CHAPTER II

CASE

I. Identity
Name : Mrs. Elita
Age : 31 years old
Occupation : Housewife
Address : Kp Cigarung 01/09
Education : Senior high school
Marital Status : Married
Religion : Moslem
Date of Admission : August 8th 2016

II. History
A. Chief Complaint

Lower abdominal pain

B. History of Present Illness

Patient complains about 4 months pregnancy with pain and a lump in lower abdomen
since a week ago. Patient also complaints hypomenorrhea with dysmenorrhea since a
year ago before the patient getting pregnant.

C. History of Past Illness

History of hypertension : Denied
History of diabetes mellitus : Denied
History of allergy : Denied
History of epilepsy : Denied
History of urinary tract/kidney disease : Denied
History of trauma : Denied
History of surgery : Denied

D. Family History
Patient didnt have family history of tumor and malignancy

E. History of Menstruation
Menarche : 13 years old

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 Menstrual Cycle : 27 days, regular with duration of 6 days, changed 2 pads a
day ( 60 cc)
Dysmenorrhea : (-)
Last menstrual : 4 months ago, with duration of 7 days

F. Contraception History
Patient using contraception implant for 3 years before her pregnancy.

G. Marital History
Patient is married for 10 years with her first husband.

H. Obstretric History
Labor Birth Breast
No Years Gestational Age Sex
History Weight Feeding
1 1997 9 month Spontaneous Male 2900 1 year
grams

III. PHYSICAL EXAMINATION

General condition : Moderate

Level of consciousness : Composmentis
Vital Sign
Blood Pressure : 110/70 mmHg
Heart Rate : 79 beats per minute
Respiratory rate : 18 times per minute
Temperature : 36,1C
Height : 154 cms
Weight : 55 kgs

A. General Examination
Eyes : Anemi conjunctiva -/-; Icteric sclera -/-
Mouth : Wet oral mucosal membrane
Thorax
Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
Lung : Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-, crackles -/-
Mamae : Aerola hyperpigmentation, nipple retraction -/-, breast milk -/-
Abdomen
Inspectio : Convex on suprapubic, lump on regio illiaca dextra
Palpation : Tenderness (+) on suprapubic, uterus with tender and

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 solid consistency and enlargement (2 fingers below
umbilicalis), surface is enlarged uniform in a single
fibroid.

Ovarian Cyst
Gravida 15-16
Percussion : Dull on suprapubic weeks
Auscultation : Bowel sounds (+)
Ekstremitas : Edema , CRT < 2 seconds
- -
- -
B. Status Obstetrikus
Fundus uteri : 3 fingers from umbilical
Fetal heart rate : 140 times per minute
Uterus contraction : (-)
C. Gynecologic Examination
Inspection
Vulva : Within normal limits, mass (-), ulcer (-), hyperemia (-)
Vagina : Within normal limits, mass (-), ulcer (-), hyperemia (-)
Inspeculo
Vagina : Erotion (-), bleeding (-), mass (-), inflammation (-)
Portio : Erotion (-), fluxes (-), fluor albus (-), bleeding (-), mass (-),
inflammation (-)
VT Bimanual
Vulva : Pain (-), Mass (-)
Vagina : Pain (-), Mass (-)
Portio : Pain (-), Mass (-)
Uteri corpus : Uteri in gravida 15-16 weeks
Adnexal : Lump in right ovary the size of an egg

IV. Laboratory Examination

Type Result Unit Normal Value
HEMATOLOGY
Hemoglobin * 7.4 g/dL 1214
Leukocyte * 24,900 /L 4,00010,000
Hematocrit * 23 % 3747
Eritrocyte * 3.7 /L 3.85.2
Platelets * 338,000 /L 150,000450,000
Erytrocytes Index
MCV * 62 fL 80100
MCH * 20 pg 2634

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 MCHC 33 g/dL 3236
Imunoserologi
HIV Kualitatif Non reactive Non reactive
Kidney Function
Colour Yellow Yellow
Clarity Turbid Clear
pH 5.0 4.68.0
Specific gravity 1.020 1.0051.03
Leukocyte Negative cell/L Negative
Nitrit Negative Negative
Protein Negative cell/dL Negative
Glucose Negative mg/dL Negative
Ketones Negative mg/dL Negative
Urobilirubin Normal mg/dL <1
Bilirubin Negative Negative
Eritrocyte Negative cell/dL Negative
Urinalysis
Leukocyte 8-12 /hpf <6
Eritrocyte 3-6 /hpf <3
Epithelial cells Positive (+) /lpf 115
Casts Negative /hpf Negative
Crystals Negative /hpf Negative
Bacteria Negative /lpf Negative
Pregnancy Positive

V. Imaging
Transabdominal sonography (TAS) August 9th 2016: found an unilateral cyst in the right
ovary with the diameter of 3.5 x 2.6 cm

VI. Resume
G2P1A0 31 years old on 4 month pregnancy came with chief complaint of pain in
the lower abdomen since a week ago. Patient also complaints hypomenorrhea with
dysmenorrhea since a year ago before the patient getting pregnant.
On physical examination, blood pressure was 110/70 mmHg, heart rate was 79 bpm,
respiration rate was 18 times per minute, and temperature was 36,1 C. Palpated mass in
regio iliaca dextra with size 3-4 cms, flat surface, cystic consistency and mobile with no pain
if moved. Laboratory test showed 7,1 g/dL hemoglobin.

VII. Differential Diagnosis

- Ovarian cyst

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 - Torsion ovarian cyst
- Endometriosis cyst
- Malignancy suspicion

VIII. Working Diagnosis

G2P1A0 31 years old gravida 15-16 weeks with ovarian cyst

IX. Planning
Conservative treatment
Premaston 3x1 PO
Dextrose 5% infuse
Asamefenamat 3x1 PO
Transabdominal sonography (TAS)

X. Follow Up
Date Subjective Objective Assessment Planning
August 8th Pain in the BP: 100/60 G2P1A0 31 - Observe the vital
HR: 83 bpm
2016 right lower years old signs
RR: 21 times/min
12pm - Premaston 3x1
abdomen Temp: 37,1 gravida 15-16
- Dextrose 5%
Hb: 7,1
weeks with - Asamefenamat 3x1
- PRC Blood
ovarian cyst
transfusion
August 9th Pain in the BP: 90/60 mmHg G2P1A0 31 - Observe the vital
2016 right lower HR: 85 bpm years old signs
07am - Premaston 3x1
abdomen RR: 20 times/min gravida 15-16
- Dextrose 5%
Temp: 37,5 weeks with - Asamefenamat 3x1
- Blood transfusion
ovarian cyst
- Transabdominal
Sonography
August 10th Pain in the BP: 100/60 mmHg G2P1A0 31 - Observe the vital
2016 right lower HR:78 bpm years old signs
07am - Premaston 3x1
abdomen RR: 18 times/min gravida 15-16
- Dextrose 5%
minimal Temp: 35,8 weeks with
Hb: 8,9 g/dL
ovarian cyst

XI. Prognosis
Quo ad vitam : Bonam
Quo ad functionam : Bonam

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 Quo ad sanationam : Bonam