Professional Documents
Culture Documents
PREFACE
CHAPTER II
CASE
II.
PATIENTS IDENTITY
Name
Age
Gender
Religion
Address
Job
Marital Status
HPHT
Date of entry
Weight
Height
: Mrs. FH
: 44 years old
: Female
: Islam
: Muka Kuning
: Housewife
: Married
: 15 january 2016
: December, 8th 2016
: 55 kg
: 158 cm
ANAMNESIS
Patient come to obstetrics poli with complaint bleeding from vagina after
sexual intercourse since almost 1 month ago. She had much discharges
(leuchorrea) since 6 years ago thats clear and foul-smelly.
MAIN COMPLAINT
Bleeding from vagina after coitus since almost 1 month ago .
HISTORY OF PRESENT ILLNESS
A woman 26 years old by her own self went to obstetrics poli, hospital of
embung fatimah, batam city with complaint bleeding from vagina after
sexual intercourse since almost 1 month ago. She had much discharges
(leuchorrea) since 6 years ago thats clear and foul-smelly. She had checked
herself to clinics but it never get better.
Pregnancy history, patient born her first child: boy, weight : 3000 gr by
normal childborn at clinic on 2011.
PERIODS HISTORY
Patient admited, her first period at 14 years old. Her periods cycles regular
every single month. Periods cycles 28 days, for 3-5 days. LMLP is
November, 25th 2016.
MARITAL HISTORY
Married just once at 2003, she were 27 years old.
PREVIOUS MEDICAL AND OPERATIONS HISTORY
(-)
CONTRACEPTION HISTRORY
(-)
ALERGIC HISTORY
(-)
PREVIOUS ILLNESS HISTORY
(-)
FAMILYS ILLNESS HISTORY
(-)
III.
PRESENT STATUS
GENERAL STATUS
General Condition
Consciousness
Weight
Height
Blood Pressure
Heart Rate
Respirasi Rate
Temperature
: good
: compos mentis
: 55 kg
: 158 cm
: 110/70 mmHg
: 78x/i
: 20x/i
: 36,7 oC
PHYSICAL EXAMINATION
Head
: Conjungtivity : anemis (-)
sclera
: ikterik (-)
Neck
: Lymph gland
: normal
Thyroid gland : normal
Thoraks
: lung : - inspection : simetris
Heart
Abdomen
Ekstremity
normal
Percussion
: sonor at all lungs path
Auscultation : vesikuler (+/+), rhonki : (-/-),
wheezing (-/-)
: heart sound S1-S2 regular, murmur (-) gallop (-)
: tense looking dan glowing (+), bowel sound (+)
: Edema : -/Varises: -/Akral : warm (+)
IV.
LABORATORIUM
Routine Blood Test
Hb
: 14,8 gr/dl
Leukocytes
: 8.600
Ht
: 42%
Eritrocytes
: 5,5 juta/ul
Trombocytes
: 260 ribu/ul
Blood Group
: O Rh+
HIV
: negatif
HbSAg
: negatif
Blood Glucose : 135 mg/dl
V.
DIAGNOSE
Cervical Polyp
Follow up at ward
Date : December, 8th 2016
S
A
P
S
O
A
P
SURGERY REPORT
Pre-surgery Diagnose
Cervical Polyp
December, 9th 2016, surgery start at 11.25 and finish at 11.55. Patient on Litotomys
potition. On potition theres polip 3x2 cm. Doing extirpation and then DSL for
remove the polyp. Take the polyp to PA. And surgery done.
Diagnosis Post-operasi
Post Extirpation and DSL of Cervical Polyp
Post Surgery Treatment
A
P
(-)
General status: good
consciousness : compos mentis
blood ressure: 130/90 mmHg
heart rate : 83x/i
Respiratory rate: 20x/i
T : 36,7 C
General Physical Examination: Normal
Gynecology Examination: Blood (-)
Post Extirpation and DSL of Cervical Polyp
IVFD D5% 20 tpm
Asam mefenamat tab 3x500mg
Amoxycilin tab 3x500mg
SF tab 1x1
VI.
RESUME
Patient 44 years old, with cervical polyp. At December 8th 2016, patient
come by her own self to obstetrics poli, hospital of embung fatimah, batam
city with complaint bleeding from vagina after sexual intercourse since
almost 1 month ago. She had much discharges (leuchorrea) since 6 years
ago thats clear and foul-smelly. She had checked herself to clinics but it
never get better. Observation result, general condition : good, blood pressure
= 110/70 mmHg, heart rate= 78x/i, respiratory rate : 20x/i, temperatur =
36,7c,. Gynecology Examination: Blood spot(+).
CHAPTER III
THEORY
1
Definition
The cervix is a tubelike channel that connects the uterus to the vagina. A polyp is a
mass of tissue projecting from a mucous membrane. Cervical polyps are growths that
usually appear on the cervix where it opens into the vagina. Polyps are usually smooth,
soft, cherry-red to reddish-purple or grayish-white. They are considered fragile because it
is common for polyps to bleed when touched. They vary in size and often look like bulbs
on thin stems. Cervical polyps are usually not cancerous (benign) and can occur alone or
in groups. Most polyps are small, about 1 centimeter to 2 centimeters long. Because rare
types of cancerous conditions can look like polyps, all polyps should be removed and
examined for signs of cancer. (Harvard)
Ectocervical polyps can develop from the outer surface layer cells of the
Epidemiology
Polyps are rare, occurring in about one in every 10,000 women. They are more
common in women who have been pregnant more than once. More than 99% of
polyps are benign. The incidence of malignant polyps of the cervix is rare. Less
leading up to menopause.
Chronic inflammatory disease that irritates the cervix.
Clogged blood vessels in the cervix.
Manifestation
Cervical polyps often cause no symptoms. If symptoms do occur, they may
include:
Diagnosis
Diagnosing cervical polyps is relatively easy because they are usually clearly
visible during a pelvic examination. They appear red or purple fingerlike growths
9
the
endocervical canal
may be hypoechoic or echogenic
identifying the stalk attaching to the cervical wall helps differentiate it
Treatment
The most effective and least invasive way to remove polyps is with a
polypectomy during a pelvic exam. This can be done by gently twisting the polyp
until it is freed. After the polyp is removed, the base is cauterized to stop the
bleeding.
Depending on the size of the polyp, other methods of removal include:
Differential Diagnosis
For a polypoid lesion within the cervical canal consider:
Complication
10
Prognosis
The outlook is excellent. The vast majority of cervical polyps are not cancerous.
Once removed cervical polyps tend not to grow back on the original site.
However, they can occur in other parts of the cervix. For this reason, a regular
pelvic examination is recommended so that new growths can be spotted and
treated before they cause symptoms. (harvard)
CHAPTER IV
DISCUSSION
11
Theory
Symptos :
Supportive Examination
Inspeculo
Management
Theory
Polyp
Explaination
12
BAB V
CLOSING
A. CONCLUSION
Mrs. SP 26 years old come to clinic hospital of embung fatimah on
september 6th 2016 at 10 am with complain pain on her stomach for 3
days.
Ay physical and supportive examination, we find abdomen skin looks
strained and glowing, hurt (+), acites (+), and AFI >25 cm based on USG.
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BIBLIOGRAPHY
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