CASE

P0A0, 18 years old, with myoma uteri

Identity

Name
Age
Ethnic
Religion
Occupation
Education
Date of admission

: Mrs.
: 18 years old
: Javanese
: Moslem
: Employee
: Senior high school
: March 28th 2016 at 13.00

Anamnesis:

Chief complaint
Lower quadrant pain since 1 week ago.

History of Present Illness

One week before admission, the patient felt abdominal pain in the

lower quadrant. The pain felt like her abdomen was kneaded and it happened
intermittenly. The pain became more severe during patient walking and
standing. The simptoms getting better with a rest.
lump at left lower quadrant of her abdomen. The lump was not painful and
the size 5 x 5cm. She felt that her lump getting bigger each day till now with
the size of 13 x 17cm. The lump not associated with pain. One month before
admission, the patient went to hospital husada for check-up to internist and do
USG for the lump. The USG result was multiple myoma submucosa,
lobulated shaped with the biggest size 135 x 172 x 193 mm, clear regular
edge at anterior aspect on left side of cavum uteri that extended to
intraabdomen.

History of Past Illness

History of hypertension

History of diabetes mellitus

History of allergy

History of asthma

History of trauma

History of surgery

: denied
: denied
: denied
: denied
: denied
: denied

History of menstrualcycle

Menarche

: 15 years old

Menstrual cycle

duration of 5-6 days per month, dysmenorrhea (+)

First day of last menstrual period
: 24/02/2016

Marital history: never married

Contraception History: none

Obstetrics History: none

: 28 days, regular, with

Physical Examination
General condition
: calm
Level of consciousness
: compos mentis
Vital Signs
Blood pressure
: 120/80 mmHg
Heart rate
:70x/minutes
Respiration rate
: 16x/minutes
o
Temperature : 37,2 C
Body weight on admission : 52 kg
Body height
: 160 cm
Body Mass Index
: 24 kg/m2

General Examination

Eyes
Mouth
Thorax

Heart

: anemic conjunctiva -/-, icteric sclera -/: wet oral mucous membrane
: regular 1st and 2nd heart sounds, murmur - ,

gallop

Lung

: vesicular breath sounds +/+, rhonchi -/-,

wheezing -/
Mammae

: areola hyperpigmentation -/-, nipple retraction

-/-, breast milk -/Abdomen

Inspection

Palpation

Percussion

Auscultation
Extremities

: convex, linea nigra -, striae gravidarum : supel, pain with palpation (-)
: dull at umbilical to left lumbal quadrant
: bowel sounds (+), 3 times / minute
: edema -/-, CRT < 2 seconds

Gynecologic Examination

First day of the last menstrual period: 24/02/2016

Inspection
: fluor albus (-), normal vulvovaginal

Laboratory Examination
Hemoglobin
: 11 g/dl
Hematocrit
: 34 %
Leucocyte
: 6200/uL
Trombocyte
: 412.000/uL
Bleeding time
: 2 minutes
Clotting time
: 4 minutes
Random blood glucose : 82 mg/dL
HBsAg
: (-)

Working Diagnosis
P0A0, 18 years old, with myoma uteri
Planning
1.
2.
3.
4.
5.

Pro myomektomy (August 29th 2016,13 :30am)

Preoperative fasting for 8 hours
IVFD Ringer Lactate 500cc preoperation
Ceftriaxone 1 g IV 1 hour preoperation
Consult to anesthesiologist :
- Omeprazole 40mg caps (night)
- Ativan 1mg (night)
- Check PT/APTT (PT= 13,3 seconds, aPTT= 27,8 seconds)
- Preoperative fasting for 6 hours

Operation Report
Anesthesia: spinal anesthesia
- Patient was placed in operating table in supine posittion
- At 13:15am, spinal anesthesia was performed
- Aseptic and antiseptic procedure was done on vagina region, patient feet
and other area except the operation area were closed with sterile fleece
- Vertical incision was made 20 cm until muscular layer was seen
- As the perineum opened, it wasnt found myoma utery
- uterus bikornuate
- The abdomen was cleaned and hemostasis is done.
- Suture abdomen layer by laper till closed
- Operation was done
Post operation instruction :
-

Futrolit 1500 cc/24 jam

Ceftriaxone 2 x 1 g
Kaltrofen supp 3 x 2
Ranitidin amp 1 x 1

Date
Subjective
th
29 of Pain (+)

Objective
General

appearance

Assessment
Planning
: P0A0, 46 years Continue the plannin

Maret
2016
(05.00)

Nausea (-)
Headache (-)
Urination (+)
Defecation (+)

moderately ill
old
with therapy
Consciousness: compos mentis
multiple
BP: 110/80 mmHg, RR: 18
myoma uteri.
bpm, pulse: 68 bpm, t: 36,3oC
Eyes:
Anemic conjunctiva -/-,
icteric sclera -/ Mouth : Wet oral mucosa

membrane
Thorax
o Heart: Regular 1st
and 2nd heart sounds,
murmur -, gallop Lung: Vesicular breath
sounds +/+, rhonchi -/-,
wheezing -/Mammae:Areola

hyperpigmentation

-/-,

nipple

-/-,

retraction

breast milk -/Abdomen

o Inspection:
Convex,operation scar(-)
o Palpation:
Palpable
mass at umbilical to left
lumbal

regio,

clear

reguler edge, immobile,

pain on palpation (-)
o Percussion
:
Dull at umbilical to left
lumbal regio
o Auscultation

Bowel sounds (+), 3

times/minute

Extremities:

warm,

Edema -/-, CRT< 2 seconds

30h of Pain on post- General

appearance

: P0A0, 18 years - Aff katheter

March
2016
(05.00)

op

area

(+) moderately ill

old,
post
Consciousness: compos mentis
VAS=2-3
laparatomi
BP: 100/60 mmHg, RR:18
Nausea (-)
eksplorasi
Urination (+)
bpm, pulse: 79bpm, t: 36,7oC
via catheter,
dengan temuan
UO: 1,3cc/kg/hr (3.5hrs)
clear yellow,
uterus
Drain: 250 cc (3.5hrs)
sediment (-),
biconaute
Eyes
:
POD - 1
blood (-)
Anemic conjunctiva -/-,
Defecation (-)
icteric sclera -/since post-op
Mouth : Wet oral
Flatus (+)
mucosa membrane
Thorax
Heart
:
Regular 1st and 2nd heart
sounds, murmur -, gallop
Lung

Vesicular breath sounds

+/+,

rhonchi

wheezing -/Mammae

-/-,
:

Areola
hyperpigmentation

-/-,

nipple

-/-,

retraction

breast milk -/ Abdomen

Inspection

Convex, operation scar

(+) covered by bandage,
blood (-)
Palpation

supple,pain (+) post op

area
Percussion
Tymphanic
Auscultation

:
:

Bowel sounds (+), 3

times/minute

- Cefadroxil 3x500m

tab po
- Mefinal 3 x 500 m
po

Extremities:

warm,

Edema -/-, CRT< 2 seconds

th

31

of Pain

March
2016

on

Genitalia

catheter

installed
the General
appearance

: P0A0, 18 years - Cefadroxil 3x500m

post-op area(+) moderately ill

Consciousness: compos mentis
VAS= 3-4
BP: 110/60mmHg, RR: 16
Nausea (-)
Urination (+), bpm, pulse: 76 bpm, t: 36,5oC
Eyes
:
clear yellow,
blood (-)
Defecation (-)
since post-op

Anemic

Regular 1st and 2nd heart

sounds, murmur -, gallop
:

Vesicular breath sounds

+/+,

rhonchi

wheezing -/Mammae

-/-,
:

Areola
hyperpigmentation

-/-,

nipple

-/-,

retraction

breast milk -/ Abdomen

Inspection

Convex, operation scar

(+) covered by bandage,
blood (+) 5cc
Palpation

supple,pain

lower

abdomen
Percussion

(+)

post tab po
- Mefinal 3 x 500 m

po
- dulcolax supp
dengan temuan OBH 3 x 15 ml
eksplorasi

biconaute
oral POD - 2

icteric sclera -/ Mouth : Wet

Lung

laparatomi

-/-, uterus

conjunctiva

mucosa membrane
Thorax
Heart

old,

Tymphanic
Auscultation

Bowel sounds (+), 4

times/minute

Extremities:

warm,

Edema -/-, CRT< 2 seconds

Genitalia : catheter
(+)
10 of Pain on the General appearance : mild ill
P0A0, 46 years
Consciousness: compos mentis
August post-op area(+)
old,
post
BP: 120/80mmHg, RR: 18 pm,
2015
VAS= 2-3
subtotalis
pulse: 80 bpm, t: 36,2oC
Nausea (-)
hysterectomy
Eyes
:
Loss
of
as
Anemic conjunctiva +/+, (POD-3)
appetite (-)
Urination (+),
indicated
by
icteric sclera -/ Mouth : Wet oral multiple
clear yellow,
th

blood (-)
Defecation (-)
since post-op

mucosa membrane
Thorax
Heart

myoma uteri

sounds, murmur -, gallop

:

Vesicular breath sounds

+/+,

rhonchi

wheezing -/Mammae

-/-,
:

Areola
hyperpigmentation

-/-,

nipple

-/-,

retraction

breast milk -/ Abdomen

Inspection

wa

discharged with:
- Cefadroxil

3x500mg tab po
- Tramadol 3x50m
tab po
- Acid tranexamic
x 500mg
- Ranitidine

8mg
- Dycynone 3 x

Regular 1st and 2nd heart

Lung

Patient

Convex, operation scar

(+) covered by bandage,
Palpation
:
supple,pain (+) post op

tabs
- Vit.K 3 x 1 tab
- Dulcolax 2 x 1 tab

area
Percussion
Tymphanic
Auscultation

:
:

Bowel sounds (+), 4

times/minute

Extremities:

warm,

Edema -/-, CRT< 2 seconds

Genitalia : catheter
(+)
Final Diagnosis
P0A0, 46 years old, post subtotalis hysterectomy as indicated by multiple myoma
uteri