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Case Report

Patient’s ID

Name : Ms. F
Age : 34 years old
Address : Anduring
MR No. : 00 99 44 41
Admission date : Jan 24th, 2018
Anamnesis

• A 34 years old patient admitted to the Gynecology Ward of Dr. M.


Djamil General Hospital Padang on Jan 24th, 2018 sent by
Gynecology Clinics, with Right neoplasm ovaroan cyst planned to
have laparotomy
Present Illness History

• Previously patient have plained to hernia inginalis laparascopyc ,it was


canceld cause thre was a huge mass in her abdomen, it ovarian cyst
suspected, and than the doctor perform trans adominam hernioraphy
operatif.
• the patient did’t felt a mass in her abdomen
• Abdominal pain (+)
• Bleeding from vagina was absent
• Menstrual History : menacre at 13 years old, regular cycle, which last for 5
to 7 day each, cycle with amout of 2-3 times pad change/day without
menstrual pain. Last day menstruation periode 15-01-2018
• The patient not married yet
• No complain in urinary and bowel habits
• No history or weight loss in the short time, normal appetite
Previous Illness History
• No history of the same illness
• History of any cardiac, lung, liver, dm and renal disease was unknown
• No history of allergy

Family Illness History


• No history of the same illness
• No history of any contagious, or psychological disorder run in the family
Physical Examination

Gen Conc BP HR RR T BH BW BMI


moderate CM 120/80 73 21 36.7° 155 50 20.8

Eyes : conjunctiva was not anemic, sclera was not icteric


Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Thorax : Heart / Lung – within normal limit
Extremity : UAC 23 cm, physiological reflex +/+, pathological
reflex -/-
Gynecological Records

Abdomen
• Inspection : Seems not enlargement, cicatrix (+) hernia inguinalis operatif
• Palpation : A cystic mass size until 1 finger simpisis, feeling mobile, no
tenderness, slippery surface
• Percussion: no shifting dullness
• Auscultation : normal peristaltic sound
Genitalia

• Inspection : vulva and urethra – within normal limit

• Inspeculo : Not perform

• VT bimanual : Not Perform

• Rt : Lowest part of mass hard to identify


Laboratory Finding

Parameter Result Normal Value Unit

Haemoglobin 10,7 12.00-14.00 g/dl

Leucocyte 4.680 5.00-10.00 103/mm3

Thrombocyte 328.000 150.00-400.00 103/mm3

Hematocrit 35 37.00-43.00 %
Parameter Result Normal Value Unit

Calsium 8,6 8.1-10.4 u/l


Potassium 3,4 3.5-5.1 mmol/L
Sodium 140 139-145 mmol/L
Random Blood Glucose 109 < 200.00 mg/dL
Total Protein 6,6 6.0-7.8 g/dL
Albumin 4,2 3.5-5.2 g/dL
Globulin 2,4 0.00-0.00 g/dL
SGOT 27 0.00-31.00 u/L
SGPT 24 0.00-34.00 u/L
Ureum 17 15.00-40.00 mg/dL
Creatinine 0,6 0.60-1.20 mg/dL
Ca 125 : 16.19

RMI : 1x1x16.19 = 16.19


Diagnosis

Right Neoplasm Ovary Cyst


Jan 25th, 2018, At 12.00 am :

• laparoromy was performed in spinal anesthesia


• After peritoneum opened  exploration  appear a greys white mass
from right ovarian  Impresion right Ovarian Cyst Neoplasm  performed
right salphingo-oovorectomy
• Left ovary within normal limit
• The specimen was sent to Pathological anatomy lab
• Blood loose during surgery : 50 cc
Diagnosis :
• Post right salphingo-oovorectomy on indication of right ovarian cyst
neoplasm

Plan :
• Closed post surgery monitoring
Thank You