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Case No.

36

Name
: Mrs. N
Age
: 45 years old
MR No. : 891065
Date
: May 11th, 2015

History Taking :
A 45 years old patient was admitted to
the gynecology ward room of Dr. M.
Djamil Central General Hospital on
may 11th , 2015 with chief complain
bleeding from vagina since 3 days ago,
there is no bleeding now. The patient
feels fatigue and weakness.

Present Illness History :


Abdomen enlarge since 1 years ago
She got a long and plenty menstruation, since 5 days
ago, 4-5 times pads changing a day, no pain.
Previously, her period was reguler every month, but
since 1 years ago she got along and plenty
menstruation, duration was 10-12 days, the duration 34 times pads changing a day. The doctor had been
suggested the patient to got laparotomy, but the
patient refused it.
Abdomen enlarge didnt perceived by the patien
Patient has been married 15 years and have 3 children
Last menstrual period : May 08th, 2015
No history of fever, trauma, flour albus
Post coital bleeding history (-), dyspareunia (-)
Decrease of weight body (-)
Miction and defication was normal

Previous Illness History :


There wasnt previous history of heart, lung,
liver, kidney, DM, hypertension and drug allergy
Family Illness History :
There wasnt history of hereditary disease,
contagious and psychological illness in the
family.
Marriage History: 1 x, 1990
Pregnancy/Abortion/Delivery History: 3/0/3

Physical Examination :
GA
Cons
BP
Mdt
BW
BH
BMI

CMC

100/70

PR

RR

84

20

37

: 48 kg
: 150 cm
: 21,33 kg/m2

Eyes
Neck
Chest
Abdoment
Genitalia
Extremity

Conjunctiva was anemic,


Sclera wasnt icteric
JVP 5-2 cmH2O, tyroid gland no enlargement
H/L normal
Gyn Record
Gyn Record
Edema -/-

Gynecologic Record :
Abdomen :
I
abdominal enlarge,
Pa a solid mass was palpable 3 finger
above
SOP, mobile, pressure pain (-),
rebound tenderness (-), DM (-)
Pe dull above mass
Au normal peristaltic sound

Genitalia
I :V/U normal, no vaginal bleeding
Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (-),
Portio : NP, size equal to an adult thumb,
tumor (-),
laceration (-), fluxus (-) ,sondage
curette bump(+).

VT bimanual :
vagina : tumor (-)
portio
: MP, size equal to an adult
thumb,
move when the mass moved,
closed OUE
CUT
: as big as adult fist
A/P
: supple in left and right side
CD
: not protruded

Hemoglobine
Leukocyte
Trombocyte

Result
4,4
10.300
266.000

Normal Value
12-14
5,0-10,0
150-400

Unit
g/dl
103/mm3
103/mm3

Hematocryte
Erytrocyte
MCV
MCH
MCHC

15
2.830.000
54
15
15

37,0-43,0
4,0-4,5
82-92
27-31
37-43

%
/mm3
fL
Pg
%

PT

10,2

10,0-13,60

second

APTT

34,5

29,20-39,40

second

INR

0,95

< 1,2

USG (13/5/2015)

Ultrasound
(13/05/2015)
AF uterus with 12,0 x 7,1 x 6,6 cm in size
Endometrial line was pushed to posterior
side
An hyperechoic mass from anterior corpus,
3,8 x 4,7 cm in size, feeding artery (+)
Right ovary 4,7 x 2,4 cm in size
Left ovary 2,4 x 2,8 cm in size
Impression:
Uterine myoma

Diagnose :
Uterine myoma+ severe anemia
Management :
Control GA, VS
Informed consent
Consult to internist departement
Blood transfusion
Plan: improvement general appearence

(18/05/2015 after general


appearance improvement )
Hemoglobine
Leukocyte
Trombocyte

Result
12,6
4.730
177.000

Normal Value
12-14
5,0-10,0
150-400

Unit
g/dl
103/mm3
103/mm3

Hematocryte

38

37,0-43,0

PT

11,1

10,0-13,60

second

APTT

35,5

29,20-39,40

second

INR

0,97

< 1,2

Diagnose :
Uterine Myom
Management :
Control GA, VS
Informed consent
Consult to anesthesiologist
Plan :
Laparotomy Hysterectomy

At 09.30 am laparatomy was perfomed


when peritoneum was opened, there
was rubbery mass as big as adult fist in
size Impression: uterine myom. Left and
right ovarian was normal.
Total hysterectomy was performed.
Blood during operation 150 cc

Diagnosed :
Post Totalhysterectomy o.i uterine myom

POST OP

Hemoglobine
Leukocyte
Trombocyte

Result
12
15.900
229.000

Normal Value
12-14
5,0-10,0
150-400

Unit
g/dl
103/mm3
103/mm3

Hematocryte

39

37,0-43,0

Thank you