Case Conference

October 24th, 2023

Ms. M, 47 y.o, D020597

Department of Obstetric Gynecology
Faculty of Medicine, Diponegoro University
Kariadi Hospital, Semarang
2023
 Clinical History
Chief Complaint: Distended abdomen
History of Present Illness:
The patient came as a referral from RSUD Sunan Kalijaga Hospital. The patient came with a chief
complaint of distended abdomen since the last 1 to 2 months. The patient's accompanying complaint was
an menstrual pain. Complaint of blood discharge from the birth canal (-). Vaginal discharge (-). Micturition
also felt incomplete. The patient was suspected of ovary tumour. The patient was referred to Dr. Kariadi
Central General Hospital for further treatment. Decreased appetite was denied. Currently, complaints of
defecation and urination are denied.

• Menstrual history : June 2023

• Marriage history : 1x – 27 years
• Obstetric history : P2A0 – youngest children is 23 years old
• Contraceptive history : Injection, pills
• Past medical history : Hypertension (-), Diabetes mellitus (-), heart disease (-) allergy (-)
• Family history : Hypertension (-), Diabetes mellitus (-), heart disease (-) allergy (-)
• Prior surgery : Denied
 General Status
General condition : Compos mentis

Vital sign :
• BP : 150/93 mmHg
• RR : 20 bpm
• HR : 95 bpm
• T : 36,5 C

Height : 158 cm Weight : 65 kg BMI: 26.0 kg/m2 (Overweight)

Eye : Pale conjunctiva (-/-), icteric sclera (-/-)

Neck : Palpable mass (-), trachea deviation (-), neck stiffness (-)
 General Status
Thorax
Abdomen
Heart I : Scar (-)
I : Apex beat (-) A : Bowel sound (+) normal
Pa : Palpable apex beat on 5th ICS on the left midclavicular Pa : Distended as big a 6 months pregnancy
line Pe : Shifting dullness (-), flank dullness (+)
Pe : Normal heart configuration Extremities:
A : Regular 1st & 2nd heart sound, murmur (-), gallop (-) CRT < 2 s
Edema
Lung - -
I : Symmetrical chest wall movement - -
Pa : Similar bilateral vocal fremitus
Pe : Sonor at both lungs
A : Vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
 Gynecological Status
Inspection : Fluxus (-), fluor (-)
Baby’s head
Vulva / Urethra : No abnormalities
Cavum Uteri: Chicken’s egg sized
Adnexa / Parametrium : Palpable mass as
big as 8 months pregnancy

Rectal Toucher
Anal sphincter tone : Normal
Anal mucosa : smooth
Ampula Recti : Not collapsed
Palpable mass as big as baby’s head, tends
to origin ated from uterus, mobile
Patient Profile
 Laboratory
Hematology (28/8/2023)
Hemoglobin 11.6 g/dL
WBC 6.3 10^3/uL
HBsAg Negative -
Thrombocyte 303 10^3/uL Ca-125 Normal -
Blood Glucose - mg/dL
SGOT 19 U/L
Coagulation
SGPT 12 U/L PPT 12.0 (11.4) -
Ureum 25 mg/dL PTTK 27.8 (25.9) -
Creatinine 0.8 mg/dL
Sodium (Natrium) 141 mmol/L
Potassium 4.0 mmol/L
(Kalium)
Chloride 101 mmol/L
Chest X-Ray
(9/2023)

• CONCLUSION
• Cardiomegaly (LV): Apex moved laterocaudally
• No sign of metastaes or other abnormalities on both
lung fields and visualized bones
Pap Smear
(28/8/2023)

• CONCLUSION
• Negative for intraepithelial lesion or malignancy (NILM)
 HOGI Score
Weight loss :0
Solid part :0
Ascites :0
CA 125 (5,01) :0
Ri (< 0,40) :0
Total :0

RMI 3 score : 1 x 1 x 5,01= 5,01

 Diagnosis
• P2A0 48 y.o.
• Cystic ovarian neoplasma (NOK)
 Procedure

• Pro Salphingoophorectomy Unilateral + Frozen

Section
Thank You