practice
enough cases to increase the general
practitioner competence.

Female, 60 yo., from Gianyar, complaint

with right breast lump since 6 months
ago. Feel discomfort and become bigger in
the last 2 months. She has no family
history of breast cancer and has no history
of another cancer.
Instruction :
As a polyclinic doctor, perform history
taking, physical examination, laboratory
examination and etc. (diagnostic process)
for this patient. After diagnostic process,
you have to make planning treatment!

About tumor, progressivity, metastatic

symptom (lung, liver, bone, brain
symptom), risk factor (menarche,
pregnant, labour, breast feeding,
hormonal contraceptive, family history,
radiation history)

Right breast lump,

size 4 cm, hard
consistency,
irregular surface,
unclear border,
mobile, slight
tenderness
Enlargement of
single lymph node
on right axilla, 2 cm
in diameter, hard,
mobile

Mammography right breast

US mamma and axilla L&R
FNAB
Routine laboratory findings :
CBC, RFT, LFT, RBS, electrolyte

Diagnostic

From non invasive to invasive : US, mammography,

FNAB, biopsy (core needle, incisional or excisional)

Staging

TNM system stage I to IV

T evaluation :

physical examination with ruller

USG, mammography
CT scan/ MRI
N evaluation :
physical examination (axilla,
supraclavicular)
US axilla
M evaluation :Absolute : Chest x ray (lung metastatic)

Liver US ( liver metastatic)

Optional : Head CT scan

Bone survey/scan
Contralateral breast mammography

Planning treatment depends on Karnofsky

score and stage
Stage IV patient with Karnofsky score less
than 70 plan for palliative treatment
Stage
treatment
adjuvant
I
surgery
II
surgery
chemotherapy
III
surgery
chemotherapy,
radiotherapy
IV
chemotherapy surgery,
radiotherapy
Hormonal therapy depends on hormonal
status
Molecular targeting therapy depends on
targeting therapy marker

Acute appendisitis is surgical cases that

are often found in the emergency
department
General practitioner was play central role
in diagnosing patients
Misdiagnosis can lead to the collapse of
the patient towards a more severe
complications with morbidity and even
mortality

Male, 20 yo, from Denpasar, came to ER with

Chief complaint right lower abdominal pain
since yesterday. Previously he felt epigastrial
discomfort and 6 hours after that radiated to
right lower part. The pain followed with
fever. He never feel like this before. He
works as a bank administration staff.
Instruction :
As a night duty doctor, perform a diagnostic
process and plan for treatment for this
patient.

Ligath sign
Fever history
Peak incidence on 20-30 yo
For differential diagnose : diarrhea, UTI,
dyspepsia, colitis, diverticulitis
The same history to rule out chronic
appendicitis with acute exacerbation

Vital sign : BP : N, pulse , RR : N,

temperature
Inspection : flat, no distention
Auscultation : normal bowel sound
Percussion : tymphany
Palpation : tenderness on mc burney area,
Rovsing sign, Psoas sign, rebound
phenomenon, Dunphy sign, Ten horn sign,
Obturator sign, local defance muscular
DRE : pain on 9-11 oclock

Laboratory findings :

Radiologic examination:

CBC ( increase WBC, specific white blood

count shift to the left, Hb, RBC, PLT : N)
BOF ( rule out urinary stone)
US ( doughnut sign/ target sign)

Differential diagnose:
Ureteral colic (stone, infection)
UTI (cystitis, pyelonephritis)
Gastroenteritis
Dyspepsia
Colitis
Malignancy (tumor of caecum)

As a general practitioner, you can

perform pre operative preparation, such
as :
Fluid and electrolyte correction with IV
placement
Antibiotic intravenous
Fasting
Informed consent