Pasien Masdalipah

Mrs. M, 47 yo, P2A0, Bataknese, Moeslem, Housewife, married to

Mr. H, 57 yo, Bataknese, Moeslem, enterpreneur, the youngest child
is 21 yo.

CC : Menstrual pain
This has been experienced since 1 years ago, worsened
when menstruating at 2nd and 3rd day. History of long
menstruation and heavy menstruation (-). History of vaginal
bleeding outside the menstrual cycle (-). History of abdominal
mass (-). History of post coital bleeding (-). Vaginal discharge (+),
odor (-), itchi (-). Micturition and defecation no abnormality.
Previous illness :-
Previous medical :-
Contraception history : -

Menstruation history: Menarche 11 y.o, underpad

changing around 3-4 times/day, duration 5-7 days,
regularly, dismenorrhea: (+)
LMP: 05 08 2017
Present State
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 80 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,6 OC Edema : (-)

Localized St :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)

Neck : No abnormalities

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Abdominal : lax, peristaltic (+) normal, not palpable mass

Vaginal bleeding : (-)

Ginecology state :
Inspeculo : Smooth portio, erosion (-), F/A (-), blood (-), mass (-)

Vaginal toucher : Uterine AF with normal size, palpable cystic mass,

smooth surface, immobile, on the left, tenderness (-), The origin of
mass from the left adnexa. Right Adnexa was not palpable. Both of
Parametrium was laxed. Cavum Douglas not protruded.
 LABORATORY FINDINGS on August 14th 2017 :
Hb : 11,1 N: 12-14 gr/dl
Leukocyte : 6530 N:4000-11000/mm3
Hematocrit : 33,0 N: 36,0-42,0/%
Platelet : 344.000 N:150000-400000/mm3
Fasting Glucose : 80,95 N : 74-106 mg/dl
Post Prandial Glucose : 100 N : 76-140 mg/dL
Albumin : 3,90 N : 3,6-5
Ureum : 30,52 N : > 50 mg/dl
Creatinin : 0,87 N : 0,6-1,2 mg/dl
 LABORATORY FINDINGS on August 14th 2017 :

Natrium : 145 N :135-155

Kalium : 4,80 N : 3.6-5.5
Cloride : 112,0 N : 96-106
Ca125 : 291,50 N : 0-35 U/ml
USG TAS
USG TAS
 USG TAS
Uterus normosize, Adnexa : The ovaries appear
enlarged, bounded not firmly, size 9x6 cm

Conclusion : ovarian cysts

Diagnosis:
Ovarian cysts

Plan : cystectomy on August 29th 2017