CLINICO-PATHOLOGICAL CONFERENCE

Sebelas Maret University School of Medicine

Prof Dr.R Soeharso Orthopaedic Hospital
Dr.Moewardi General Hospital
CAS
E1

Name : Mr. Muhroji

Age : 31 y.o
RM : 013
From : Polyclinic
History Taking
Chief Complaint :
Lump on the right heel
Recent History :
2 years ago patient complained about lump on his right heel.
The lump was getting bigger, but the progresivity is low. Patient
also complain about pain, increasing while he walks and
reducing while he rests.
6 month before admission patient examined his self to
orthopaedics and performed photo radiology on his heel also
refers to patologist for FNAB. the result of FNAB show as soft
tissue tumor. After that, patient being referred to Moewardi
Hospital.
History of trauma (-), anorexia (-), night pain(+), loss of body
weight (-), dyspnea (-), chronic cough (-), chronic fever (-),
History Taking

Past History:
History of trauma (-)
Significant weight body loss (-)
Chronic cough (-)

FAMILY
Cancer History (-)

SOSIOECONOMIC
Machine operator
Physical Examination

Karnofsky score : 100

Head : no abnormality
Neck : no abnormality,
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : no abnormality
Shoulder : no abnormality
Extermities : look at local examination
Abdominal : no abnormality
Local Physical Examination

Right Ankle region:

L : Skin intact, swelling (+), deformity unclear
venectation (-), skin color same with around
F : tenderness (+), NVD (-)
M : ROM Ankle full
Laboratory Examination
January 19th, 2016
Hb : 13,4 g/dl
Hematokrit : 30 %
Leukosit : 4300 rb/ul
Trombosit : 342 rb/ul
Eri : 5.64

PT : 13.3
APTT : 28.9

GDS : 125
HbsAg : (-)
Na : 135
K : 3.9
Cl : 107
Ca : 1.35
X-Ray Right Ankle (December 28th, 2016)
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
1 April 2016
MRI (January 30th, 2017)
Hasil PA (April 19th, 2017)
INITIAL ASSESSMENT
 PLAN

Excission + Byopsi
Post Op