RM 10 Date: 19/9/11 time: 19.00wib Ms.

D, 29 years old, virgin, Javanese, Muslim,was admitted to Haji Adam Malik General Hospital with: Chief Complain: vaginal bleeding History: It was experienced since 2 days .Color of the blood is red, blood clotting(+),volume 5x changed pad/day. History of massage (-), history of trauma (-), white discharge (+), bad odor (+), itchy (+). Patient also complained abdominal enlargement since 1 year, which gradually grew. Heart burn (+). Decreasing of appetite (+), decreasing of weight (+), nausea (+), vomiting (+). Mixturation (+), Defecation (+) normal. History of prolonged menstrual cycle and a lot of blood (+) since 1 year. History of illnesses: History of medications: History of menstruation: menarche since 13 years old, irregular, duration 3-5 days, volume 2-3x change pad/day, menstrual pain (+). Last menstruation : ?-08-2011. History of long menstrual cycle and a lot of blood (+) with 10-15 days duration, volume 5-7x change pad/day . History of operations : Present status: Sense : Compos mentis BP HR RR T : 100/70 mmHg : 100x/I : 20x/I : 39 C Anemia Icteric Dyspnoe Cyanose Edema : (+) : (-) : (-) : (-) : (-)

Localize status: Abdomen : soepel, peristaltic (+), palpable cycstic mass with upper margin between umbilicus and xyphoid process, lower margin is on the symphisis area, mobile, flat surface, muscular rigidity (-). Vaginal Bleeding: (+)

Inspeculo / VT: not performed Digital Rectal Examination: Sphincter ani tight, mucosa smooth, ampula recti empty, uterus cannot be evaluated, parametrium right=left tense, palpable cystic mass as big as 32-34 weeks pregnancy age, mobile, flat surface. Laboratorium Result (19/09/2011) -Hb: 4gr/dL -Leucocyte: 19.740/mm3 -Ht: 13.1% -Thrombocyte: 315.000/mm3 USG TAS(19/09/2011) - urinary bladder filling good -uterus AF size 8.18x4cm -hipo and hiperechoic is seen all around the abdominal area with unmeasurable size, septa (+), papille (-) - free fluid (-) Conclusion: Permalignant cyctic adnexa tumor Diagnosa: PUD + cyctic adnexa tumor + anemia Therapy: -IVFD RL -> cor 2 flask -> continue RL -> 30gtt/i - Ceftriaxone inj 1gr/12hours -Transamin inj 1amp/8hours -Ranitidine inj 1amp/12hours -Paracetamol tab 3x500mg R/ - transfusion PRC: Needs: Hb x weight x 4

= (10 4) x 40 x 4 = 6 x 40 x 4 = 960cc = 6 bags of PRC @ 175 cc per bag. -USG : supervisors comfirmation Report supervisor oncall, Dr. D. A. , SpOG -> Acc

Laboratorium : Tumor marker (20/09/2011) -AFP (Alpha feto protein): 29.27 ng/mL -CEA: 0.5 ng/mL -CA 125: 48.18 U/mL Faal Hemostasis (21/09/2011) -Feritin: 411.60 ng/mL - Iron (Ferum): 16 mg/dL -TIDC: 193 g/dL Hematologi (22/09/2011) -Reticulocyte: 2.54 % - Ret. He : 16.3 pg

Consultation (20/09/2011): Name: Rospita Handayani Age: 29yo Sex: Female MR: 487286

Consult to: Internal Medicine Subdivision : HOM Diagnose: Solid Adnexa Tumor Susp. Malignancy + Anemia ec ? Chief complaint: Malaise Present status: Sense: Compos mentis BP: 100/70 mmHg HR: 100x/I RR: 20x/I T: 39 C Laboratorium (10/09/2011): -Hb: 4gr/dL -Leucocyte: 19.740/mm3 -Ht: 13.1% -Thrombocyte: 315.000/mm3 - D dimer: 760 -Alb: 2.3 -Na/K/Cl: 130/3.4/99 Request consultation: Request consultation on theraphy advice dan transfusion tolerance for our patient who is up for 6 bags of PRC transfusion. Thank you for your cooperation. Consultants Feedback: With all due respect, Thank you for the consult, from history taking, physical examination, diagnosyic examination : Anemia : + Icteric : Dyspnoe: Cyanose: Oedema: -

Dx: Anemia ec - Chronic disease + Solid Adnexa Tumor suspect malignancy + Hipoalbuminemia -Def. Ferum Hemorrhage

Transfusion tolerance: Low-risk Suggestions: - Pretransfusion capillary blood test SI/TIBC/Feritin Reticulocyte

Follow-up on 23th Sept 2011 Complaint: continuous bleeding Present status: Sens BP HR RR T : Compos Mentis : 100/40mmHg : 116 bpm : 20 bpm : 38.4oC Anemic Icteric Cyanosis Dyspnoe Edema : (-) : (-) : (-) : (-) : (-)

Localized status Abdomen : soepel, palpable mass (+), semi-solid with upper margin between umbilical and processus xiphoideus, lower margin on the simphisis, smooth, mobile (+), pain (+). : (+), twice a day : (+) : (+)

Genital: Vaginal Bleeding ` Mixturition Defecation Diagnosis Therapy

: Solid Adnexa Tumor suspect malignancy with anemia :

-IVFD RL 20 gtt/i - Ceftriaxone inj. 1 gr/ 12h Planning

-

: Repeat routine blood examination ECG Chest X-Ray Continous transfusion (2 bags left)