Mrs.

EKA/30/UA
Anamnase
CC :

Physical Examination and supportive exam

Menstrual :

Diagnosis and
Planning
Diagnosis:

Marrital : 1 times, 29 years

Obstetric :

Previous illness:
-

Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : 3 fingers below proc. xyphoideus (29 cm), right back, cephalic,
U 5/5, his (-) DJJ 127 x/m, EFW 2480 gr
VT : Portio soft, posterior, eff 0 %, cephalic, fetal membran and lower part
can not be asessed
USG Confirmation :
Laboratory Finding:
Hb: 13,6; Leuko: 11900; Ht: 42; Trombo: 265000; DC: 0/2/78/16/4; PT: 11,3; APTT: 32,0;
Bil. Direct 0,15; Bil. Indirect: 0,12; SGOT: 12; SGPT: 9; Alb: 4,0; GDS: 111; Ur: 14;
Kreatinin : 0,44; Na: 139; Ca: 9,1; K: 4,1

Planning :
LSCS
DPJD : NS

Mrs. NUR/43/UA
Anamnase

Physical Examination and supportive exam

CC : Labial
mass
Patient referred
from OBG/Y to
RSMH with
atherom in labia.
Since 3 years ago,
Patient
complained this
symptom and has
been operated (no
PA result). Since 3
months post
operation, the
mass came back
again, but patient
did not control.
Since 2 months
ago, patient
complained pain
in them mass.
Patient came to
OBG/Y and
referred to RSMH.
History of vaginal
bleeding (-),
vaginal discharge

Menstrual : Menarche 14 years old, reguler, 28 days cycle for 2-4 days,
last menstrual date 21 october 2016
Marrital : 1 times, 29 years
Obstetric : P1A0
Prior operation :
-Atherom cyst incision 3 years ago
-Cesarean section in 2000
Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not palpated,
Tenderness (-), mass, Free fluid sign (-) operation scar (-) not inflammed
Vaginal Speculum exam : Portio non livide, no cervical opening, fluor (-),
fluxus (-), E/L/P (-)
vaginal toucher: Portio ellastic, no cervical opening, CUT in normal line,
Right and Left AP no
USG Confirmation :
Laboratory Finding:
Hb: 11,6; Leuko: 6000; Ht: 36; Trombo: 262000; DC: 0/2/47/47/4; BT: 2; CT: 9; Bil.
Direct 0,19; Bil. Indirect: 0,24; SGOT: 15; SGPT: 12; Alb: 4,8; GDS: 99; Ur: 34;
Kreatinin : 0,82; Na: 147; Ca: 9,5; K: 3,5

Diagnosis and
Planning
Diagnosis:
Atherom of labia
Planning :
Cyst insicion
DPJD : AF

Mrs.ROS/62/RA
Anamnase

Physical Examination and supportive exam

CC : Vaginal
Bleeding
Since 2 months
before came to
hospital, patient
complained
vaginal bleeding.
History of
abdominal
pain(+), vaginal
discharge (-), post
coital bleeding (-),
post coital pain (-),
bladder problem
(+), defecation
problem (-).
Patient went to
OBG/Y and
conducted biopsy
with PA resukts
(30-092016)/2016212 :
squamous cell
carcinoma non
ceratinazed in
cervix, well
differentiated,

Menstrual : Menopause since 2 years ago

Marrital : 1 times, 40 years
Obstetric : P7A0
Prior operation :
- Biopsy in 2016
Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not palpated,
Tenderness (-), mass, Free fluid sign (-)
Vaginal Speculum exam : Portio irreguler, mass (+) exophylic, fluor (-),
fluxus (-), E/L/P (-)
vaginal toucher Portio irreguler, mass (+) exophylic, Right and Left AP no
tense, no protution in cavum of Douglas
Rectal toucher : anal sphincter tone normal, rectal ampulla empty,
intralumen mucuos (-), Right and Left CFS 50%.
USG Confirmation :
Laboratory Finding:
Hb: 12,5; Leuko: 8300; Ht: 37; Trombo: 148000; DC: 0/1/52/39/8; PT: 11,5; APTT: 24,9;
SGOT: 18; SGPT: 21; Alb: 4,8; GDS: 99; Ur: 34; Kreatinin : 0,82; Na: 147; Ca: 9,5; K: 3,5

Diagnosis and
Planning
Diagnosis:
Ca cervix stage IIB
Planning :
Radical Hysterectomy
DPJD : IS

Ms. REC/29/UA
Anamnase

CC : Abdominal
enlargment
Since 3 years ago,
patient complained
abdominal
enlargment.
Tenderness (-) , back
pain (+), History of
vaginal bleeding (-),
vaginal discharge (-),
weight loss (+) in last
1year, loss of apetite
(+). Patient went to
Khadijah hospital,
and reffered to
RSMH.
Previous illness:
-

Physical Examination and

supportive exam
Menstrual : Menarche 13 years old, regular, 28 cycle for 7 days,
last menstrual date 16 october 2016
Marrital : not married
Obstetric : Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : convex, no tense, simetric, Fundal of not palpated,
Tenderness (-), mass (+) size 30x25 cm, solid, Free fluid sign (-)
Vaginal Speculum exam and vaginal toucher are not done
USG Confirmation :
-Laboratory Finding :
Hb: 8,3; Leuko: 5500; Ht: 31; Trombo: 228000; DC: 0/12/56/24/8; PT:
13,5; APTT: 31,44; Bil. Total: 1,06; SGOT: 32; SGPT: 8; Alb: 4,2; GDS:
98; Ur: 14; Kreat: 0,43; Na: 141; K:3,8; Ca: 8,7; AFP : 1,04; CEA:
1,79; CA 125 : 21,40

Diagnosis and
Planning
Diagnosis:

NOP dekstra
Planning :
Laparatomy VC
DPJD : AN

Mrs.MAR/35/RA
Anamnase

Physical Examination and supportive exam

CC : Vaginal
Bleeding
Since 6 months,
patient
complained
vaginal bleeding.
History of vaginal
dicharge (+) for
more than 1 year.
Patient came to
OBG/Y in
Prabumulih and
conducted cervix
Biopsy with the
results (PA
257/DH/2016) :
atypical
endometrial
hyperplasia
(EIN)high
suspectibility of
malignancy.
Ppatient controlled
to Hermina
Hospital with dr.
Amirah Novalian,
Sp.OG(K) and

Menstrual : Irreguler since last 10 years

Marrital : 1 times, 10 years
Obstetric : P0A0
Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not palpated,
Tenderness (-), mass, Free fluid sign (-)
Vaginal Speculum exam : Portio non livide, no cervical opening, fluor (+),
fluxus (-), E/L/P (-), vaginal toucher : Portio ellastic, no cervical opening,
Right and Left AP no tense, no protution in cavum of Douglas
Rectal toucher : anal sphincter tone normal, rectal ampulla empty,
intralumen mucuos (-)
USG Confirmation :
-Uterus AF shae and size are normal , endometrial line (+) thickened 0,5
cm with vascularisation that limited to uterine wall (RI 0,275), basale
stratum reguler
-Endocervix andp ortio normal
-Right ovarium is normal size 3,43x2,13x2,51 cm, volume 9.66 cm2
-Left ovarium > normal size 3,08x2,46x2,79 cm, volume 11,04 cm2
-Results : Endometrial thickening with vascular appearance, malignancy
can not be ruled out
Laboratory Finding:
-

Diagnosis and
Planning
Diagnosis:
Atypical Endometrial
Hyperplasia
Planning
Hysteroscopy
DPJD : AM

Mrs. REN/27/RA
Anamnase
CC : Prolonged Menstruation
Patient complain about having prolonged
menstruation in the form of brown red
spot since February, with 1-2 days no
bleeding period. Patient then came to
OBG/Y and was given a drug, but she
forgot the name. Bleeding stopped within
10 days, and continue again. Patient
then went to RSMH.
Previous illness:
-

Physical Examination and

supportive exam
Menstrual : Menarche 12 years old,
irregular, 10 days, last menstrual date :
May 2016
Marrital : 1x, 2 years
Obstetric : P0A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 85x/m, RR:
20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric,
Fundal
of
uterine
non
palpable,
Tenderness (-), mass (-), Free fluid sign
(-)
Vaginal Speculum exam :Slick Portio, no
cervical opening, fluor (-), fluxus (-), E/L/P
(-)
Vaginal toucher : Portio ellastic, no
cervical opening, CUT in normal line,
Right AP and Left AP no tense, no
protrusion of cavum Douglas
USG Confirmation :
-

Diagnosis and Planning

Diagnosis:

PCOS + 2,5 years primary

infertil
Planning :
HDLO
DPJD : AW

Thank you