PATIENT 1

Mrs. N, 42 yo, P0A1, Acehnesse, Moslem, Junior high school,

Housewife, Married 1x with Mr. R 45y.o, acehnesse, Moslem, Senior
high school, Enterpreneur.

Cc : Stomach feels enlarged

E : This has been experienced by the patient for last 3 months,
history of stomachache (-). Hiatory of vagina bleeding (-). History of
prolonged menstruation (-). History of vaginal discharge (+), smell(-),
itchy (-). history of weight loss (-). History of decreased appetite (-).
Urinated and defecated normal.
first day of last menstruation : (-)
estimated delivery date : (-)
Gestational age :
ANC :
patients urinate is normal. Patients defecated is normal.
History of Previous Illness : Tyroid, Hidroadenitis supuratif
History of Medication : Euthyrox 100mg
History of Surgery : Thyroidectomy (3/1/2017)
History of chemotherapy : (-)
History of using contraceptive pills : (-)
History of menarche : 13 yo/28 days/duration 7 days/ frekwensi 2-3
doek/days
History of menopause : (-)
Delivery History :
Vital Signs
Sens : Fully Alert Anemic : (-)
BP : 120/80 mmHg Icteric : (-)
Pulse : 85 x/i Cyanosis: (-)
RR : 20 x/i Dypsnoe: (-)
Temp : 36,6°C Edema : (-)

General state : Mild BW : 45 kg

Illness State : Mild BH : 150 cm
Nutritional state : Mild BMI : 18 kg/m2

Generalized Status :
• Head : Inferior palpebra conj anemic (-/-), icteric (-)
• Neck : surgical scar (+), dry, mass (-).
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing (-)/(-), rhales (-)/(-)
• Abdomen : Soepel, peristaltic (+). Solid mass (+) size 10x15 cm,
mobile, bumpy surface, tenderness(-).
• Extremities sup/inf : Within no arbnormalities
Gynecological State

Inspeculo : smooth portio, erotion (-), discharge

(-), bleeding (-).
vaginal examination (VT) : smopoth portio, uterus >BB palpable
solid mass, sized 10x15 cm, uneven
surface, tenderness (-), limp
parametrium, CD not stand out.
Rectal Examination (RT) : (-)
Diagnosis : Ovarian cyst susp. Malignancy + mioma
uteri
Plan :.
USG TAS.

Report to supervisor dr. Hanudse Hartono,

SpOG.K Approved
 USG
May 5th 2019
 USG
May 5th 2019

• Result : Ovarian cyst + mioma uteri

 Laboratorium finding at September 13th, 2019
Hb : 11,3 N : 12-16 gr/dL
Leucocyte : 13.710 N : 4000-11000/uL
Hematocrite : 33 N:36,0-47,0/%
Platelet : 182.000 N:150.000-450.000/uL
At random glucose: 54 N: < 200 mg/dl
BUN :3 N : 10-20 mg/dL
Ureum :6 N: 21-43 mg/dL
Creatinine : 0,49 N: 0,6-1,1 mg/dl
Na : 134 N: 135-155
K : 4,0 N :3,6-5,5
Cl : 103 N: 96-106
APTT : 28,8 C : 33,3s
PT : 13,8 C : 17s
INR : 1,80

Ca 125 : 232,7
IRK : U x M x Ca 125
= 3 x 1 x 232,7
= 698,1
Thank You