PRE-OPERATIVE PLANNING RESUME

MONDAY, 24TH FEBRUARY 2020

COT I

Date of visit/ hospitalized 19-12-2019

Identity
Name Dewi Kurniawati
Med Rec/ Reg 0001154131
Age 30-05-1999 ( 20 yo)
Address Air Kumbang, Banyuasin
Operator Dr. Amirah Novaliani, SpOG (K)
Resident dr. Andini Zuitasari
Anamnesis
Chief complaint Abdominal mass
History Since 1 month before admission, patient
felt there was a mass in abdomen and
become bigger.

History of vaginal bleeding (-), history of

dyspereunia (-), history of post coital
bleeding (-), history of loss of apatite
(-).Patient admitted had pain during
urination, blood (-), history of weight
loss (-)
Past operation & Past Illness (-)
Marrital Married 1x for 3 years
Obstetric P1A0
Menstrual Menarche 12 yo, regular, LMP :
November
Economic and nutrition status Moderate
Physical examination
General condition Good RR 20 x/m
Sens CM Pulse 80 x/m
BP 120/80 mmHg Temperature 36,5oC
Weight N/A kg Height N/A cm
Gynecology status PL flat abdomen, supple, mass (-), 1
fingers above umbilical, mobile, size
20x20 cm, tenderness (-), free fluid sign,
with lower border in symphysis, right
border in right LAA, left border in left
LMC
Insp : portio didn’t livide, closed OUE,
erosion (+), laceration (-), polyp (-)
VT : portio firmed, closed OUE, CUT ~
normal, both AP was supple, CD didn’t
protruded
Test Pack (+)
US Result - Anteflexed uterine, normal shape and
19-12-2019 size, homogen myometrium, regular
(Dr.Amirah Novaliani, SpOG (K)) basalis stratum, opened uterine cavity
- There was hypoechoic solid mass with
vascularization (+), RI 0,22 ~ left solid
ovarian neoplasm malignancy was
suspected
- Righ ovary in normal limit
- Both renal in normal limit
- Hepar and lien in normal limit, there is
no metastases node

C/ left solid ovarian neoplasm with

malignancy was suspected

Adviced : Laboratory examination (LDH,

APP, B-HCG)
 -

Radiology Result (-)

Laboratory examanination Hb 12,6 g/dL WBC 6450/mm3 Ht 37%
20-12-2019 PLT 373000/mL PT 15,1 INR 1,6 APTT
28,5 SGOT 32 U/L SGPT 5 U/L
Albumin 4,5 g/dL BSs 76 mg/dL Ureum
15 mg/dL Creatinin 0,59 mg/dL Ca 8,9
mg/dL Na 144 mEg/L K 3,9 mEg/ Cl 110
mmol/L
Diagnosis Solid ovarian neoplasm malignancy was
suspected
Planning Laparotomy FS