Case no.

100
 IDENTITY
Patient Husband
Name : Mrs. E Name : Mr. E
Age : 48 years old Age : 51 years old
MR No. : 01 01 09 79 Education : Senior High School
Education : Senior High School Job : Entrepreneur
Job : House wife Address : Payakumbuh
Address : Payakumbuh
 Admission date : 24/04/2018
A 48 years old patient was admitted to the Gynecology Ward of Dr.
M. Djamil Central General Hospital on April, 23th 2018 at 11.00 am
referred from Polyclinic of Dr. M. Djamil Central General Hospital
with diagnosed Uterine myoma + twice previous CS history.

Chief Complain :
Felt mass in abdomen since 3 years a go
Present Illness History:
• Patient complaint about having a mass in her stomach since 3 years ago
• Bleeding from vagina (+) since 3 month ago amount of 4-5 times pad
change/day , 1 month ago patient was hospitalized with severe anemia and
got 4 pack of PRC trasfusion.
• History of post coital bleeding , dispareunia (-)
• History of body weigh decreasing extremely (-)
• History of fever, trauma, and fluor albus (-)
• Menstruation History : menarche at 12 years old, regular 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
• Last menstrual period in March, 2018
• Urination and defecation was normal
• Patient have 2 children with the youngest one is 8 years old
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 : Senior high school
History of Occupation : house wife
History of contraception : (-)
History of Habit : Smoke (-), Alcohol (-),
Drugs (-)
Obstetry and Sosioeconomic history
• Patient was marrried once at 1999

• History of Gravid/Abortion/Partus : 2/0/2

• 2000 , female, 3500gr, CS , OG doctor, in payakumbuh district
hospital, live, wound healed within 7 days
• 2010 ,male, 3400gr, CS , OG doctor, in payakumbuh district hospital,
live, wound healed within 7 days

• Family Planning History : IUD from 2001-2009

and 2011-2015
Physical Examination

GA Cons BP HR RR T
Mdt CMC 110/70 78 18 36,6

BW : 60 kg
BH : 160 cm
BMI : 23,21 kg/m2 (normoweight)
UAC : 24 cm

Eyes Conjunctiva wasn’t anemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment OR
Genitalia OR
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Gynecologi record
Abdoment :
• I : seem enlarge like 7 months pregnancy,
sikatriks (+) at linea mediana
• Pa : mass was palpable 3 fingers above
umbillicus, as big as volley ball, fixated,
consistency solid, smooth surface,
pressure pain (-), release pain (-), muscular
defense (-)
• Pe : dull above tumor mass
• Au : Peristaltic sound normal
Genitalia : I V/U normal
Inspeculo :
• Vagina :
Tumor (-), Laceration (-), Fluxus (-), there’s no
blood in the fornix posterior
• Portio :
NP, tumor (-), laceration (-), fluxus (-), OUE was
closed, sondage was 5 cm
VT bimanual :
• Vagina : tumor (-)
• Portio : NP, size as big as thumb adult finger, OUE was closed, mass
was move when the portio being moved
• CUT : as big as volley ball
• AP : weak left=right
• CD : didn’t protrude
Laboratory Finding
Parameter Result Normal Range
Haemoglobine 10,3 gr/dl 9,5 – 15

Haematocryte 31 % 28 – 40

Leucocyte 7400/mm3 5,9 - 16,9.103

Trombocyte 233.000/mm3 146 - 429.103

Erythrocyte 4.176/mm3 2,71 – 4,43. 106

APTT 33,8 22.6 – 35.0

PT 11,1 9.6 – 12.9

USG
USG
USG

• Uterus size bigger than normal was fulfilled the monitor screen
• A large mass hipoechoic was fulfilled the monitor screen
• Right ovaryan size: 2,4 cm x 1,1 cm
• Left ovaryan size: 2,1 cm x 1,1 cm

impression : Uterine Myoma

CT SCAN
CT SCAN

Uterus was much bigger than normal

A large and small (multiple) mass with isodens density, sized
21x15x20cm , regular border.
Both of adnexa was in normal limit

Impression :
Multiple Uterine myoma
Diagnosis
P2L2 Uterine myoma + twice previous CS history

Management :
Control GA, VS
Informed consent
Inj Cefriaxone 1gr before procedure
Crossmatch 4 units of PRC

Plan
laparotomy on April 24th , 2018
April 24th , 2018 at 11.00 am
Laparotomy was performed
After peritoneum opened, there was reddish
mass as big as volley ball
Exploration was performed, mass was from
uterine, left ovarium adhesive with uterine, and there is darkred cystic mass at
right ovarium, size was 2x2cm
Uterine was being out from abdomen,
impression  uterine myoma + right endometriosis cyst
plan : total hysterectomy + Right cystectomy
Total hysterectomy and left salphigooophorectomi + Right cystectomy was
performed

Diagnosis
Post total hysterectomy and left salphingooophorectomy + right
cystectomy o/i Uterine myoma + Right endometriosis cyst

Plan
monitoring post operation
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