Case report No

PPDS OBGIN FK UNAND

RS. Dr. M. DJAMIL PADANG
VISI
Menjadi Institusi pendidikan yang menghasilkan Dokter Spesialis Obstetri
yang profesional dan bermartabat serta unggul dalam bidang obstetri
emergensi di Indonesia pada tahun 2023

MISI
1. Menyelenggarakan pendidikan yang berkualitas dan professional serta
mengutamakan kepentingan pasien, sehingga menghasilkan lulusan
Spesialis Obstetri dan Ginekologi yang kompeten dan bermoral tinggi.
2. Menghasilkan penelitian penelitian yang ikut mewarnai
perkembangan Ilmu dan profesi Obstetri dan Ginekologi.
3. Melaksanakan pengabdian masyarakat yang bersifat solutif terhadap
permasalah Obstetri dan Ginekologi mendasar yang ada di masyarakat.
Identity

Name : Mrs. L
Age : 37 YO
Address : Jambi
Education : High school grad
Occupation : House wife
MR No. : 99.30.59
Date : November 1st 2017

A 37 years old patient was admitted to the gynecology ward

room of Dr. M. Djamil Central General Hospital on October 30th
2017 at 13.00 am referred from gynecology polyclinic diagnosed
with bilateral adenomyosis cyst pro laparotomy
 Present illness hystory

Having mass in her stomach (+) since 1 years ago, at first that was
as big as chicken's egg, but now that is as big as
Abdominal pain (+) since 3 months ago
Vaginal bleeding (-)
History of post coital bleeding (-)
Dispareunia (-)
History of fluor albus (-), fever (-), trauma (-)
History of massive weight loss (-)
Menstruation history : menarche at 12 YO, irregular cycle every
month which last for about 4-5 days each cycle with the amount
of 2-3 times pad changes/day with menstrual pain
Patient has married, has 2 child, the youngest was 10 YO
Bowel and bladder was normal
Previous Illness History
There was no previous history of heart disease, lung, liver,
kidney, DM, hypertension, and allergy
Family Illness History
There was no history of contagious disease, hereditary and
physiological illness in the family
History of formal education : Senior high school
History of Occupation : house wife
History of contraception : (-)
History of Habit : Smoke (-), Alcohol (-),
Drugs addiction (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 110/70 82 22 36,8

BW : 60 kg
BH : 160 cm
BMI : 23,4 (normal)
Eyes : Conjunctiva wasnt anemic; Sclera wasnt icteric
Neck : JVP 5-2 cmH2O, no enlargement of tyroid glands
Chest : Lung / Heart was Normal
Abdoment : GR
Genitalia : GR
Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
Gynecology record
Abdomen
I : Seems enlargement
Pa : abdominal tenderness (-), rebound tenderness (-), defanse
muscular (-) a mass was palpable 3 finger below umbilical,
mobile (-)
Pe : tympani
Au : Peristaltic sound was normal

Genitalia
I : V/U normal, bleeding from vagina (-)
Inspeculo
Vagina : Tumor (-), laceration (-), fluxus (-)
Portio : MP, size equal to adult toe, tumor (-), laceration (-),
sodase + 9 cm AF

Bimanual VT
Vagina : Tumor (-) laceration (-)
Portio : Tumor (-) laceration (-)
CUT : A mass was palpable 3 fingers above symphisis pubis
AP : Tumors's bottom pool was palpable
CD : Not protruded
 Laboratory finding
Parameter Result Unit
Parameter Result Unit
Haemoglobin 12,2 g/dl
SGOT 13 u/l
Leucocyte 9.570 103/mm3
SGPT 22 u/l
Thrombocyte 392.000 103/mm3
RBG 97 mg/dL
Hematocrit 36 %
Ur 18 mg/dL
PT 10,7 Detik
Kr 0,8 mg/dL
APTT 32,2 Detik
Total protein 7,2 %
Natrium 143 mmol/L
Albumin 3,7 u/l
Kalium 4 mmol/L
Globulin 3,5 mg/dL
Chlorida 109 mmol/L

Calsium 8,5 mg/dl

USG
Uterus AF, size 8,1 x 3,3 x 4,1 cm,
Endline (+) 0,8 cm
There is cystic mass size size 5,3 x 4,2 cm at
ovarium dextra
There is cystic mass size 5,5 x 6,5 cm at ovarium
sinistra
Impression : Bilateral Endometriosis cyst
Diagnose
Bilateral Endometriosis Cyst

Management
Control GA, VS
Informed consent
Consult to anestesiologist
Consult to digestive surgery
Crossmatch PRC 2 unit

Plan
Laparatomy on November 1st 2017
November 1st 2017, 09.00 am, Laparotomy was performed
After peritoneum was opened exploration was performed,
seem two masses reddis-white in colour, the mass came from
left and right ovarian. Impresion bilateral adenomiosis
Uterine's size in normal limit.
Bilateral cystectomy was performed
Exploration was performed to see bleeding come from
Blood loss during surgery 300 cc
Diagnose
Post bilateral cystectomy on indication of bilateral
endometriosis cyst
 Follow Up Nov 2nd 17
08.00 WIB

S/ Fever (-), abdominal pain (-) PPV (-)

O/
Gc cons BP HR RR T
Mdrt CMC 120/70 88 20 36,7

Abd: Tenderness pain (-) , rebounds tenderness pain (-) defans

muscular (-)
Gen: I: v/u normal PPV (-)

A/ Post bilateral cystectomy on indication of bilateral endometriosis

cyst
 Laboratory finding
Post Op
Parameter Result Unit
Haemoglobin 12,1 g/dl

Leucocyte 12.050 103/mm3

Thrombocyte 313.000 103/mm3

Hematocrit 35 %
Ganti Foto
THANK YOU