Case No 11

Identity

Name : Mrs. M
Age : 70 years old
Occupation : Housewife
MR : 01.02.57.04
Adress : Painan
Admission Date : Oct 1th 2018
Anamnese

A 70 years old patient was reffered to the

Urogynecological Polyclinic of Dr. M. Djamil Central
General Hospital on OCt 1 st 2018 with diagnose
uterine prolaps grade III
 Present Illness History
The patient was admited from Urogynecology Polyclinic at Dr. M. Djamil
General Hospital at Oct 1st 2018 with chief complain a mass came out from
introitus vagina as big as chicken's egg since 1 years ago
Felt can't resist to pee since 2 weeks ago
History of fever (-), trauma (-), leucorhea (-)
Abdominal pain (-)
Bleeding came out from vagina was absent
Dyspareunia (-) Post Coital Bleeding (-)
Have no menstruation since 20 years ago
No complain of bowel tract disorder.
Menstrual History : menarche at 12 years old, regular cycle, once a month
which last for about 3-5 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain
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 phsycological illness run in the family.
 Occupation, Socioeconomics, Psychiatry, and
Habitual History:
Marital history: once in 1968
History of pregnancy/abortion/parturition: 8/0/8
1. 1969/female / term/ spontaneous/ midwife/ alive
2. 1972/ female/ term/ spontaneous/ midwife/ alive
3. 1975/ female/ term/ spontaneous/ midwife/ alive
4. 1978/ male/ term/ spontaneous/ midwife/ alive
5. 1982/ male/ term/ spontaneous/ midwife/ alive
6. 1985/ male/ term/ spontaneous/ midwife/ alive
7. 1987/ female/ 3500 gram/ term/ spontaneous/ midwife/
alive
8. 1990/ male/ 3400 gram/ 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 110/80 80 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 opening, OUE (+)
Laboratory Findings
Parameter Result Normal Limit Unit
Haemoglobin 12, 7 11,6 - 13,9 g/dL
Hematocrit 40 31 – 41 %
Leucocyte 9590 5,7 - 13,6. 103 /mm3
Thrombocyte 402.000 174 - 391. 103 /mm3
aPTT 37, 4 23.0 – 38.9 Seconds
PT 10,5 9.7 – 13.5 Seconds
Parameter Result Normal Limit Unit
RBG 91 < 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 4,1 3,5-5,1 Mmol/dl
Natrium 143 136-145 Mmol/dl
Chloride serum 108 97-111 Mmol/dl
Total Protein 7,8 6,6-8,7 g/dl
Albumin 4,8 3,8-5,0 g/dl
Globulin 3,0 1,3-2,7 g/dl
Total Bilirubin 0,6 0,3-1,0 Mg/dl
Bilirubin direct 0,2 <0,20 Mg/dl
Bilirubin indirect 0,4 <0,60 Mg/dl
SGOT 16 <32 u/l
SGPT 12 <31 u/l
Diagnosis :
Uterin prolaps Grade III
Management :
Control GA, VS
Informed consent
Crossmatch PRC 1 unit
Consult to internist, cardiologist and anesthesiologist
Report to Operating Room

Plan :
 Transvaginal Hysterctomy
04/10/2018 at 08.30 am
Transvaginal Hysterectomy and anterior- posterior colporrhapy were
performed
Intraoperative bleeding 100 cc

Diagnosis:
Post Vaginal Hysterectomy and anterior- posterior colporrhapy on
indication of uterine Prolaps stage III
Management:
Post operative monitoring
 Post Operative Follow Up

• Control GA, VS, Vaginal Bleeding

• Laboratorium post operative
• IVFD RL 20 gtt
• Ceftriaxone 2x1 gr (IV)
• Analgetic Suppose (if necessary)
Post Operative Laboratorium
• Hb : 11,2 g/dl
• Leucocyte : 11.220 /mm3
• Thrombocyte : 220.000 /mm3
• Hematocryte : 34 %
THANK YOU