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    Bayu Permana
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    This medical record documents a 23-year-old female patient who was referred from gynecology with complaints of an increasingly enlarged abdomen over the past 2 months along with intermittent abdominal pain. A physical examination revealed a mass above the symphysis that was mobile and tender. Ultrasound imaging showed a multilocular ovarian cyst, and laboratory tests including CA-125 were performed, leading to a presumptive diagnosis of ovarian malignancy and recommendation for conservative surgery.

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    Original Title

    SAKDIAH HASIBUAN

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    This medical record documents a 23-year-old female patient who was referred from gynecology with complaints of an increasingly enlarged abdomen over the past 2 months along with intermittent abdominal pain. A physical examination revealed a mass above the symphysis that was mobile and tender. Ultrasound imaging showed a multilocular ovarian cyst, and laboratory tests including CA-125 were performed, leading to a presumptive diagnosis of ovarian malignancy and recommendation for conservative surgery.

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    Download as pptx, pdf, or txt
    10 views9 pages

    Case No

    Uploaded by

    Bayu Permana
    This medical record documents a 23-year-old female patient who was referred from gynecology with complaints of an increasingly enlarged abdomen over the past 2 months along with intermittent abdominal pain. A physical examination revealed a mass above the symphysis that was mobile and tender. Ultrasound imaging showed a multilocular ovarian cyst, and laboratory tests including CA-125 were performed, leading to a presumptive diagnosis of ovarian malignancy and recommendation for conservative surgery.

    Copyright:

    © All Rights Reserved
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    of 9

    Case No

    Nn.Sakdiah H, 23 th, MR 01.08.27.56


    Date Clinical Data Supportive Axamination Diagnose Management
    27/5/ Anamnesis USG : P0H0 + NOK susp -
    2020 •Pasien dikonsulkan dari Ginekologi NOK multilokulare malignancy Conservative
    10.00 •Perut terasa semakin membesar surgery
    sejak 2 bulan yang lalu Labor
    •Nyeri perut (+) hilang timbul Hb/Ht/Leuko/Trombo : -Dr. Andi
    •Keluar darah dari kemaluan (-) 12,4/37/11.590/363.000 Friadi,
    •Keputihan (-), demam (-), trauma (-) Pt/APTT : 11,1/28,6 Sp.OG(K)
    •Tidak ada keluhan BAB Albumin : 3.6
    •BAK lancar SGOT/SGPT : 17/9
    •Riwayat penurunan berat badan Ur/Cr : 17/0,7
    secara drastis disangkal Na/K/Cl : 141/3,6/107
    Ca-125 : 148,08
    AFP: 0.9
    CEA: 0,52
    Clinical Data Supportive examination Diagnosis Management
    27/5/ KU Kes TD HR RR T
    2020 Sdg CMC 110/70 80 17 36,5

    Abdomen :
    I : Tidak tampak membuncit
    Pa : Teraba massa 1 jari diatas simpisis, permukaan rata,
    mobile, nyeri tekan (+)
    Pe : Pekak di atas massa
    Au : bising usus (+) N

    Genitalia :
    I V/U tenang, PPV (-)
    Surat Masuk
    Laboratoriu
    m
    US
    G
    Laporan Operasi
    Foto
    Terimakasih

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