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Case No

Identity
Patient Husband

Name : Mrs. S The patient’s husband was already die


since 6 years ago
Age : 68 years old
Occupation : Housewife
MR : 01054468
Address : Padang
Admission Date : Juli, 17th 2019
Anamnesis

A 68 years old patient was admitted from


Urogynecology Polyclinic of Dr. M. Djamil Central
General Hospital on July, 17th 2019 with diagnose
grade IV uterine prolapse
Present Illness History
 The patient was admitted from Urogynecology Polyclinic at Dr. M. Djamil
General Hospital at July, 17th 2019 with chief complain a mass came out
from vaginal as big as adult fist since 3 years ago
 Abdominal pain (-)
 Bleeding came out from vagina was (-)
 Dyspareunia (-) Post Coital Bleeding (-)
 No complain of urinary
 History of fever (-), trauma (-), leucorrhea (-)
 Have no menstruation since 16 years ago
 No complain of bowel tract disorder.
 Menstrual History : patient already menopause since 16 years ago
Previous Illness History:
• There was no previous history of heart, lung, liver, kidney
disease, DM , hypertension or allergy.
Family Illness History:
• There was no history of any hereditary or contagious disease,
or psychological illness run in the family.
Occupation, Socioeconomics, Psychiatry, and
Habitual History:
 Marital history: once in 1969
 History of pregnancy/abortion/parturition: 8/0/8
1. 1970/ female/ term/ spontaneous/ midwife/ alive
2. 1972/ male/ term/ spontaneous/ midwife/ alive
3. 1976/ male/ term/ spontaneous/ midwife/ alive
4. 1980/ male/ term/ spontaneous/ midwife/ alive
5. 1983/ female/ term/ spontaneous/ midwife/ alive
6. 1986/male/term/ spontaneous/ midwife/ alive
7. 1989/female/ term/ spontaneous/ midwife/ alive
8. 1992/female/ term/ spontaneous/ midwife/ alive
• History of family planning : (-)
• History of education : elementary school
• History of Occupation : Housewife
• Habitual history : Smoke (-), Alcohol (-), Drugs
(-)
Physical Examination :

GA Cons BP HR RR T
Mdt CMC 110/70 78 20 36,5

BW : 50 kg
BH : 150 cm
BMI : 21.2  normoweight

Eyes Conjunctiva anemic (-/-), Sclera icteric (-/-)


Neck JVP 5-2 cmH2O, no enlargement of tyroid gland
Thorax H/L were normal.
Abdoment GR
Genitalia GR
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Gynecological record
Abdomen:
I : no enlargement observed
Pa : Abdominal pain (-), rebound tenderness (-),
muscular defans (-)
Uterine fundal was difficult to be examined
Pe : Tympani
Au : normal peristaltic sound
Genitalia
Insp : V/U Normal
Vaginal Bleeding (-)
 There was a redness in colour mass as big as duck egg coming
out from the vaginal ostium, OUE (+)
Laboratory Findings
Parameter Result Normal Limit Unit
Haemoglobin 10,4 11,6 - 13,9 g/dL
Hematocrit 34 31 – 41 %
Leucocyte 13.890 5,7 - 13,6. 103 /mm3
Thrombocyte 421.000 174 - 391. 103 /mm3
APTT 34,5 23.0 – 38.9 Seconds
PT 10,4 9.7 – 13.5 Seconds
Parameter Result Normal Limit Unit
RBG 187 < 200 Mg/dl
Ureum 26 10,0-50,0 Mg/dl
Creatinine 0,5 0,6-1,1 Mg/dl
Calsium 9,6 8,1 – 10,4 Mg/dl
Kalium 4,0 3,5-5,1 Mmol/dl
Natrium 138 136-145 Mmol/dl
Chloride serum 107 97-111 Mmol/dl
Total Protein 7,0 6,6-8,7 g/dl
Albumin 3,2 3,8-5,0 g/dl
Globulin 3,8 1,3-2,7 g/dl
Total Bilirubin 0,2 0,3-1,0 Mg/dl
Bilirubin direct 0,1 <0,20 Mg/dl
Bilirubin indirect 0,1 <0,60 Mg/dl
SGOT 14 <32 u/l
SGPT 5 <31 u/l
HbSAg Non-reactive Non-reactive
Anti-HIV Non-reactive Non-reactive
Diagnosis :
Grade IV Uterine

Management :
 Control GA, VS
 Informed consent
 Klisma

Plan :
 Transvaginal Hysterectomy
18/07/2019 at 11.00 am
Transvaginal Hysterectomy and colpocleisis were performed
Intraoperative bleeding 300 cc
Uterine mass was checked to PA Lab

Diagnosis:
Post Transvaginal Hysterectomy + colpocleisis on indication of grade IV
uterine Prolapse

Management:
Post operative monitoring
Cross match PRC
Transfusion 1 Pack of PRC post operatif
Post Operative Treatment

• Control GA, VS, Vaginal Bleeding,


Intraabdominal Bleeding
• IVFD RL 20 gtt
• Inj. Ceftriaxone 2x1 gr (IV)
• Urine catheter 24 hours
• Laboratorium post operative
THANK YOU