Name Age MR No.

Address

: Mrs. Bayarti : 53 years old : 75 51 00 : Sungai Limau, Padang Pariaman

Anamnesis : A 53 years old patient was admitted to the gynecologic room of dr. M. Djamil Hospital padang on sept 20th 2011 sent by polyclinic with diagnosed ovarian cyst pro laparatomy. Present Illness History : Swelling on her stomach was felt since 2 months ago, pain (-). Vaginal bleeding out of menstrual cyce was absent First date of Last menstrual period was agust 24th 2011 Menstrual history : menarche at 12 years old, regular cycle once a month, which last for 67 days, for 2-3 times pad changed/day, pain (-). Histoy of memstruasi pain was (+) when young, and disappear History of fever (-), trauma (-), leukore (-) Patient had marriage, have 4 child, the youngest 24 years old History of loss weight was deny. Bladder and bowel was normal. Previous Illness History : There wasnt previous history of heart, lung, liver, kidney, DM, hipertention Family Illness History : There wasnt history of contagious disease, hereditary and physicological illness in the family Physical Examination : GA Cons BP PR Mdt CMC 120/80 84 Eyes Neck Chest Abdoment Genitalia Extremity

RR 20

T 370c

Weight 70 kg

Height 160 cm

: conjunctiva wasnt anemic, sclera wasnt icteric : JVP 5-2 cmH2O, tyroid gland no enlargement : H/L normal : Ginekology record : GR : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Gynecologic Record Abdoment : I : enlarged slightly, cicatric (-) Pa : cyst mass was palpated as high as umbilicus, size equal to baby head, smooth surface, mobile, pressure pain (-), release pain (-), muscular defense (-) Pe : tymphani Au : Peristaltic sound (+) normal Genitalia :I V/U normal Inspekulo : Vagina : tumor (-), leceration (-), fluksus (-) Portio : MP, size equal to an adultfoot toe, tumor (-), laceration (-), fluxus (-)

OUE was closeded, uterus sonde 7 cm, antefleksi. VT bimanual : - Vagina : tumor (-) - Portio : MP, size equal to an adultfoot toe , tumor (-). - CUT : cannt evaluation AP : right : cyst mass was palpated, size equal to baby head, smooth surface, pain (-) left : weak. CD : didnt protrude, under pool mass was palpated, cystic, smooth surface, pain (-). Laboratorium : Hemoglobin : 13,1 g% Leukosit : 6.600/ mm3 Hematokrit : 39% Trombosit : 196.000/ mm3 PT : 11,4 detik APTT : 29,0 detik GDS : 97 mg/dl Total Protein : 5,8 /dl Albumin : 4,3 g/dl Globulin : 1,5 g/dl SGOT : 16 u/l SGPT : 14 u/l Ureum : 16 mg/dl Kreatinin : 0,7 mg/dl Kalsium : 7,1 mg/dl Natrium : 141 mg/dl Kalium : 4,1 mg/dl Klorida : 109 mg/dl Ca 125 : 37,00 U/ml Internal Consultation result

Diagnosis : ovarian cyst Management - Control GA, VS - Informed consent - Prepare for transfusion blood Plan : Laparotomy

Sept 21th 2011 At 12.00 am : Laparotomy was perfomed At 01.00 pm : Finished laparotomy After peritoneum was opened, theres a cocolte mass, Perform exploration : the mass size equal to baby head , cystic consistency, smooth surface, adhesion (-). the mass was from right ovarian. Uterus, left tube and ovarian size and shape smaller was normal. Adesion (-), asites (-), there is no sign of malignancy. Impression : left ovarian neoplasm Plan : rightt salfingooovorectomy rightt salfingooovorectomy and pomeroy tubektomi was done Bleeding during operation was about 100 cc pomeroy tubetomi sinistra

Diagnose : Post right salfingooovorectomy on indication of right ovarian cystic and post