PATIENT 1

Ms. R, 19 yo, Virgo, Javanese, Moslem. The patient was admitted to USU Hospital on October 4 th 2022 at
09.16 am with:

Cc : Period cramps
E : This has been experienced since 2nd grade of senior high school, getting worse in this past 3
months. History of abdominal enlargement (+) this past year. History of palpable mass (+) this past year
and getting bigger. Irregular menstruation has been experienced this past month. Frequency of changing
pad 2-3 pad/day. Micturition and Defecation within normal limit. This patient was referred from other
hospital with diagnosis susp. Dermoid cyst.
History of Previous Illness :-
History of Medication :-
History of Surgery :-
History of Contraception :-
History of Radiology :-
History of Menstruation : Menarche at 12 yo, regular, cycle 28-30 days,
changing pads 2-3x/day, dysmenorrhea (+) ,
LMP : September 1st 2022
 Score
0

NLR:
1.90

EWS Score: 1
MEOWS

Total Score : 1
 X-Ray Thorax
September 16th 2022

Conclusion: Cor and Pulmo within normal limit

Vital Signs
Cons: Fully alert Anemic : (-)
BP : 105/80 mmHg Icteric : (-)
Pulse : 81 x/min Cyanosis : (-)
RR : 20 x/min Dypsnoe : (-)
Temp : 36.7 C Edema : (-)
SpO2 : 99% via room air

General state : Moderate BW : kg

Nutritional state : Obese Height : cm
Illness State : Moderate BMI : kg/m2

Generalized Status
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : Vesiculer (+/+)
Additional sound : wheezing(-)/(-), rhales (-)/(-)
• Extremities : oedema pretibial (-/-)
• Lymph nodes : no enlargement
Localized State
Abdomen : laxed, peristaltic (+), palpable cystic mass, smooth surface, with upper pole 3 fingers below
processus xyphoideus, and lower pole as level as symphysis, mobile, pain (-)
Vaginal Bleeding : (+)

Gynecological State
IRT : Tight sphincter ani, smooth mucose, ampulla recti was empty. Uterus anteflexion, normal sized,
palpable cystic mass, smooth surface, mobile. Upper pole 3 fingers below processus xyphoideus, lower pole
as level as symphysis. Unknown origin, right and left parametrium were laxed, cavum douglas was not
protruded.
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022
 USG TAS
September, 26th 2022

- Bladder was filled

- UT sized 5.4 x 3.8 x 4.3 cm
- E-Line thickness 9.4 mm
- Right and Left Ovarium was difficult to assess
- Seen hypo-hyperechoic appearance cannot be measured by caliper, septa (-), papil (-),
vascularization (-). Unknown origin.
- Free fluid (-)

Conclusion: Dermoid ovarian cyst dd susp. malignancy

 • Hb : 13.9 N: 12-14 gr/dL
• Leukocyte : 9,240 N: 4.000-11.000/uL
• Hematocrite : 42.1 N: 36,0-42,0/%
• Platelet : 326,000 N: 150.000-400.000/uL
• MCV : 88.10 N: 82 – 92 fL
• MCH : 29.10 N: 27 – 33.7 pg
• MCHC : 33.00 N: 32 – 36 %
• Neutrofil Abs : 5.57 N: 2,7 - 6,5 10^3/L
• Lymphocyte Abs : 2.84 N: 1,5-3,7 10^3/L
Laboratory Findings •
•
Glucose ad random
PT
:
:
96
15.20
N: <200 mg/dL
C: 14.50 seconds
October, 4th 2022 • INR : 1.05
• APTT : 40.50 C: 35.90 seconds
• TT : 15.20 C: 20.90 secondsl/L
• Ureum : 20.40 N: <50 mg/dL
• Creatinine : 0.67 N: 0.6 – 1.3 mg/dL
• HbsAg : Non Reactive N: Non Reactive
• Anti HIV : Non Reactive N: Non Reactive
• Rapid Antigen Covid-19 : Non reactive N: Non Reactive
Diagnosis : AUB-P + AUB-M + Obesity grade II

Therapy:
• IVFD RL 20 dpm
• Inj transamine 500 mg/8 hr

Planning :
• Laparatomy Surgical Staging-fertility sparing on October 5th 2022
• Consult to Anesthesiology Department

Reported to supervisor on duty dr. M. Rizki Yaznil, M.Ked(OG), Sp.O.G, Subsp. Onk Approved
THANK YOU