Mrs.

Lala Sundari/33/RA
Anamnase

Physical Examination and supportive exam

CC : Abdominal
enlargement and
pain in abdomen
Since 1 years ago os
complain her
stomach become
bigger, in the
beginning just as
big as a fist,
menstrual period
reguler,
dysmenorrhea (+) ,
Vomitting (-),
weiightloss (-)
Previous illness:

Menstrual : Menarche 13 years old, reguler, 30 days cycle for 6 days

Marrital : 1 times, 15 years
Obstetric : P1A1
Prior operation : Physical examination :
BP : 130/90 mmHg, HR : 82x/m, RR: 18x/m, T: 36,7C
General status : Normal
Gynecologic status :
Abdomen : bloated, no tense, FUT hard to examine, mass (+) cytic mix

Diagnosis
and
Planning

Diagnosis
:
Solid
multilocula
r ovarium
neoplasma
susp
malignanc
solid size 26x2x22 cm, mobile, tenderness (+), ascites (+), free fluid y
sign (-)

Inspekulo : Portio pullled to anterior not livide, stuck when

inserted sondae , fluor (-), fluxus (-), E/L/P (-)
Planning
VT :Portio palpable in anterior, no cervical opening, CUT in normal :
line, Right and Left AP tense, no protution in cavum of Douglas
Laparatom
RT : anal sphincter tone normal, rectal ampulla empty, intralumen
y VC
mucuos (-), Right and Left AP no tense CFS 100%

USG Confirmation :

Uterus retroflexed and adnexa, normal, (GAK KEBACA DPJD : AT

TULISANNYA)
There is a cystic mix solid mass with papil and fill with
serous fluid
Left ovarium size and shape normal (2,1x1,3cm)
Hepar and renal normal
Right renal size 7,9x4,2 cm
Left renal size 8,0x5,2 cm
Result : solid multilocular ovarium neoplasma serous

Laboratory Finding: :

Mrs. Nuriba bt Zainuddin/49/UA

Anamnase

Physical Examination and supportive exam

CC : Vaginal
Bleeding
Since 2
months ago os
complain that
she had fresh
blood vaginal
bleeding, as
much as 4
times changing
underwear,
Abdominal
Pain (-)
Whittish
history (+), 18
days ago os
complain
vaginal
bleeding
decrease and
appear to be a
wane spotting
bleeding
outside
menstrual
cycle, whittish
history (-),
micturition and
defecation

Menstrual : Menarche 13 years old, reguler, 28 days cycle for 5 days

Marrital : 1 times, 25 years
Obstetric : P4A3
Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 80x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine palpated 2 finger
above umbilical, Tenderness (-), mass (-), Free fluid sign (-)

Inspekulo : Portio non livide, no cervical opening, fluor (-), fluxus

(+) not active bleeding, E/L/P (-)
VT :Portio ellastic, no cervical opening, movement pain of portio
(-), CUT in 15 weeks line, Right and Left AP tense, no protution in
cavum of Douglas

USG Confirmation :
Uterus Increase inl size and bumping.
Pictured
hyperechoic
with
no
demarcated
border
with
vascularization size 5,04x5,91 cm in corpus uterii probably an
adenomyosis uterii
Both ovaium normal

Result : Adenomyosis Uterii

Laboratory Finding:

Diagnosis and
Planning
Diagnosis:
Susp
endometriosis
Planning :
LEETZ
DPJD : AT

Mrs. Furqoni bt Sanusi/51/UA

Anamnase

Physical Examination and supportive exam

Diagnosis and
Planning

CC : Vaginal
Bleeding
Since 1
months ago os
complain that
she had fresh
blood vaginal
bleeding, as
much as 2
times changing
tampoon,
Abdominal
Pain (-) Wane
bleeding
outside
menstrual
cycle (+),
whittish history
(-), micturition
and defecation
normal. Patient
referred from
muhammadiya
h hospital

Menstrual : Menopause 3 months ago

Marrital : 1 times, 30 years
Obstetric : P4A0
Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 80x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine palpated 1 finger

Diagnosis:
Abnormal
uterine bleeding
e.c L1 (Myoma
Uterine
Subserous)

Previous
illness:

Planning :
Inspekulo : Portio slick,pictured mass size 4x4cm from OUE, fluor Laparatomy
below umbillical, Tenderness (-), mass (-), Free fluid sign (-)

(-), fluxus (+) not active bleeding, E/L/P (-)

VT :Portio ellastic,palpable mass size 4x4 cm, movement pain of DPJD : AT
portio (-), CUT 20 weeks , Right and Left AP tense, no protution in
cavum of Douglas
RT : anal sphincter tone normal, rectal ampulla empty, intralumen
mucuos (-), Right and Left AP tense CFS 100%, no protution in cavum of
Douglas

USG Confirmation :
Uterus size and shape normal.
Endometrial line (+), stratum basalis reguler, endocervix and portio
normal,
Pictured hyperechoic with no demarcated border with feeding artery

size 6,42x7,01 cm in fundal of uterii probably myoma uterii

subserous
Both ovaium normal

Result : Myoma uterii subserous

Laboratory Finding:
Hb: 10,0; Eritrosit: 3,93; Leu: 6,6 ;Ht: 32; Trombo: 298000; DC:
0/14/57/23/5; PT: 12,5; APTT ; 27,1 Alb: 3,7 CA125 :20,02