Ms.

N, 19 yo, virgo, karonese, Senior High school, moslem once at

admitted to Gynecology Outpatient Clinic USU General Hospital on
November 06th 2019 with chief complained:

Cc: vaginal bleeding

E : This has been experienced by the patient since 1 year ago,
blood was clotting . Lower abdominal pain (+). History of vaginal
discharge (+) brown and fishy odor. History of itchy on genitalia (-),
menstruation frequencies 5 sanitary pads/day. Duration 2 weeks –
1 month.bleeding had active since 1 year. Diarrhea >5x/day since 1
week ago, history of abdominal massage (+). Defecation and
micturition showed no abnormalities.
Previous illness :-
Previous medication : -
Previous surgery :-
History of contraception: -

History of menstruation: Menarche at 12 y.o, regular cycle

28 days, 7 days, frequencies 4x
sanitary pads/day, menstrual pain (-).
Present State :
Cons : Fully Allert Anemic : (-)
BP : 120/80 mmHg Icteric : (-)
HR : 82 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,5 OC Edema : (-)
General condition: Moderate BW : 52 kg
Nutrition state : Moderate Height : 158 cm
Illness condition : Moderate BMI : 20.88

Localized State :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)
Neck : No abnormalities
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Abdomen : abdominal enlargment (+), perisltaltic (+) normal , solid mass was
palpable with upper pole on umbilical and lower pole difficult to
examine, flat surface,mobile , pain (-)
Extermitas : Oedem (-/-), Cyanosis (-/-)
Gynecological State
Abdomen : abdominal enlargment (+), perisltaltic
(+) normal , solid mass was palpable with
upper pole on umbilical and lower pole
difficult to examine, flat surface,mobile ,
pain (-).
Vaginal Bleeding : (-)

Gynecological state :
Inspeculo : not performed
Vaginal examination: not performed
TAS
TAS
TAS
TAS
 TAS
• Bladder filled.
• Anteflexion Uterus sized 15.3x 8.6x1/2 cm.
• Mass was found with size 4.1x4.0, 3.4 x 3.7,
4.1 x 4.2
Conclusion: Multiple uterine fibroid +
adenomiosis
 Laboratorium findings on September 16th 2019:
Hb : 13.8 N : 12-16 gr/dL
Leucocyte : 9170 N : 4000-11000/uL
Hematocrite : 42.4 N : 36,0-47,0/%
Platelet : 371.000 N : 150.000-450.000/uL
MCV : 85.7 N: 81 – 99
MCH : 27.9 N : 27.0 – 31.0
MCHC : 32.5 N: 31.0 – 37.0
Diagnosis :
Multiple uterine fibroid

Plan :
- Miomectomy on November 6th 2019

Reported to Supervisor dr. Oky Prabudi, M.Ked(OG), SpOG.K, 

Approved