MORNING REPORT

GENERAL HOSPITAL OF WEST

NUSA TENGGARA PROVINCE
27 January 2021
Team in charge:
Intan, Osa
 PATIENT IN WARD

NO NAME AGE DIAGNOSE

1. Mrs. E 29 y.o Ovarian cancer
 CASE 1
IDENTITY
• NAME: Mrs. E
• AGE: 29 years old
• ADDRESS: Sukamulia, East Lombok
• ADMITTED: 26 January 2021
• MR NUMBER: 148598
 SUBJECTIVE
26/01/2021 MAIN COMPLAINT: Low back pain
11.00 WITA PRESENT MEDICAL HISTORY:
VK TERATAI Initially, patient felt there is a mass in her lower abdomen since 3 years ago, and she only felt pain
ROOM when she touched the mass. However, the mass grew progressively, and the patient began to felt
pain in the lower left abdomen that radiated to the waist. The pain was felt quite intense until it
disturbs her activities. Patient then went to the Selong Hospital and diagnosed with a left ovarian
cyst. There, surgical removal of the cyst and histopathological examination were performed
(October 2020). The results of histopathological examination showed malignancy. The patient was
then referred to the NTB General Hospital and has received one time chemotherapy since then.
Currently, the only remaining complaint is intermittent low back pain.
Weight loss (-), vaginal bleeding (-), urination and bowel disorders (-)

PAST MEDICAL HISTORY:

Left ovarian cyst sinistra (+), DM (-), Hypertension (-), allergy (-)

HISTORY OF FAMILY DISEASE:

 SUBJECTIVE
26/01/2021 OBSTETRIC HISTORY:
11.00 WITA 1. 2017/female/3300 gr/aterm/pervaginam/midwife
VK TERATAI
ROOM HISTORY OF CONTRACEPTION: Hormonal injection ± 3 years.
NEXT FAMILY PLANNING: Sterile

MENARCHE: 14 years old

HISTORY OF MENSTRUATION CYCLE: 1x every month, regular, duration 7 days, no
complaints
 OBJECTIVE
26/01/2021 GENERAL STATUS: Local Status:
11.00 WITA GC : well Eye : anemic -/-, icteric -/-
GCS : E4V5M6 Cor : S1S2 single regular, murmur (-),
VK TERATAI gallop (-)
ROOM BP : 120/80 mmHg
HR : 90 bpm Pulmo : vesicular (+/+), wheezing (-/-), rhonchi (-/-)
RR : 20 x/min
Abdomen:
Temp : 36,3°C Inspection : distention (-), scar (+)
SpO2 : 98% in room air Palpation : mass (+) in left lower quadrant, felt
hard, the size 3x2 cm, irregular
Body Weight : 50 kg surface, fixed, unwell border, pain on
Body Height : 150 cm palpation (-), hepar and lien not
BMI : 22,22 kg/m2 palpable.
Auscultation : bowel sounds (+) 12 x/min
Percussion : tympani at upper quadrant, dull at
lower quadrant
Extremity : edema (-/-), warm acral (+/+)
(-/-)
 OBJECTIVE
26/01/2021 OBSTETRICAL STATUS:
11.00 WITA Genitalia Examination:
VK TERATAI Inspection :
ROOM • Pubic area : growth hair pubic normal, excoriation (-), inflammation (-)
• Vulva area : Lesion (-), mass (-), inflammation (-)
• Mayor and minor labia : inflammation (-), gland bartholin swelling (-)
• Perineum : lesion (-), scar (-)

Inspeculo : not evaluated

VT :
• Vaginal wall  rugae normal, mass (-)
• Uterus  anteflexion
• Portio  smooth, mass (-)
• Left adnexa mass (+) felt hard, size 3x2x3 cm, irregular surface, fixed, unwell
border
• Right adnexa mass (-)
 LAB
Parameter Score Referral Score
HGB 12,5 12.0-16.0
WBC 8950 4000-10000
RBC 4.55 3.50-5.00
PLT 245000 150000-400000
HCT 40 36 – 48
MCV 88.5 80.0-100.0
MCH 27.4 26.0-34.0
MCHC 31.0 32.0-36.0
PT 13.1 11.5-15.5
APTT 33.7 28.0-38.0
 LAB
Parameter Score Referral Score
N-FBG 95 <160
RFT
Ur 19 10-50
Cr 0.7 0.6-1.1
LFT
SGOT 14 0-40
SGPT 14 0-41
ELECTROLYTE
Na 143 135-146
K 3.8 3.4-5.4
Cl 107 95-108
 LAB

Parameter Result Normal value

HBsAg Rapid Non reactive Non reactive
HISTOPATHOLOGIC
AL EXAMINATION
(15-10-2020)
 THORAX
RONTGEN
(30-12-2020)

Cor and pulmo in

normal range
 ASSESMENT
26/01/2021 • Ovarian cancer
11.00 WITA
VK TERATAI
ROOM

PLANNING
26/01/2021
11.00 WITA Planning Therapy: Planning Observation:
VK TERATAI • Pro surgical staging and • Monitoring general condition and vital
ROOM hysterectomy sign
THANK YOU