Mrs.

E
tim gyn
Identity
• Name : Mrs. E • Husband name : Mr. S
• Age : 42 years old • Age : 45 Years Old
• Address : solok selatan • Address : Solok Selatan
• Education : junior high school • Occupation : Enterpreneur
graduate
• Occupation : House wife
Chief complaint
• A 42 years old patient was admitted to gynecology ward room
referred from gynecology polyclinic of Dr. M. Djamil Central General
Hospital on October 29th, 2018 at 10.40 am with chief complain
bleeding from vagina since 5 days ago with diagnosed hyperplasia
endometrial complex (CIN II-III) + pulmonary hypertension pro
laparotomy.
 Present Illness History
• Bleeding came out from vagina since 1 weeks ago, wetting 1 piece of underwear, red-black, cob,
amount 4-5x change of pad/day, without pain.
• Initialy, 1 month before, the patient have controlled to Yarsi Padang General Hospital 1 month
ago with chief complain vaginal bleeding, and then curettage was performed, with result non
atypical complex endometrium hiperlplasia mild - moderate displacia (CIN II-III) and have got
drug but no improvement. then patient reffered to Gynecologic polyclinic of dr. M.DJamil
General Hospital.
• Menstrual history : menarche at 13 years old, irregular cycle, during 5-7 days, change of pad 2-
3x/day, pain (-).
• Complain enlargement of the abdomen was absent
• History of dyspareunia and post coital bleeding was denied
• No history of fever, trauma, flour albus
• Miction and defication was normal
• Patient have 4 children, the younger is 17 years old
Previous Illness History :
patient had history of Pulmonary Hypertensio since 3 years ago, routine
controlled once per month to internist in Solok Selatan. patient got dorner
2x200 mg (PO)

Family Illness History :

There wasn’t history of hereditary disease, contagious and phsycological illness
in the family

• Marrital history : once in 1992

• History of family planning : (-)
• Education : junior high school
• Occupation : house Wife
Physical Examination
GA Cons BP PR RR T
Mdt CMC 160/100 85 20 37

BW : 52 kg
BH : 150 cm
BMI : 22,7 kg/m2

Eyes Conjunctiva was anemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment Gyn Record
Genitalia Gyn Record
Extremity Edema -/-
 Gynecologycal record
Abdoment :

I : no enlargement, sicatrix (+) Pfanenstiel, once previous cesarean section

Pa : no mass was palpable, pressure pain (-), release pain (-), DM (-)
Pe : thympani
Au : Peristaltic sound normal
Genitalia :

I : V/U normal, vaginal bleeding (+)

Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (+) seem red
black blood in posterior of fornix
Portio : MP, size equal to an adult toe, tumor (-),
laceration (-), fluxus (+), seem red-black blood
ooze from canalis cervicalis, OUE was closed,
sondage 10 cm
VT bimanual :
vagina : tumor (-)
portio : MP, size equal to an adult
thumb, posterior, pain (-)when moved,
OUE closed
CUT : Anteflexion, size equal to adult fist
A/P : normal
CD : not protruded
Laboratory:
No. Parameter Results Normal range

1 Hemaglobin 11,6 g/dl 12-14

2 Hematokrit 36 % 37-43

3. Leukosit 11.720/mm3 5-10

4. Trombosit 316.000/mm3 150.000-400.000

5. APTT 30,7 det 29,2 – 39,4 det

6. PT 11,8 det 10,0 – 13,6 det

Laboratory:
No. Parameter Results Normal range

7 GDS 101 mg/dl <200

8 ureum 21 mg/dl 10-50

9 creatinin 0,5 mg/dl 0,6-1,2

10 calsium 9,1 mg/dl 8,1-10,4

11 Natrium 140 Mmol/L 136-145

12 Kalium 3,9 Mmol/L 3,5-5,1

Laboratory:
No. Parameter Results Normal range

13 chlorida 112 mg/dl 97-111

14 Total protein 6,8 g/dl 6,6-8,7

15 albumin 4,5 g/dl 3,8-5,0

16 globulin 2,3 g/dl 1,3-2,7

17 SGOT 14 u/L <32

18 SGPT 13 u/L <31

 Consult
• Cardiologist
D/ Pulmonary Hypertension
Th/ Dorner 2x200 mg (PO)
Operation Tolerance : Goldmann risk Score Class III 14% Cardiac Complication
• Internist
D/ Pulmonary Hypertension
Operation Tolerance :
Cardiovascular : Goldmann risk score class III 14% cardiac complication
Pulmonar : moderate
metabolic : mild
Hematologic : Moderate
• Anastesiologist
D/ ASA II
Th/ Prepare ICU for post Operative
Diagnosis:
hyperplasia endometrial complex non atypic (CIN II-III) + pulmonary hypertension pro laparotomy.

management :
• Control GA, VS,
• Informed consent
• Report to operation room
• booking ICU
• Bowel prep 3 days
• Cross Match 2 PRC + 2 FFP

Plan:
•Laparotomy Hysterectomy
 Operative
November 1st , 2018
• At 02.00 pm laparatomy was perfomed
when peritoneum was opened, no adhesion, exploration was performed, uterus size equal to Adult fist. Both of Adnexa were normal
Total hysterectomy was performed
blood during operation ± 100 cc

Diagnosed :
Post Total Hysterectomi on indication hyperplasia endometrial complex non atypic (CIN II-III) + pulmonary hypertension

Management :
• Observation In ICU
• IVFD RL gtt XX
• Inj. Ceftriaxone 2x1 gr (IV)
• Inj. Tranemic Acid 3x500 mg (IV)
• inj. Vitamin K 3x10 mg(IV)
• inj. Omeprazole 2x4 mg (IV)
• Paracetamol inf 3x500 mg (IV)
• post operation blood test analysis
• therapy based on intensivist