Case No.

Mrs. Arina S. 50 yo. MR 00 92 46 53. SM

Tanggal Data Klinis Pemeriksan penunjang Diagnosa Tindakan
4/2/2021 Anamesa Laboratorium 13-1-2021 Suspected Ovarian Tumor Surgical staging
11.00 WIB • Abdominal pain (+) since 2 moths ago Hb: 12,2
• enlargement of abdomen since 2 moths ago Leu: 10.540 - Dr. dr. Syamel
• Vaginal bleeding (-) Tromb: 605.000 Muhammad,
• dispareunia (-), post coital bleeding (-) Ht: 36 SpOG (K)
• weight loss (+) 3 kg in the last 1 month Hitung jenis : 0/1/6/61/24/4/mielosit 2%
• urination and defecation in normal limit PT : 10,2
• Marriage history : once, 2 children, 20 yo APTT : 23,4
• History of DM since 2 years ago and routinely taken
Total prot: 8.1
medication : Glimepirid 2x1 mg, and metformin 2x500 mg
Alb: 4,3
glob: 3,2
Physical examination Bil Tot: 0,3
GA Con BP HR RR T Bil Direk: 0.1
Sdg CMC 130/80 82 20 37 Bil Indirek: 0.2
SGOT: 18
Abdomen : SGPT: 27
I : seem enlarged, cicatrix (-) Ur: 19
Pa : mass palpable 2 fingers above pubis, smooth Cre: 0.7
surface, mobile,terderness (-), rebound tenderness GDS: 380
(-), DM (-) Na: 135
K: 4,4
Genitalia : V/U normal, PPV (-) CL: 103
Inspekulo HBsAg NR
vagina : tumor (-), laceration (-), fluxsus (-) HIV NR
portio : MP, tumor (-), laceration (-), OUE closed Ca-125 : 41,9

VT Bimanual Pelvic Ultrasound : suspected ovarian tumor

Vagina : tumor (-)
Portio : MP, 3 x 2 cm, tumor (-), laceration (-) Chest X-R: Heart and Lung within normal Limit
CUT : Cannot be determined
AP : the lower part of tumor was palpable at right CT-Scan : Right ovarian cyst
adnexal
CD : not protruded
Admission Letter
Laboratorium
Consult result
Consult Result
USG
Ro thoraks
CT-Scan
CT-Scan
Operation report
Thank you