Name : Mrs.

E
Age : 49 years old
No. MR : 01.03.10.73
Admission date : October 27th 2018

A 49 years old patient was admitted to the Emergency room of Dr.

M. Djamil Central General Hospital on October 27th 2018 at 07.00
am with chief complaint of intermitteng vaginal bleeding since 6
months ago and increased within 1 week before admission
Present Illness History:
• Bleeding from vagina (+) intermittent since 6 months ago and increased
within 1 week before admission, amount of 1-2 times pad change/day, wasn’t
painful.
• Mass felt in abdomen was denied
• History of Post coital bleeding , dyspareunia (-)
• History of extreme decreased body weight (-)
• History of fever, trauma, and fluor albus (-)
• Menstruation History : menarche at 13 years old, irregular cycle, every month
which last for about 5-7 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain
• Last menstrual period: forgotten
• Urination and defecation was normal
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
Marriage history : once in 1992
History of pregnancy/abortion/delivery : 3/0/3
1.1993, men, 3000 gram, aterm, spontanious, by midwife, alive.
2.1997, women, 3200 gram, aterm, spontanious, by midwife, alive.
3.2003, women, 3100 gram, aterm, spontanious, by midwife, alive.

History of formal education : Senior high school

History of Occupation : house wife
History of contraception : patient never uses any birth control or
contraception
History of Habit : Smoking (-), Alcohol consumption (-),
Drugs usage (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 120/80 80 18 36,8

BW : 109 kg
BH : 160 cm
BMI: 42,57 kg/m2
UAC : 29 cm

Eyes Conjunctiva was anemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment Gyn Record
GenitaliaGyn Record
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
 Gynecologic record

Abdomen
I : no enlargement
Pa : Uterine fundal wasn’t palpable, Tenderness (-),
Rebound Tenderness (-), DM (-)
Pe : Tympanic sound
Au : Peristaltic sound was normal

Genitalia
I : V/U normal, bleeding from vagina (-)
Inspeculo
• Vagina : Tumor (-), Laceration (-), Fluxus (-)
• Portio : MP size equal an adult toe, Tumor (-), Laceration
AF
Bimanual VT
• Vagina : Tumor (-), laceration (-)
• Portio : MP equal an adult thumb, tumor (-),
laceration (-)
• CUT : Uterus was palpable as big as chicken egg
• AP : Soft right - left
• CD : Not protruted
Laboratory, October 27th, 2018
Parameter Result Normal Range
Hemoglobin 7,2 gr/dl 9,5 – 15

Hematocrit 24 % 28 – 40

Leucocyte 11,040/mm3 5,9 - 16,9.103

Trombocyte 351.000/mm3 146 - 429.103

APTT 36,8 22.6 – 35.0

PT 11,8 9.6 – 12.9

Plano test -
Diagnosis
Abnormal uterine bleeding e.c susp. Hyperplasia endometrium
Moderate anemia
Plan
Improvement of general condition
Gynecology USG
Curretage PA
Crossmatch PRC 4 units
Laboratory, October 29th, 2018
Parameter Result Normal Range
Hemoglobin 10.6 gr/dl 9,5 – 15

Hematocrit 33 % 28 – 40

Leucocyte 15.420/mm3 5,9 - 16,9.103

Trombocyte 250.000/mm3 146 - 429.103

USG October 30th, 2018
USG
USG
• Anteflexion uterine, size was normal 9.6x9.31x9.41, there was no
myoma or adenomyosis
• Endometrial line was (+) and thick (1.81)
• Right ovary size: 3.10 x 2.03 cm
• Left ovary size: 2.31 x 1.70 cm
• Impression : Endometrial hyperplasia

Plan
• Curretage
• Consult to anesthesiology
October, 31st , 2018 at 11.00 am
• Curretage was performed
• Bleeding during curretage 10cc
• Endometrial and endocervical tissue was delivered to Aanatomical
Pathology Laboratory

Diagnosis
• Post curretage oi endometrial hyperplasia

Plan
monitoring post operation
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