Case report No

Identity
Patient Husband
Name : Mrs. R Mr. B
Age : 48 YO 50 YO
Address : Lima puluh Kota Lima puluh kota
Education : Elementary school Elementary school
Occupation : House wife Entrepreneur
MR No. : 01 02 76 48
Date : October 2nd, 2018

A 48 years old patient was admitted to the gynecology ward

room of Dr. M. Djamil Central General Hospital on October 1st
2018 at 09.00 am referred from gynecology polyclinic diagnosed
with P2L2 + uterine myoma with cystic degeneration
 Present illness hystory

• Patient was complain enlargement of the lower stomach since 6

month ago
• History of lower abdominal pain (-)
• Vaginal bleeding (-)
• History of post coital bleeding (-)
• Dispareunia (-)
• History of fluor albus (-), fever (-), trauma (-)
• History of massive weight loss (-)
• Menstruation history : menarche at 13 YO, irregular cycle every
month which last for about 4-5 days each cycle with the amount
of 2-3 times pad changes/day without menstrual pain
• Patient has married, has 2 children
• Bowel and bladder was normal
Previous Illness History
• There was no previous history of heart disease, lung, liver,
kidney, DM, hypertension, and allergy
Family Illness History
• There was no history of contagious disease, hereditary and
physiological illness in the family
History of formal education : Elementary school
History of Occupation : house wife
History of contraception : (-)
History of Habit : Smoke (-), Alcohol (-),
Drugs addiction (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 110/70 78 20 36,7

BW : 65 kg
BH : 150 cm
Eyes : Conjunctiva wasn’t anemic; Sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, no enlargement of tyroid glands
Chest : Lung / Heart was Normal
Abdoment : GR
Genitalia : GR
Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
Gynecology record
Abdomen
I : seems a little enlarge
Pa : mass was palpated 2 finger below umbilical, mobile,
smooth surface, solid consistency, pressure pain (-), release
pain (-), DM (-)
Pe : Dull above mass
Aus : peristaltic sound was normal

Genitalia
I : V/U normal, vaginal bleeding (-)
Inspeculo
Vagina : Tumor (-), laceration (-), fluxus (-)
Portio : MP, size equal to adult thumb, tumor (-), laceration (-),
sondage + 9 cm AF

Bimanual VT
Vagina : Tumor (-) laceration (-)
Portio : Tumor (-) laceration (-)
CUT : AF, size as baby head
AP : Relax right and left side
CD : Not protruded
 Laboratory finding
Parameter Result Unit Parameter Result Unit
Haemoglobin 14,9 g/dl SGOT/SGPT 15/11 u/l
Leucocyte 8.610 /mm3 Ur/Kr 22/0,6 mg/dL
Thrombocyte 263.000 /mm3 Total protein 7,4 %
Hematocrit 44 % Albumin 4,6 u/l
PT 11,2 Detik
Globulin 2,8 mg/dL
APTT 35,3 Detik
Ca-125 24,9 < 35 U/ml
Natrium 143 mmol/L
CEA 3,11 0-5
Kalium 3.8 mmol/L
Chlorida 106 mmol/L
Calsium 9.2 mg/dl
USG
• Seems Uterus bigger than normal, size more than
monitor screen
• Seems appearance of Hypo and Hyperechoic mass,
feeding artery (+)
• Both adnexa were hard to identified
Impression : Uterine Myoma with cystic degeneration
Diagnose
P2L2 + uterine myoma with cystic degeneration

Management
Control GA, VS
Informed consent
Crossmatch PRC 2 unit
Antibiotic : Inj. Ceftriaxone 1 g IV (Skintest)

Plan
Elective Laparotomy on October 2nd 2018
October 2nd, 2018
Laparatomy was performed
- After peritoneum was opened, seems uterine bigger than
normal, size about a baby head, smooth surface, solid
consistency, pink color, no adhesion.
- Both Ovarian and tube were normal
- Impression : uterine myoma, plan: Total hysterectomy
- Total hysterectomy was performed

Diagnose
Post total hysterectomy oi of uterine myoma with cystic
degeneration
Plan
– Observation after operation
– Check Routine Blood test 6 hours after operation
– IVFD RL 20 dpm
– Inj. Ceftriaxone 2x1gr (IV)
– Inf. Metronidazole 3x500 mg (IV)
– Pronalges supp (if needed)
– Urine Catheter 4 days
THANK YOU