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CASE NO

PATIENT IDENTITY
• Name : Mrs. L
• Age : 41 years old
• MR : 99 38 23
• Address : Pasaman
• Occupation : Housewife
ANAMNESIS
Chief Complaint
• A 41 years old patient was admitted to
ginecology ward of Dr. M. Djamil Central
General Hospital on November 28th, 2017 at
09.00 PM from polyclinic with diagnosis
multiloculare cyst ovarian neoplasm +
Multiple uterine myoma + toxic noduler goiter
PRESENT ILLNESS HISTORY
• Patient complaint about having a mass in her stomach since 1
years ago
• Bleeding from vagina since 3 days ago. Red blackish color.
Wetting 1-2 pads/day, without pain
• Nervousness (+), preference for heat (+), excessive sweating
(+)
• History of post coital bleeding (-), dispareunia (-)
• History of body weight extremelly decreasing (-)
• History of fever trauma and flour albus (-)
• Menstruation history : menarche at 13 years old, irregular
cycle, every month which last for about 4-5 days each cycle
with 2-3 times pas chnge /day without menstrual pain.
• Urination dan defecation was normal
PREVIOUS ILLNESS HISTORY
PREVIOUS ILLNESS HISTORY
• She has toxic struma goiter since 1,5 years ago, she get PTU and bisoprolol
from internist
•There wasn’t previous history of heart, lung, liver, kidney, DM, hypertension
and allergic reaction

FAMILY ILLNESS HISTORY


•There wasn’t history of contagious, hereditary and physiological illness in the
family

•MARRIAGE HISTORY : Once in 2006


•HISTORY OF PREGNANCY/ABORTION/DELIVERY : 0/0/0
PHYSICAL EXAMINATION
GA Cons BP HR RR T Urin output
Mdrt CMC 110/70 72 18 36,5 200cc/at time
BW : 54 kg
BH : 155 cm
BMI : 22,78
Eyes : conjungtiva was anemic, sclera wasn’t icteric, exopthalmos (+)
Neck : JVP 5-2 cmH20, thyroid was palpable
Abd :I : Enlarged as preterm pregnancy
Pa : There’s mass palpated 3 finger upper umbilical, size equal to
baby's head, immobille in centre, pressure pain (-), release
pain, muscular defence (-)
Per : Dulness on top of tumor
Aus : Peristaltic sound was normal
PHYSICAL EXAMINATION
Gen : V/U normal, active vaginal bleeding (-)

Inspeculo
Vagina : Tumor (-), laceration (-), fluxus (-)
Portio : NP, size equal an adult thumb, tumor (-), laceration (-), fluxus (-),
OUE closed, sondage 7 cm

Bimanual Vaginal Examination


Vagina : Tumor (-)
Portio : NP, size as big as adult thumb, OUE closed, portio moved when
mass being moved, movement pain (-).
CUT : AF, size equal to baby's head, sondage 7 cm
AP : Tumors's bottom pool was palpable from right adnexa
CD : didn’t protrude
LABORATORY RESULT
PARAMETER RESULT NORMAL VALUE
Haemoglobin 12,4 12-16
Leukosit 12.540 5.000-10.000
Trombosit 320.000 150.000-400.000
Hematokrit 39 37-43
PT 11,3 9,2-12,4
APTT 36,8 28,2-38,2
Glukose Level 75 <200
Ureum 15 10-50
Creatinin 0,6 0,6-1,2
Calsium 8,8 8,1-10,4
Natrium 145 136-145
Kalium 3,8 3,5-5,1
Clorida 104 97-111
LABORATORY RESULT
PARAMETER RESULT NORMAL VALUE
Protein total 8,0 6,6-8,7
Albumin 5,0 3,8-5,0
Globulin 3,0 1,3-2,7
SGOT 16 <32
SGPT 19 <31
Ca 125 52,62
T3 1,79 0,9-2,5
FT4 11,41 10,6 - 19,4
TSH 0,0024 0,25-5

RMI : 1 x1 x 52,62 = 52,62


USG
USG
• Uterus size 7,5 x 4,01 cm
• There’s were two hypoechoic masses in corpus
uterine with firm borderline size 6,23 x 4,91 cm
and 10,85 cm x 8,79 cm, feeding artery (+)
• There’s was multiloculare cyst mass in right adnexa
with size 5,8 x 4,8 cm

Impression : Multiple myoma


Multiloculare Cyst Ovarian Neoplasm
A/ Multiple myoma + Multiloculare Cyst Ovarian
Neoplasm + IP 11 years
P/ Control GA, VS
•Informed consent
•Report to anaesthesi and OR
•Prepered crossmatch 2 unit of PRC
•Ceftriaxone inj 1 gr (skin test)
•Laparotomy (Nov 29th 2017)
November 29th 2017, 09.15 am, Laparotomy was performed
• After peritoneum was opened
• Exploration was performed, seem multiple white masses as big
as baby's head from uterine and both of adnexas were
normally
• Impresion multiple uterine myomas
• Supravaginal Histerectomy was performed
• Exploration was performed to see bleeding come from
• Blood loss during surgery ± 250 cc

Diagnose
• Post Supravaginal Histerectomy on indication of multiple
uterine myoma
Th/
• IVFD RL 20 tpm
• Inj Ceftriaxone 2 x 1 gr
• Inf Metronidazol 3 x 500 mg
• Inj Tranexamid Acid 3x 500 mg
• Inj Vit K 3x 1 amp
• Inj Vit C 3x 1 amp
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Pronalgess supp
Laboratory finding
Nov 29th 17, 20.00 pm
Parameter Result Unit
Haemoglobin 11,5 g/dl
Leucocyte 17.790 103/mm3
Thrombocyte 230.000 103/mm3

Hematocrit 36 %
Follow Up Nov 30th 17
08.00 WIB

• S/ Fever (-), abdominal pain (-) PPV (-)


• O/
Gc cons BP HR RR T
Mdrt CMC 130/80 80 20 36,8

• Abd: Tenderness pain (-) , rebounds tenderness pain (-) defans


muscular (-)
• Gen: I: v/u normal PPV (-)

• A/ Post Supravaginal Histerectomy on indication of multiple uterine


myoma days 2
Th/
• IVFD RL 20 tpm
• Inj Ceftriaxone 2 x 1 gr
• Inf Metronidazol 3 x 500 mg
• Vit C 3x 1 tab
• Asam mefenamat 3x500 mg
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• kateter
Follow Up Dec 1st
08.00 WIB

• S/ Fever (-), abdominal pain (-) PPV (-)


• O/
Gc cons BP HR RR T
Mdrt CMC 110/80 74 18 36,6

• Abd: Tenderness pain (-) , rebounds tenderness pain (-) defans


muscular (-) , wound was clear
• Gen: I: v/u normal PPV (-)

• A/ Post Supravaginal Histerectomy on indication of multiple uterine


myoma day3
Th/

• Inj Ceftriaxone 2 x 1 gr
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Aff IVFD
• chateter
Follow Up Dec 2st
08.00 WIB

• S/ Fever (-), abdominal pain (-) PPV (-)


• O/
Gc cons BP HR RR T
Mdrt CMC 120/80 76 18 36,8

• Abd: Tenderness pain (-) , rebounds tenderness pain (-) defans


muscular (-)
• Gen: I: v/u normal PPV (-)

• A/ Post Supravaginal Histerectomy on indication of multiple uterine


myoma day4
Th/

• Cefixime 2 x 200mg po
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Aff Chateter
Follow Up Dec 3st
08.00 WIB

• S/ Fever (-), abdominal pain (-) PPV (-)


• O/
Gc cons BP HR RR T
Mdrt CMC 120/70 82 18 36,9

• Abd: Tenderness pain (-) , rebounds tenderness pain (-) defans


muscular (-)
• Gen: I: v/u normal PPV (-)

• A/ Post total Histerectomy and right salphingooforektomy on indication


of uterine myoma – day5
Th/

• Cefixime 2 x 200mg po
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• go home
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