Identity Mrs.

Yuli Yanti/ 27 YO/ 1120118/ PALEMBANG/URI-ARM/ HE

Chief complain Vaginal bleeding
Recent illness Chief complained: Vaginal bleeding
history Since 2 weeks before admission, patient admitted has vaginal bleeding, for 5x changing
13.02.2021 pad in 5 days and then 2-3x changing pad/days on red black colour, history of tissue
discharged (-), history of trauma (-), history of consume traditional medicine (-), history of
abdominal massage (-), history of post coital bleeding (-), history of leucorrhea (-), patient
had normal defecation and urination. Patient referred from Sriwijaya Hospital with
diagnosed AUB caused by C1 was suspected.
Prior history of Patient came to Sriwijaya Hospital with diagnosed AUB c.b C1 was suspected. Patient
illness was plan to performed curettage.
Marital status Married 1x for 10 years
Reproduction Menarche at 13 years old, cycle of 28 days, regular, for 7 days, LMP : December 20th
status 2020-December 25th 2020
January 12th 2021-January 16th 2021
January 29th 2021-now
Obstetric history P1A2
1. 2012, full-term, female, 3900 g, spontaneous delivery, midwife, stillbirth
2. 2018, abortion, 8 weeks gestation, curettage at Ar-Rasyid Hospital
3. 2019, abortion, 9 weeks gestation, curettage at Ar-Rasyid Hospital
Physical BP: 120/80 mmHg Pulse: 92 bpm T: 36.8oC, RR: 20x/minute
Examination BW 88 kg BH 155 cm
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement (-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Obstetrical External examination
examination Flat, supple, uterine fundal height unpalpable, tenderness (-), mass (-), free fluid sign (-)

Speculum examination
Unlivide portio, closed OUE, fluor (-), fluxus (+), not active bleeding,
erosion/laceration/polyp (-)
Vaginal Toucher
Firm portio, closed OUE, normal uterine size, no palpable mass in both adnexa,
rectovaginal pouch not protrude
US ERD Anteflexed uterus with normal shape and size 7,73x5,06x1,72 cm
-
ARM
Homogenous myometrium, regular basal stratum, endometrial line (+) 0,83 mm
13.02.2021 -
Both ovaries in normal limit, right ovary size 3,38x3,42x 3,02 cm and left ovary si
-
ze 3,51 x 1,23 cm
Liver in normal limit
-
Both renal in normal limit
-
C/ There wasn’t any abnormality in internal genitalia
Laboratory Hb 8,6 g/dL RBC 3910/m3m WBC 14740/mm3 Ht 29% PLT 448000/µL MCV 74,2 fL
examination
MCH 22 pg MCHC 30 g/dL DC 0/0/79/19/5 Reticulocyte count 2,39 PT 13,9 INR 1,03
13.02.2021
APTT 28,6 Fibrinogen 436 SI 45 TIBC 398 Albumin 3,8 UR 19 Cr 0,79 Ca 9,0 BSS 97
Na 146 K 4,2
HBsAg non-reactive VDRL non-reactive TPHA non-reactive Anti-HIV non-reactive
Urinalysis Blood +++ Eritrocyte 400-430
Diagnosis  Abnormal uterine bleeding caused by O1 was suspected
 Moderate anemia
Management · Observation of vital sign and bleeding
· Laboratory examination
· US confirmation
· PRC tranfussion until Hb >10 g/dL