CASE REPORT

N0. 15
Name : Mrs. E
Age : 48 years old
MR No. : 912481
Address : Solok
Date : May, 08th 2015
Anamnesis :
A 48 years old patient was admitted
to Emergency Room of Dr. M. Djamil Central
General Hospital on May 04th, 2015 at 03.00
pm with chief complain bleeding from
vagina since 5 days ago
Present Illness History :

 Bleeding came out from vagina since 5 days ago,

wetting 1 piece of underwear, red-black, cob,
amount 4-5x change of pad/day, without pain
 Initialy, patient had the vaginal bleeding in 2012. She
got the medication from gynecologist in Solok
general hospital, curetage was performed with result
endometrial polyp. She got 8 unit of PRC.
 In 2015, the patient have controlled to Solok General
Hospital 1 month ago with chief complain vaginal
bleeding, and then curettage was performed, with
result non atypical simplex endometrium hiperlplasia
and have got drug but no improvement. She got 2
unit of PRC at RSUD SOlok
 Menstrual history : menarche at 13 years old, irregular
cycle, during 5-7 days, change of pad 2-3x/day,
pain (-)
 Complain enlargement of the abdomen
was absent
 History of dyspareunia and post coital
bleeding was denied
 No history of fever, trauma, flour albus
 miction and defication was normal
 Patient have 3 children, the younger is 17
years old
Previous Illness History :
There wasn’t previous history of heart, lung,
liver, kidney, DM and hypertension and
drug allergy

Family Illness History :

There wasn’t history of hereditary disease,
contagious and phsycological illness in the
family
Physical Examination :
GA Cons BP PR RR T
Mdt CMC 130/70 85 20 37

BW : 52 kg
BH : 150 cm
BMI : 22,7 kg/m2

Eyes Conjunctiva was anemic,

Sclera wasn’t icteric
Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment Gyn Record
Genitalia Gyn Record
Extremity Edema -/-
Gynecologic Record :

Abdoment :
I no enlargement, linea mediana sicatrix, previous
cesarean section
Pa no mass was palpable
pressure pain (-), release pain (-), DM (-)
Pe thympani
Au Peristaltic sound normal
Genitalia :
I : V/U normal, vaginal bleeding (+)
Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (+) seem
red black blood in posterior of fornix
Portio:
MP, size equal to an adult thumb, tumor (-),
laceration (-), fluxus (+), seem red-black blood
ooze from canalis cervicalis, OUE was closed,
sondage 7 cm
VT bimanual :
vagina : tumor (-)
portio : MP, size equal to an adult
thumb, posterior, pain (-)when moved,
OUE closed
CUT : Anteflexion, size equal to chicken egg
A/P : normal
CD : not protruded
Laboratory :
Hb : 8,9 gr% (12-14)
Leucocyte : 7.000/mm (5000-10000)
Hematocrit : 27 % (37-43)
Trombocyt : 342.000/mm3 (150000-400000)
Eritrocyt : 3,9 x 106 /mm3 ( 4-5 x 106 )
Diagnose :
Abnormal uterine bleeding caused by
endometrial hyperplasia + with failure of
medical treatment+ moderat anemic (Hb : 8,9
gr%)

Management :
Control GA, VS, vaginal bleeding
Informed consent
Tranfusion of PRC

Plan :
Improve of condition
Patient in care during 3 days and has got 2
transfusion of PRC
Anamnesis :
Vaginal bleeding (+), Febris (-)

Physical
GA Examination
Cons BP : PR RR T
Mdt CMC 130/70 85 20 37

Abdomen : Gynecologi record

Genitalia : Gynecologi record
Laboratory :
Hb : 10,8 gr% (12-14)
Leucocyte : 6.700/mm (5000-10000)
Hematocrit : 34 % (37-43)
Trombocyt : 326.000/mm3 (150000-400000)
Diagnose :
Abnormal uterine bleeding caused by non-
atypical simplex endometrial hyperplasia with
failure of medical treatment

Management :
Control GA, VS, vaginal bleeding
Informed consent

Report to consultant :
Prepare to Hysterectomi

Plan :
Hysterectomi
May 08th, 2015
 At 09.30 am laparatomy was perfomed
when peritoneum was opened, no adhesion, exploration
was performed, uterus size equal to chicken egg. Both of
Adnexa were normal
Total hysterectomy was performed
blood during operation ± 100 cc

Diagnosed :
Post Total Hysterectomi on indication abnormal uterine
bleeding caused by simplex endometrial hyperplasia with
failure of medical treatment

Management :
Post procedure observation
Post Op
Laboratory :
Hb : 10,7 gr% (12-14)
Leucocyt : 15.300/mm (5000-10000)
Hematocryt: 33 % (37-43)
Trombocyt : 157.000/mm3 (150000-400000)
Thank you