Documente Academic
Documente Profesional
Documente Cultură
Patient identity
Husband Identity
Name : Mrs. E
Name : Mr. S
Age : 49th years old
No. MR : 01016261 Age : 53 years old
Addres : Tiku, Addres : Tiku, Pariaman
Pariaman Occupation : Farmer
Admission date : June 10th 2018
A 49 years old patient was admitted to the Gynecology Ward room of Dr. M. Djamil Central
General Hospital on june 10th 2018 at 19.30 pm, reffered from Emergency room Dr. M.
Djamil Central General Hospital with diagnosed Uterine myom + severe anemia.
Present Illness History:
• Previously, the patient reffered from emergency room Lubuk Basung
Hospital with diagnosed AUB due to uterine myom + severe anemia (Hb :
4,8 g/dl).
• Bleeding from vagina (+) since 2 weeks ago, bleeding happens out of
menstrual period, 4 - 5 times change pads daily.
• Felt mass in abdomen was (+) since 6 month ago, the mass going bigger
untill as big as a kasti ball with abdominal pain (+)
• History of Post coital bleeding , dispareunia (-)
• History of body weigh decreasing extremely (-)
• History of fever, trauma, and fluor albus was (-)
• Menstruation History : menarche at 13 years old, irregular cycle, every
month which last for about 5-7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
• Last menstrual period: march 14th 2018
• Urination and defecation was normal
• Patient already married and have 5 children, the youngest age was 11
years old.
Previous Illness History
• There was no previous history of heart, lung, liver, kidney, hypertension and allergy.
GA Cons BP HR RR T
Mdt CMC 120/80 80 18 36,8
BW : 55 kg
BH : 155 cm
BMI : 22,21 kg/m2
UAC : 24 cm
Genitalia
I : V/U normal, bleeding from vagina (+)
Inspeculo
• Vagina : Tumor (-), Laceration (-), Fluxus (+) blood with dark red colour accumulate in
posterior fornix
• Portio : MP size equal an adult toe, Tumor (-), Laceration (-),
sondase + 12 cm, AF, OUE opened 1cm, there fluxus come out from canalis cervicalis
Bimanual VT
• Vagina : Tumor (-), laseration (-)
• Portio : MP equal an adult tumb, tumor (-),
laseration (-)
• CUT : Uterus was palpable 2 finger below
the umbilical
• AP : Soft right - left
• CD : Not protruted
Laboratory, june 10th 2018
Parameter Result Normal Range
Haemoglobine 4,3 gr/dl 9,5 – 15
Haematocryte 16 % 28 – 40
Abd : Mass (-), pain tenderness (-), rebound tenderness (-), DM (-)
Genitalia : PPV (-)
A/ P5L5 + uterine myoma + anemia with clinical improvement
P / Prepare for laparotomy
Th/
Inj. Cefotaxime 1gr
Laboratory, june 12th 2018
Parameter Result Normal Range
Haemoglobine 9,3 gr/dl 9,5 – 15
Haematocryte 30 % 28 – 40
Diagnosis
• Post total hysterectomy o.i uterine myoma
Plan
monitoring post operation
Check routine lab 6 hours post op
Inj. Cefotaxime 2x1gr
Pronalgess supp On demand
Perawatan RR
• Patient with position semi fowler ± 12 jam post operation
• Controle KU, VS, PPV, balance cairan
• IVFD RL = 28 tts/menit
• Antibiotik : Cefotaxime 2 x 1 gr (selama 3 hari)
• Bila kesakitan beri pronalges supp
• Catheter
• Check Hb 6 hours post operation, if Hb < 10 gr% transfusion until Hb ≥
10 gr%
• If meteorismus (+)/flatus (+) drink a little
THANK YOU
Laboratory, may 18th 2018
Parameter Result Normal Range
Haemoglobine 10,1 gr/dl 9,5 – 15
Haematocryte 34% 28 – 40