Patient 1

Mrs. S, 60 yo, P6A0, Bataknese, Christian, Junior High School, Housewife,

married to Mr.S, Bataknese, Christian, Juniro High School, Employee. This
patient came to USU General Hospital at Dec 3rd 2019 at 12.00 AM with :

Cc : Protruded mass from vagina

E : This has been experienced by the patient since about 1 year before admitted
to hospital, and getting worsened. History of weight lifting (+). Pain was not
found. Difficulty of micturition (+), incontinensia, and defecation within
normal limit. This Patient was referred from Bethesda Clinic diagnosed with
Cystocele.
History of Previous Illness : -
History of Medication :-
History of Surgery :-
History of Contraception : Tubectomy
History of Menarche : 11 yo, 28 days cycle, regular, 3-4 times changing
pads per day, pain (-). Menopause 10 years ago
Vital Signs
Sens : Alert Anemic : (-)
BP : 120/80 mmHg Icteric : (-)
Pulse : 80 bpm Cyanosis: (-)
RR : 18 bpm Dyspnea : (-)
Temp : 36,7°C Oedema : (-)
General state : Good
Nutritional State : Good (BMI: 23 cm/kg m2)
Illness State : Good

Generalized Status :
Head : Conj. Palpebra inferior anemic (-)/(-), icteric (-)/(-)
Neck : Within no abnormalities
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rales (-)/(-)
Abdomen : Asymetrically enlarged, peristaltic (+) normal
Extermites : Oedem (-/-), Cyanosis (-/-)
 Pop-q Assesment

+3 cm + 5 cm + 4 cm

5 cm 2 cm 8 cm

-1 cm 0 cm 2 cm

Stress Incontinensia (+)

USG TAS
 USG TAS
• Bladder was filled
• UT AF, < normal size
• Both adnexa within normal limit
• Free fluid (-)

• Conclusion: Gynecology within normal limit

 Laboratory Findings
(December, 3rd 2019)
• Hb : 12,8 N: 12 - 14 gr/dL
• Leukosit : 5870 N: 4.000 - 11.000/u
• Hematokrit : 39.90 N: 36,0 - 42,0/%
• Platelet : 393.000 N:150.000 - 400.000/uL
• PT : 11.2 N : 14.3
• APTT : 28.9 N : 31.5
• TT : 14.4 N : 21.8
• SGOT : 21 N : 5 - 35
• SGPT : 15 N : 5 - 35
• KGD ad : 123 N: <200
• Ureum : 21.2 N: 15 – 40 mg/dL
• Creatinin : 0,49 N: 0,6 – 1,1 mg/dL
• Na : 142 N : 135 – 155
• K : 4.16 N : 3.5 – 5.0
• Cl : 104 N : 96 – 106
• HbsAg : Non Reactive
• HIV : Non reactive
• Urinalisis : Normal
Diagnosis :
Uterine prolapse grade II + Cystocele grade III +
Rectocele grade II

Plan :
KA surgery on Wednesday, December, 4th 2019

Reported to supervisor on duty dr. Edy Ardiansyah,

M.Ked(OG), SpOG(K)  approved
THANK YOU