Myoma Geburt Extirpation

+ Diagnostic Curretage

Name
: Mrs. Y
Age
: 51 years old
No. MR
: 889503
Admission date: December, 2nd 2014

A 51 years old patient was admitted to the

Gynecology Ward of Dr. M. Djamil Central General
Hospital on December, 2nd 2014 at 5.00 pm referred
from Polyclinic of Dr. M. Djamil Central General
Hospital with diagnosed AUB due to myoma geburt

+ mild Anemia

Present Illness History:

Patient had chief complaint bleeding from vagina since 1
month ago, wetting 2-3 piece of underwear per day, dark
red colored, without pain. Now, bleeding from vagina (+)
Patient didnt complaint about having a mass in her
stomach.
History of Post coital bleeding , dispareunia (-).
History of body weigh decreasing extremely (-)
Patient had 2 children and the smallest child was on 24
years old.
History of fever, trauma, and fluor albus was (-)
Patient wasnt got her cycle since 15 years ago, due to
hormonal injection contraception every 3 month, last
injection in August 2014.
Menstruation History : menarche at 12 years old, irregular
cycle, every month which last for about 4-5 days each cycle
with the amount of 2-3 times pad change/day without
menstrual pain

Previous Illness History:

There was no previous history of heart, lung, liver, kidney,
hypertension and allergy.
Family Illness History:
There was no history of hereditary disease, contagious and
physiological illness in the family
History of formal education : Elementary School
History of Occupation
: Farmer
History of contraception
: hormonal injection contraception
every 3 month, last injection in August 2014.
History of Habit
: Smoke (-), Alcohol (-), Drugs (-)

Physical Examination :

GA
Mdt

Cons BP
HR
CMC 130/8 96
0

RR
20

T
36,8

BW
: 60 kg
BH : 160 cm
BMI : 23,21 kg/m2
UAC: 24 cm
Eyes
Neck
Chest
Abdoment
Genitalia
Extremity

Conjunctiva was anemic, Sclera wasnt icteric

JVP 5-2 cmH2O, tyroid gland no enlargement
H/L normal
OR
OR
Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Gynecologic record
Abdomen:
I : Seems no enlargement
Pa
: Uterine fundal wasnt palpated,
mass(-), Abdominal tenderness (-),
rebound tenderness (-), DM (-)
Pe : Tympani
Au : Peristaltic sound was normal

Genitalia : I : V/U normal, bleeding from

vagina(+)
Inspeculo :
Vagina : Laceration (-), Fluxus (-), looks
rosy mass slippery surface fill 1/3 upper
part of the vagina, size equal to puyuh egg
.
Portio : hard to be determined,

Bimanual VT
Vagina

: a mass equal to puyuh egg

size palpated, came out from cervical
canal, free from surrounding tissue.
Portio :OUE was open equal to the
size of the mass,theres a mass as
large as puyuh egg came out from
cervical canal
CUT : AF, size equal to chicken egg
AP : hard to be determined
CD : hard to be determined

No. Parameter

Result

Normal Range

Haemoglobine 9,2 gr/dl

9,5 15

Haematocryte 28 %

28 40

3.

Leucocyte

4,6. 103/mm3 5,9 - 16,9.103

4.

Trombocyte

207.103/mm3 146 - 429.103

5.

Erythrocyte

3.106/mm3

2,71 4,43. 106

6.

APTT

25,6

22.6 35.0

7.

PT

9,8

9.6 12.9

8.

MCH

31 pg

29 32

9.

MCV

91 um3

81 - 99

34 g/dL

32-36

10. MCHC

No.

Parameter

Result

Normal range

Protein Total

6,2 g/dl

6.0-7.8

Albumin

3,4 g/dl

3.5-5.2

Globulin

2,8 g/dl

0.0-0.0

SGOT

15 u/L

0.0-31.0

SGPT

11 u/L

0.0-34.0

Ureum

11 mg/dl

15.0-40.0

7
8

Creatinin
Sodium

0,5 mg/dl
135 mmol/L

0.6-1.2
139-145

Potasium

4,1

3,5-5,1

10

Chloride

102

97-111

11

Calcium

8,1

8,2 9,7

12

Random Glucose

105

60-200

D/:

AUB due to susp. Myoma Geburt + Mild Anemia

S/ :
Control GA,VS, vagina bleeding
Complete blood examination
Ro Thorax
ECG
Consult to Internist, Cardiology
Informed consent
USG
R/ Improve general condition
Report to consultant, advice :
Improve general condition
Plan to Myoma geburt extirpation

Consult result from Internal

department
Impression : - AUB due to Myoma

- Mild Anemia due to chronic illness

Ass :

- Myoma therapy according to Obgyn department

For operative procedure :
Cardiovascular risk : moderate
Pulmonar risk : mild
Metabolic risk : mild
Hematology risk : stabil

Consult result from Cardiology

department
Impression : AUB due to myoma geburt

Ass :
There is no emergency in cardiology dept
Other treatment according to Obgyn
department

USG

USG
Uterus anteflexion (5,2 x 4,1 x 5,7) cm
Theres no adenomyosis
Theres hypoechoic mass with strong border

and 4,8 x 4,0 cm in size at cervix came out

from cervical canal, echointerna (-)
Right Ovarium in normal limit 2,67 x 2,62 cm
Left Ovarium in normal limit 2,58 x 2,58 cm
Impression / Myoma Geburt

Follow Up December 4th , 2014

A/ Complaint (-)
Physical Examination :
GA
Cons
BP
HR
RR
T
Mdt
CMC
120/80 80
20
af
Eyes
: conjunctiva was anemic, sclera wasnt
icteric
Neck
: JVP 5-2 cmH2O, tyroid gland no
enlargement
Chest
: H/L normal
Abdoment : GR
Genitalia: GR
Post transfusion 2 unit PRC
D/ Abnormal Uterine Bleeding e.c Myoma Geburt

Management
Control GA, VS, Vaginal Bleeding
Informed consent
Consult to Anesthesiology and OK
Plan
Extirpation Myoma Geburt

December 5th , 2014 at 09.00 am

Extirpation of myoma geburt had been

performed
Myoma size 5x5x6 cm.
after extirpation Diagnostic Curretage had
been
performed
bleeding during operation 30 cc
D/ Post extirpation + Diagnostic curretage o.i.
myoma geburt
P/ Close monitoring post operation

THANK YOU