Case no.

Name : Mrs. E
Age : 35 years old
No. MR : 01 00 34 94
Admission date : Jan 16th 2018

A 35 years old patient was admitted to the Gynecology Ward of Dr.

M. Djamil Central General Hospital on Jan, 16th 2017 at 11.00 am
referred from Polyclinic of Dr. M. Djamil Central General Hospital
with diagnosed Uterine myoma
Present Illness History:
• In the last 1 years ago, the patient felt a mass in her abdomen, as size as a
adult head.
• Abdominal pain (+)
• Bleeding from vagina (-)
• History of Post coital bleeding , dispareunia (-)
• History of body weigh decreasing extremely (-)
• History of fever, trauma, and fluor albus was (-)
• The patient had 4 child, the youngest was 3 years old, spontaneous delivery
• Menstruation History : menarche at 13 years old, regular cycle once at
28day, every month which last for about 4-5 days each cycle with the
amount of 2-3 times pad change/day without menstrual pain
• Urination and defecation was normal
Previous Illness History
• There was no previous history of heart, liver, kidney, hypertension and
allergy.
• Patient had Lung tuberculosis finised treatment.
Family Illness History
• There was no history of hereditary disease, contagious and physiological
illness in the family
History of formal education : Senior high school
History of Occupation : house wife
History of contraception : (-)
History of Habit : Smoke (-), Alcohol (-),
Drugs (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 120/70 78 26 36,8

BW : 60 kg
BH : 160 cm
BMI : 23,21 kg/m2
UAC : 24 cm

Eyes Conjunctiva was anemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H normal
Lung : deacreased of left breating sound
Abdoment OR
Genitalia OR
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
 Gynecologic record

Abdomen
I : Seems enlargement due to 5 mount pregnancy
Pa : Mass palpated 2 finger above umbilikal, slippery
surface, not fixed
Pe : Tympani
Au : Peristaltic sound was normal

Genitalia
I : V/U normal, bleeding from vagina (-)
fluksus(-)
• Inspeculo :
• Vagina : Tumor (-), Laseration (-), Fluksus (-)
• Portio : MP, Size as adult toe, Tumor (-), Laseration (-), OUE was closed, Fluksus
(-), Sondase 8cm

• VT bimanual :
• Vagina : tumor (-) laseration (-) fluxus (-)
• Portio : MP, size as adult toe, tumor(-) laseration(-) OUE was closed
• CUT : size equal to adult head
• A/P : bottom pole was not palpable
• CD : not protude
Laboratory
Parameter Result Normal Range
Haemoglobine 10,3 gr/dl 9,5 – 15

Haematocryte 39 % 28 – 40

Leucocyte 5,1. 103/mm3 5,9 - 16,9.103

Trombocyte 370.103/mm3 146 - 429.103

HbsAg Non Reactive Non Reactive

APTT 33,8 22.6 – 35.0

PT 11,1 9.6 – 12.9

 Parameter Result Normal Value Unit

Calsium - 8.1-10.4 u/l

Potassium 4,1 3.5-5.1 mmol/L
Sodium 138 139-145 mmol/L
Random Blood Glucose 149 < 200.00 mg/dL
Total Protein 8,2 6.0-7.8 g/dL
Albumin 4,2 3.5-5.2 g/dL
Globulin 4,0 1.3-2.7 g/dL
SGOT 30 0.00-31.00 u/L
SGPT 16 0.00-34.00 u/L
Ureum 15 15.00-40.00 mg/dL
Creatinine 0,7 0.60-1.20 mg/dL
USG
• Uterus size and shape bigger
than normal
• A large mass
hiperhipoechoic with shape
border, size over the
monitor screen as 4 finger
above umbilical, feeding
arteri (+)
• Both ovarium was in normal
limit
• Impression : Uterine myoma
 Ro Thoraks
Left lung tuberculosis ( Left
destroy lung )
Pulmologist Consult

6 mouth BTA examition after lung tuberculosis treatment jan 16 2018

1. Negative
2. Negative
Micobaterium Tb not ditected

A/ Finised treatment of Lung tuberculosis

Diagnosis
• P4L4 + Uterine myoma + Finised treatment of lung tuberculosis

Management
•Control GA, VS, PPV
•Informed consent
•Consult to anesthesiologist
•Report to operation room
•Cross match PRC II Unit

Plan
•Laparotomy
Jan, 31th 2018 at 10.00 am
• Laparotomy was performed,
uterus size bigger than
normal, size as adult head.
There was intra mural
myoma uterine. Plan:
Supravaginal hysterectomi
• Supravagial Hysterectomi
was pernom

Diagnosis
• Post Supravaginal
Hysterectomy oi Intra mural
myoma uterine

Plan
monitoring post operation
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