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PATIENT IDENTITY
• Name : Mrs. L
• Age : 41 years old
• MR : 99 38 23
• Address : Pasaman
• Occupation : Housewife
ANAMNESIS
Chief Complaint
• A 41 years old patient was admitted to
ginecology ward of Dr. M. Djamil Central
General Hospital on November 28th, 2017 at
09.00 PM from polyclinic with diagnosis
multiloculare cyst ovarian neoplasm +
Multiple uterine myoma + toxic noduler goiter
PRESENT ILLNESS HISTORY
• Patient complaint about having a mass in her stomach since 1
years ago
• Bleeding from vagina since 3 days ago. Red blackish color.
Wetting 1-2 pads/day, without pain
• Nervousness (+), preference for heat (+), excessive sweating
(+)
• History of post coital bleeding (-), dispareunia (-)
• History of body weight extremelly decreasing (-)
• History of fever trauma and flour albus (-)
• Menstruation history : menarche at 13 years old, irregular
cycle, every month which last for about 4-5 days each cycle
with 2-3 times pas chnge /day without menstrual pain.
• Urination dan defecation was normal
PREVIOUS ILLNESS HISTORY
PREVIOUS ILLNESS HISTORY
• She has toxic struma goiter since 1,5 years ago, she get PTU and bisoprolol
from internist
•There wasn’t previous history of heart, lung, liver, kidney, DM, hypertension
and allergic reaction
Inspeculo
Vagina : Tumor (-), laceration (-), fluxus (-)
Portio : NP, size equal an adult thumb, tumor (-), laceration (-), fluxus (-),
OUE closed, sondage 7 cm
Diagnose
• Post Supravaginal Histerectomy on indication of multiple
uterine myoma
Th/
• IVFD RL 20 tpm
• Inj Ceftriaxone 2 x 1 gr
• Inf Metronidazol 3 x 500 mg
• Inj Tranexamid Acid 3x 500 mg
• Inj Vit K 3x 1 amp
• Inj Vit C 3x 1 amp
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Pronalgess supp
Laboratory finding
Nov 29th 17, 20.00 pm
Parameter Result Unit
Haemoglobin 11,5 g/dl
Leucocyte 17.790 103/mm3
Thrombocyte 230.000 103/mm3
Hematocrit 36 %
Follow Up Nov 30th 17
08.00 WIB
• Inj Ceftriaxone 2 x 1 gr
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Aff IVFD
• chateter
Follow Up Dec 2st
08.00 WIB
• Cefixime 2 x 200mg po
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• Aff Chateter
Follow Up Dec 3st
08.00 WIB
• Cefixime 2 x 200mg po
• Metronidazol 3 x 500 mg po
• Vit C 3x 1 tab po
• Asam mefenamat 3x500 mg po
• PTU 3x 100 mg
• Propanolol 2x 40 mg
• go home
Terimakasih