Patient 1

Mrs. A, 31 yo, P0A0, Bataknese, Christian, Bachelor,employee, married to Mr. F,

36 yo, Bataknese, Christian, Bachelor, Enterpreneur

Cc : Amenorhea

E : Irregular menstruation has been experienced by patient since adolescent.

History of vaginal bleeding outside menstrual cycle (-). History of coital bleeding
(-). History of abdominal massage (-). History of herbs consumption (-).History
of weight loss or loss of appetite (-). Micturition and defecation were normal.
History of Previous Illness :-
History of Medication :-
History of Chemotherapy :-
History of surgery :-
History of Menstruation : Menarche 12 y.o, 45-60 days cycle, irregular,
vol 2-3x changed pads per day, menstrual pain
(-), 3-4 days.
History of Contraception :-
Vital Signs
Sens : Fully alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
Pulse : 70 x/i Cyanosis : (-)
RR : 20 x/i Dypsnoe : (-)
Temp : 36,7°C Edema : (-)
General state : Moderate
Illness State : Moderate
Generalized Status :
- Head : Inferior palpebra conj. anemic (-), icteric (-)
- Neck : no abnormality
- Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rhales (-)/(-)
- Abdomen : Soepel, peristaltic (+) N
- Extremities : palmar anemic (-)
Localized State
Abdomen : Peristaltic (+), soepel
Vaginal bleeding : (-)
Micturition : (+) normal
Defecation : (+) normal

Gynecological State
Inspeculo : Smooth portio, Erosion (-), F/A (-). Blood (-)
VT : Anteflexed uterine, no palpable mass on right and left
adnexa, Right and left parametrium was laxed, Cavum
douglas not protuded.
Transvaginal ultrasound
Transvaginal ultrasound
Transvaginal ultrasound
Transvaginal ultrasound
Transvaginal ultrasound
Transvaginal ultrasound
Transvaginal ultrasound
 USG-TVS
– Uterus anteflexed size 3.73x3.69x3.31 cm
– Right adnexa (right ovary:3.63x3.15x2.79 cm)
ovaries: 15-20
– Left adnexa (Left ovary: 3.04x2.8x1.68 cm)
ovaries 10-45
– E-uve: 0.8 mm
– Free fluid (-)

Conclusion: Bilateral polycystic ovarian syndrome

Diagnosis :
Bilateral Ovarian cysts

Plan :
-Diagnostic operative laparoscopy on 24-07-2019
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