GYNAECOLOGY WARD REPORT

December 21th 2013

Consultant :
Dr. Syamsul A.Nst, Sp.OG (K)
Resident :
dr. Daniel H. Simbolon/dr.
Trisna/dr. Tri Sugeng Hariadi/dr.
Dalmy Iskandar/dr. Nutricia

Reporting
1. Post hysterectomy + ekstipation d/t
miom geburt
2. Acites + tumor adnexa
3. DIC + anemia + myoma uterine

Procedure

N
o

Transfusion
2
Bag PRC
BNO IVP
Hiisterecto
my
+extirpatio
n of
Mass After
good
conditi
on

1 Mrs. M, 47 yo, P4A0

Aspiration
Acites,
cytology
acites
Albumin
Subtitution
Transfusion

Case

Result
Operation was performed on
20th december 2013

Work Diagnoses :
Myoma cervix
Differential diagnoses :
Myoma geburt
2 Mrs. Murhayatik, 52 y.0,
P3A1
Dx : acites + tumor
adnexa
Cytology : inflammation
smear
3 Alb : 2,7
Mrs. N, 22 yo, P1A0
Dx : DIC + Anemia +
myoma uterine

Tapping

Check hb 6 hours post

transfusion

THANK YOU

1. Mida, 47 yo, P4A0

Clinical Data

Supportive
examination

Diagnosi
s

Managem
ent

Cc: history of Bleeding

from vagina
Experienced by the patient
since 3 days, volume 2-3
times change tampoon per
day, red in colour. Mass at
vulva since 1 year at first
small and grow bigger with
time. Fluor albus (+),
bleeding during sexual
intercourse (+), Lose of
body weight history (-),
lose of appetite (-),
Urination (+) Normal,
Defecation (+) normal. The
patient is delivered from
hospital Siantar with
diagnoses vaginal bleeding
et cause myoma geburt.
Previous medical history :
hypertension (+), asthma

hb/ht/leu/tr :
12,7/30,1/15600/1
75000( post Trans
Fusion 6 bag PRC)
Blood Glucose :
236
mg/dl
SGOT/SGPT
:
14/16
IU
Alkaline phos 48
U/I, Tot.bil 0,49
mg/ml,
Bil.direct0,13
mg/ml, Ureum 30
mg/dl, Creatinine
0,63 mg/dl, Na
140 mmol, K 4,6
mmol, Cl
108mmol.

Post
hystereco
my +
ekstirpatiio
n d/t Miom
geburt

BNO IVP :
hydronefrosi
s+
hydrouretra
Histerectom
y +
Extirpation
of mass
after good
condition

2. mida, 47yo, P4A0

Clinical Data

Supportive
examination

Diagnosi
s

Managem
ent

Vital sign : Cons : CM, BP

:
120/70
mmhg
HR:
80x/min, RR 20x/min, Temp
36,5 C
Anemia (+)
Icteryc (-)
Cyanosis
(-)
Dypsnoe
(-)
Edem (-)

ECG : sinus
takikardi
Chest x ray :
normal

Post
hystereco
my +
ekstirpatiio
n d/t Miom
geburt

Operation
was perform
on 20th
december
2013

Gynaecological
Examination
Inspection : solid mass
outside the vulva with stalk
originate from the
posterior part of the cervix
15x15x14 cm, solid,
blood (+), surface
laceration (+), ulcus (+),
necrotic tissue (+), the size
of tumor stalk about 2 cm.

Hb post op : 12,5
g/dl

2. murhayatik, 52 yo, P3A1

Clinical Data

Supportive
examination

Diagnosi
s

Managem
ent

CC : abominal enlarge
HPI : Patient complaint of
abominal enlarge since 4
years ago, initially small,
and then gradually
enlargedhistory of vaginal
bleeding(-)
History of leucorhea(-),
history loss of weight,
history loss of appetite,
patient has been
diagnosed with ca ovarium
by O&G in other hospital.
LMP : menopause since 10
years ago
HPD : DM,HT,asma,Allergi
(-)
HFD : DM (-),HT(-)
Menstrual history :
menarche 14 yo, regular
cycle,every 27-30

Hb/ht/leu/plt :
11,0/35,8/6300/
374000
Glu ad random :
96
Ca 125 : 14,3
CEA : 12,5
Abdominal ct scan
: left adnexa
tumor + left
hidronefrosis+
massive acites
Albumin : 2,1

Acites+
tumor
adnexa

Aspiration
acites 5
liters

Albumin post
substituion : 2,7

tapping

3. noviyanti, 22 yo, P1A0

Clinical Data

Supportive
examination

:
history of vaginal Hb/ht/leu/plt :
bleeding
6,9/35,8/6300/
This has been experienced 78000
since at 1 month ago, and
getting worst this last 1
week. The volume was 3
temponade / daily. History
of mass palpable (+) has
been experienced since 1
week
ago.
History
of
weight loss (-), History of
lost appetite ( +), History
of Leucorhea ( -), History of
sexual bleeding intercourse
(-). Normal micturition and
defecation.
Previous medical history: Previous medication
history : History of menstruation:

Diagnosi
s

Managem
ent

DIC +
Anemia +
myoma
uterine

Transfusion
FFP 5 bag
Transfusion
PRC 2 bag
Check CA
125
USG
confimation
supervisor
after good
condition

3. noviyanti, 22 yo, P1A0

Clinical Data

Supportive
examination

Diagnosi
s

Managem
ent

: Vital sign: BP 100/60

mmHg, HR 98x, RR 24x,
Temp 36,7
Gynaecology st : abdomen
soepel, solid mass palpable
with upper pole 2 fingers
above umbilicus, lower
pole in the level of
simphysis, mobile, flat
surface, pressure pain (-)
VE :cervix pushed to
anterior, UT AF, uterus
bigger than normal size,
solid mass was palpable 2
finger upper pole above
umbilicus, lower pole in the
level of simphysis mobile,
flat surface, pressure pain
(-), right/ left
parametrium : flaccid,

Inspeculo : blood
was
flown
from
introitus
vagina
source
from
OUE,cleaned,
conclusion : was
flown.
Portio was pushed
to
anterior,
difficult
to
assess.
USG TAS :urinary
bladder full ,UT AF
7,2 x 3,1 x 4,6cm,
Seen hyperechoic
homogenous,sized

DIC +
Anemia +
myoma
uterine +

Transfusion
PRC 4bag
Check CA
125
USG
confimation
supervisor
after good
condition