Oleh :
Hanantyo Iqbal Diandaru
30101306960
Pembimbing :
dr. H. Gunawan Kuswondo, Sp. OG
Identitas Pasien
• Nama Pasien : Ny. S
• Umur : 68 tahun
• No. CM : 132.50.49
• Agama : Islam
• Pendidikan : SD
• Pekerjaan : Ibu Rumah Tangga
• Alamat : Purworejo RT02/RW04 Sayung Demak
• Status penikahan : Menikah
• Nama suami : Tn. H
• Tanggal Masuk : 26 November 2018
• Dirawat di Bangsal : Baitun Nisa II
Anamnesis
Keluhan Utama
Benjolan yang terasa nyeri pada jalan lahir
Riwayat penyakit sekarang
Pasien datang ke poli obsgyn RSI Sultan Agung dengan keluhan keluar benjolan
dari jalan lahir sejak 2 bulan SMRS, benjolan tersebut terasa nyeri dan mengganggu
aktivitas pasien, benjolan tidak dapat masuk sendiri, namun pasien masih bisa
memasukkan benjolan tersebut apabila pasien berbaring. Pasien mengaku pernah
terjatuh 2 tahun yang lalu dengan posisi terduduk dan semenjak itu pasien
merasakan ada benjolan yang keluar dari jalan lahir namun dapat masuk sendiri bila
pasien berbaring. Saat itu pasien belum merasakan nyeri dan aktivitas pasien tidak te
rganggu sehingga pasien tidak memeriksakan diri ke dokter. Pasien mengaku susah
BAB, BAK masih normal.
Riwayat menstruasi
• Menarche umur 14 tahun
• Siklus teratur
• Lamanya haid 4 sampai 5 hari
• Pasien sudah menopause sejak 13 tahun yang lalu
• Riwayat KB IUD
Riwayat Riwayat Riwayat
Riwayat sosial
penyakit penyakit
pernikahan ekonomi
dahulu keluarga
43
41
PowerPoint
Presentation
38
35
30
28
Pemeriksaan fisik
Status present
Keadaan Umum
01 Baik
Kesadaran
02 Compos Mentis
Vital sign
o Tensi : 170/90 mmHg
03 o Nadi : 88 x/menit
o Suhu : 36,5o C (axilla)
o RR : 20 x/menit
Status gizi
04 o BB : 49 kg
o TB : 150 cm
Status internus
4
Paru Jantung Abdomen Ekstremitas
• Inspeksi : pergerakan • Inspeksi : perut tampak
• Inspeksi : ictus cordis
kedua hemithorax datar, striae gravidarum (-),
tidak tampak
simetris linea nigra (-), bekas opera-
• Palpasi : ictus cordis
• Palpasi : stemfremitus si (-)
teraba ICS 5, 2 cm ke
dextra sinistra sama • Auskultasi : bising usus (+)
arah medial, linea
• Perkusi : sonor pada • Perkusi : tympani
midclavicularis sinistra
seluruh lapang paru • Palpasi : nyeri tekan (-)
• Perkusi : batas
• Auskultasi : suara tambah
jantung dalam batas
-an paru (-)
normal
• Auskultasi : suara tam-
bahan (-)
Status ginekologi
Inspeksi
Tampak massa uterus keluar seluruhnya dari introitus
vagina, bentuk bulat, warna merah muda dan tidak
ada darah
Palpasi
Teraba massa ukuran 10cm x 5cm x 3cm, konsistensi
kenyal, nyeri tekan (-)
Inspekulo
Tidak dilakukan
Vaginal toucher
Tidak dilakukan
Pemeriksaan penunjang
Hematologi
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Rawat luka
01
Personal hygiene
02
28/11/18 29/11/18
Tidak ada
Nyeri keluhan
KU : baik KU : baik
TD : 154/57 TD : 130/80
HR : 80 HR : 80
RR : 20 RR : 20
S: 36 S : 36,3
Tinjauan Pustaka
Definisi
Prolaps uteri adalah turunnya uterus kedalam introitus vagina yang diakibatkan oleh
kegagalan atau kelemahan dari ligamentum dan jaringan penyokong (fasia).
Klasifikasi Friedman dan Little ( 1961 )
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