PATIENT 1

Mrs. F, 51 yo, P4A0, Bataknesse, Moslem, Senior high school,

Housewife, youngest chils is 8 yo. Married 1x with Mr. A 58 y.o,
bataknesse, Moslem, Senior high school, Enterpreneur.

Cc : urinate (-)
E : This has been experienced by the patient for last 3 days.
History of vagina bleeding (+) for las 4 days. History of prolonged
menstruation (-). History of vaginal discharge (-), smell(-), itchy (-).
history of weight loss (-). History of decreased appetite (-). Patient
was diagnose Ca Cervix std IIIB.
first day of last menstruation : (-)
estimated delivery date : (-)
Gestational age :
ANC :
patients urinate is normal. Patients defecated is normal.
History of Previous Illness : (-)
History of Medication : (-)
History of Surgery : (-)
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 : 161/95 mmHg Icteric : (-)
Pulse : 85 x/i Cyanosis: (-)
RR : 22 x/i Dypsnoe: (-)
Temp : 37°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 (-), mobile, bumpy
surface, tenderness(-).
• Extremities sup/inf : Within no arbnormalities
Gynecological State

Inspeculo : mass wqn seen,

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 : Ca Cervix std IIIB + anemia
Plan :Consult to urologi drpartemen.

Report to supervisor dr. Khairani Sukatendel, M.Ked

(OG), SpOG.K Approved
 Laboratorium finding at November 5th, 2019
Hb : 8,2 N : 12-16 gr/dL
Leucocyte : 8.700 N : 4000-11000/uL
Hematocrite : 24,2 N:36,0-47,0/%
Platelet : 280.000 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
Thank You