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Culture Documents
36
Name
: Mrs. N
Age
: 45 years old
MR No. : 891065
Date
: May 11th, 2015
History Taking :
A 45 years old patient was admitted to
the gynecology ward room of Dr. M.
Djamil Central General Hospital on
may 11th , 2015 with chief complain
bleeding from vagina since 3 days ago,
there is no bleeding now. The patient
feels fatigue and weakness.
Physical Examination :
GA
Cons
BP
Mdt
BW
BH
BMI
CMC
100/70
PR
RR
84
20
37
: 48 kg
: 150 cm
: 21,33 kg/m2
Eyes
Neck
Chest
Abdoment
Genitalia
Extremity
Gynecologic Record :
Abdomen :
I
abdominal enlarge,
Pa a solid mass was palpable 3 finger
above
SOP, mobile, pressure pain (-),
rebound tenderness (-), DM (-)
Pe dull above mass
Au normal peristaltic sound
Genitalia
I :V/U normal, no vaginal bleeding
Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (-),
Portio : NP, size equal to an adult thumb,
tumor (-),
laceration (-), fluxus (-) ,sondage
curette bump(+).
VT bimanual :
vagina : tumor (-)
portio
: MP, size equal to an adult
thumb,
move when the mass moved,
closed OUE
CUT
: as big as adult fist
A/P
: supple in left and right side
CD
: not protruded
Hemoglobine
Leukocyte
Trombocyte
Result
4,4
10.300
266.000
Normal Value
12-14
5,0-10,0
150-400
Unit
g/dl
103/mm3
103/mm3
Hematocryte
Erytrocyte
MCV
MCH
MCHC
15
2.830.000
54
15
15
37,0-43,0
4,0-4,5
82-92
27-31
37-43
%
/mm3
fL
Pg
%
PT
10,2
10,0-13,60
second
APTT
34,5
29,20-39,40
second
INR
0,95
< 1,2
USG (13/5/2015)
Ultrasound
(13/05/2015)
AF uterus with 12,0 x 7,1 x 6,6 cm in size
Endometrial line was pushed to posterior
side
An hyperechoic mass from anterior corpus,
3,8 x 4,7 cm in size, feeding artery (+)
Right ovary 4,7 x 2,4 cm in size
Left ovary 2,4 x 2,8 cm in size
Impression:
Uterine myoma
Diagnose :
Uterine myoma+ severe anemia
Management :
Control GA, VS
Informed consent
Consult to internist departement
Blood transfusion
Plan: improvement general appearence
Result
12,6
4.730
177.000
Normal Value
12-14
5,0-10,0
150-400
Unit
g/dl
103/mm3
103/mm3
Hematocryte
38
37,0-43,0
PT
11,1
10,0-13,60
second
APTT
35,5
29,20-39,40
second
INR
0,97
< 1,2
Diagnose :
Uterine Myom
Management :
Control GA, VS
Informed consent
Consult to anesthesiologist
Plan :
Laparotomy Hysterectomy
Diagnosed :
Post Totalhysterectomy o.i uterine myom
POST OP
Hemoglobine
Leukocyte
Trombocyte
Result
12
15.900
229.000
Normal Value
12-14
5,0-10,0
150-400
Unit
g/dl
103/mm3
103/mm3
Hematocryte
39
37,0-43,0
Thank you