Name : Gender : Medical Record : Date : Anamnesis : Chief complain : History of presenting illness : Past medical history : Family

history Occupational , social economy , psychososial history : General Examination : Consciousness : Blood pressure : Pulse : Temperature : Respiratory rate : Cyanosis : General apperance : Nutritional state : Height : Weight : Edema : Anemic : Icteric :

Skin : Lymph nodes : Head : Hair : Eyes : Ears : Nose :

Throat : Mouth and teeth : Neck : Chest : Heart : Abdomen : Back : Genital : Anus : Extremities : Laboratory results and laboratory findings etc : Spesific laboratory findings : Others : Summary : Working Diagnosis : Treatment : Lungs :

List of problem 1. menometrorhagia ec hyperplatia endometrium Examination : anamnesa Phisical examinatio n Laboratory test

List of problem 20/4/2011 D/ S/ menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV Laboratory test

Follow up : 20/4/2011 D/ S/ menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV Laboratory test Thy/ transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1 R/ improvement of the general appearance

20.00 no complaint Thy/ continue

21/4/2011 A/ PF/ fever (-), urinate (+), defecate (+), painful (-) General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes : moderate : composmentis cooperative : 110/80 mmHg : 72 x/minute : 20 x/minute : afebris : anemic (+), icteric (-) : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1

R/

improvement of the general appearance

22/4/2011

A/ PF/

fever (-), urinate (+), defecate (+), abdominal pain (+), PPV (+) General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes : moderate : composmentis cooperative : 120/80 mmHg : 75 x/minute : 20 x/minute : afebris : anemic (+) decrease, icteric (-) : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1

R/

improvement of the general appearance

23/4/2011 A/ PF/ fever (-), urinate (+), defecate (+), PPV (-) General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes : moderate : composmentis cooperative : 130/90 mmHg : 84 x/minute : 20 x/minute : afebris : konjunctiva subanemic, icteric (-) : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1

asam mefenamat 3x1 R/ improvement of the general appearance

20.00 complaint (-) USG result (23-4-2011) Uterus AF, size 9,8 x 5,3 x 6,8 cm No appearance of mima or adenomiosis or hyperplatia endometrium Both of adnexa are normal Summary : no appearance of internal genitalia organic abnormality

24/4/2011 A/ PF/ fever (-), cough (-), urinate (+), defecate (+) General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes Thorax : moderate : composmentis cooperative : 130/70 mmHg : 78 x/minute : 20 x/minute : 36,7C : konjunctiva anemic, icteric (-) : cor and pulmo in normal range : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1

R/

improvement of the general appearance

25/4/2011 A/ PF/ fever (-), urinate (+), defecate (+), PPV (-) General appearance : moderate

Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes Thorax

: composmentis cooperative : 120/80 mmHg : 84 x/minute : 22 x/minute : afebris : konjunctiva anemic (-), icteric (-) : cor and pulmo in normal range : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1

R/

improvement of the general appearance

26/4/2011 A/ PF/ fever (-), urinate (+), defecate (+), PPV (-), lower abdominal pain (+) General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes Thorax : moderate : composmentis cooperative : 120/80 mmHg : 84 x/minute : 20 x/minute : afebris : konjunctiva anemic (-), icteric (-) : cor and pulmo in normal range : gynecologic examination

Abdomen and genitalia D/ S/ Thy/

menometrorhagia ec hyperplatia endometrium control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1

asam mefenamat 3x1 R/ repeat USG

27/4/2011 A/ (+) PF/ General appearance Consciousness Blood pressure Pulse Respiratory rate Temperature Eyes Thorax : moderate : composmentis cooperative : 130/90 mmHg : 72 x/minute : 20 x/minute : afebris : konjunctiva anemic (-), icteric (-) : cor and pulmo in normal range : gynecologic examination fever (-), urinate (+), defecate (-), PPV (-),lower abdominal pain (+), flatus

Abdomen and genitalia D/ - hyperplatia endometrium

- Suspect endometriosis (small) S/ Thy/ control the general appearance, vital sign, PPV transamin 3x1 vit K 3x1 vit C 3x1 asam mefenamat 3x1