PATIENTS PROFILE Name Age RN IC Number Marital Status Parity LMP Race Religion Address Occupation Date of admission

Time of admission Date of clerking Place of clerking : Ruhaidah binti Harun : 40 years old : HSNZ : 730906115344 : Married :2 : 15/09/2013 : Malay : Muslim : Panji Alam, Kuala Terengganu : Clerk : 20/10/2013 : 9 am : 22/10/2013 : Gynaecological Ward 5EF , HSNZ, KT

CHIEF COMPLAINT Admitted for scheduled operation of ovarian syst on 22/10/2013. HISTORY OF PRESENT ILLNESS My patient was admitted for scheduled operation of avarian cyst on 22/10/2013. She was diagnosed to have ovarian cyst on 17/10/2013 at the private clinic. She came to the clinic with the chief complaint of right iliac fossa pain and abdominal swelling. She went to the clinic because the pain was increase in frequency and intensity. The doctor did ultrasound and a huge ovarian cyst was diagnosed. The pain was started early of this year and it is intermittent. The pain was cramping in nature and sometimes radiate to the back. It was reoieved by applying massage oil and there was no axcerbating factor. The severity of the pain was 3/10. She also claimed that there was abdominal distention at suprapubic area until the umbilical area and it was

more on the right side. The size of the mass was increase during menses but it was gradually decreased in size after the menses. There waere no dyspepsoa, no pressure symptoms like leg swelling, vericose vein, urinary and bowel symptoms. There was also no abnormal uterine bleeding, no history of subfertility, no postcoital bleeding, no dyspaerunia, no lossof appetite, no weight loss and no hoerseness of voice. SYSTEMIC REVIEW CVS - no chest pain, no shortness of breath, no orthopnea, no PND, no ankle edema - no cough, no wheezing, no haemoptysis - no nausea, no vomiting, no diarrhea, no constipation, no malena, no hematemesis

Respiratory system GIT

Genitourinary system - no frequency, no urgency, no dysuria, no haematuria, no nocturia CNS - no headache, no dizziness, no blurring vision, no insomnia

MENSTRUAL HISTORY She attand her menarche at the age of 14 years old. Her menstrual cycle is 7/28 days and regular. She used 2-3 pads on first and second day and it is fully soaked. But she used 2 pads per day until day 7 and it is not fully soaked. There is no dysmenorrhea, no menorrhagia and no intermenstrual bleed. PAST GYNAECOLOGICAL HISTORY She doesnt has any past gynaecological disease before. There is also no menorraghia, no dysmenorrhea, no intermenstrual bleed, no dyspareunia and no postcoital bleeding. She havent done pap smear before. PAST OBSTETRIC HISTORY She has two children and both are boys. The eldest shild is 11 years old and the second child is 6 years old. Both of her children born with spontaneous vaginal delivery at term with no antepartum, intrapartum and postpartum complications. Birth weight are between 2.9-3.4 kg. She beastfeed both of her children till 4 month. She was not taking any OCP or IUCD. PAST MEDICAL/SURGICAL HISTORY She has no history of chronic disease like hypertension, diabetes mellitus, cardiac problems, thyroid disease, asthma, or any other medical conditions. She never done any operation before.

FAMILY HISTORY She has 7 siblings and all are healthy. Her mother has diabetes mellitus and her mother has hypertension. There are no family history of gynaecological problem or malignancy. SOCIAL HISTORY Her education level is diploma and work as a clerk in a bank. She is a widow for 4 years because her husband was died 1 year ago. She has no financial problem. Her house condition and environment is good. DRUG HISTORY Currently, she does not take any drugs. There is no any drug allergy. DIET HISTORY She eat normal balance adult diet and she has no any food allergy. PHYSICAL EXAMINATION General Examination The patient appears alert, conscious and well orientated to time and space. She was lying comfortably on the bed propped up with one pillow. There were no sign of pain respiratory distress. Hydrational and nutritional status was good. Vital Signs Pulse rate : 64 beats/minute, rhythm is regular, volume is normal and equal on both sides. Respiratory rate : 21 breaths/minute Temperature : 37 degree celcius Blood pressure : 125/79 mm Hg On examination of hand,hand was warm, no pallor, no palmar erythema, no koilonychias, no peripheral cynosis, no clubbing and capillary refilling time was less than 3 seconds. On examiation of eyes, there was no sign of jaundice on sclera, and no pallor on conjuctiva. On examination of nose, there were no discharge and no nasal polyps. On examination of mouth, there were no glossitis, no angula stomatitis, no oral thrust, no dental caries and oral hygine was good. The tongue was moist and no central cynosis. On examination of neck, there were no thyroid swelling and no lymph node enlargement.

On examination of leg, there were no ankle edema and no dilated veins. Abdominal Examination On inspection, abdomen was slightly distended with mass and assymetrical. There was linea nigra and striae albicans. Abdomen moves symmetrically with respiration. Umbilical was centrally located and inverted. There also were no surgical scar and dilated veins. On light palpation, abdomen was soft and non tender. On deep palpation, There was mild tenderness on the right iliac fossa area but it was more to the right side. The mass was palpable about 20 weeks size on suprapubic area until the umbilical area. The margin was well define and regular. Surface was smooth and it was cystic in consistency. It also can be move side to side. It was oval in shape and the size was 14 cm x 10 cm. I also cant cant below it. There was also no slpleenomegaly, no hepatomegaly and kidney was ballotable. On percussion, There was dullnes over the area of the mass. There were no shifting dullness and no fluid thrill. There was no ascites. On auscultation, bowel sound was normal. Systemic Examnation Review CVS S1 and S2 can be heard . There were no murmur and no added sound. Respiratory system Vesicuar breath sounds can be heard on both side of chest and no wheezing, no crackles and no abnormal sounds heard. CNS All are intact. SUMMARY Puan Ruhaidah binti Harun, 40 years old women, para 2, present with a problem of right iliac fossa pain and abdominal swelling. She is a widow and low paruty. She was diagnosed to have ovarian cyst on 17/ 10 / 2013 at the private clinic and reffered here for scheduled operation. On examination, Abdomen was slightly distented with mass and assymetrical.On deep palpation, There was mild tenderness on the right iliac fossa area but it was more to the right side. The mass was palpable about 20 weeks size on suprapubic area until the umbilical area. The margin was well define and regular. Surface was smooth and it was cystic in consistency. It also can be move side to side. It was oval in shape and the size was 14 cm x 10 cm. I also cant cant below it.

PROVISIONAL DIAGNOSIS Ovarian Cyst Points for - Pain, abdominal mass, mobile side to side, cystic in consistency. Points against Cant get below it, no dyspepsia (GI symptoms), no pressure symptoms, no hirsutism, no virilisation and no history of subfertility. DIFFERENTIAL DIAGNOSIS

Name : Syamim Syuhada Sazali Student ID : 1000923062 Topic : Ovarian Cyst