Mrs.

Tri Supartini/48/UA
Anamnase

Physical Examination and supportive

exam

CC : Vaginal
bleeding
Since 1
months ago os
complain
vaginal
bleeding os
come to
gynecoogist
and said that
she have
cervical
cancer
stadium IB
and scheduled
to be operated
Previous
illness:

Menstrual : Menarche 14 years old, 28 days for 5 days,

Marrital : 1 times, 19 years
Obstetric : P1A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not
palpable, Tenderness (-), mass (-), Free fluid sign (-)
Inspekulo: Portio irreguler, fragile, easy to bleed, mass (+)
exophylic size 1x1 cm fluor (-), fluxus (+) , E/L/P (-)
VT :Portio irreguler, mass (+) exophylic 1x1 cm, fragile, easy to
bleed Right and Left AP no tense, no protution in cavum of
Douglas
RT : anal sphincter tone normal, rectal ampulla empty,
intralumen mucuos (-)
USG Confirmation :
- Uterus RF size and shape normal
- Endometrial line (+) thickness 0,2 cm, homogen , portio and
endocervix normal
- Both ovarium normal, right ovarium 2,0x1,4 cm and left
ovarium 1,7x1,5 cm
- Both renal normal
Result:There is not abnormakity in internal genitalia
Laboratory Finding : Hb: 10,3; Eritrosit: 3,65; Leu: 8,1 ;Ht: 31; Trombo: 481000; DC:
0/2/67/23/8; SGOT : 17; SGPT: 9; Alb: 3,7

Diagnosis and
Planning
Diagnosis:
Ca Cervix std IB
Planning :
Radical
hysterectomy
DPJD : RT

Mrs. Rusmala Dewi/38/UA

Anamnase

Physical Examination and supportive exam

Diagnosis
and Planning

CC : Want to
operate
Os complain
dismenorrhae
that disturbing
her dail
activity
accompanied
by vomitting
(+), nausea (-)
foot spasm
(+), the pain
started 1 days
before the
preiod until
the period is
over. Os
consuming
analgesia and
said that the
drugs reduce
the pain,
whittish
history (-),
osthen come
to
gynecologist

Menstrual : Menarche 12 years old, regular 28 days for 7 days,

Marrital : Obstetric : P0A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not palpable,
Tenderness (-), mass (-), Free fluid sign (-), operation scar good.

Diagnosis:
Adenomyosis
uteri

RT : anal sphincter tone normal, rectal ampulla empty, intralumen

mucuos (-), slick mucose

USG Confirmation :
- Uterus become bigger and irregular,
- In posterior corpus there is a hyperechoic mass with no
demarcated border size 5,3x4,0x6,3 cm probably a
adenomyosis uterii
- Endometrial line (+) o,3 cm stratum basalis reguler, endocervix
and portio normal
- Right adnexa : non visible ovarium, there is a cystic mass with
tissue border size 2,6x1,7x1,6 cm probably a pseudocyst
- Left adnexa : left ovarium stick to uterine, visible custic mass
with echo interna size 3,1x2,1 cm probably a endometriois cyst
Result : - Adenomyosis uterii + left endometriosis cyst
- Stickyness of internal genitalia
- Post SOD ?
Laboratory Finding :
Hb: 12,8; Eritrosit: 4,42; Leu: 7,0 ;Ht: 39; Trombo: 267000; DC:
0/3/60/31/6; SGOT : 16; SGPT: 8; Alb: 4,1

Planning :
Laparatomy
DPJD :

Mrs. Terisna Wisni Utama/21/RA

Anamnase

Physical Examination and supportive

exam

Diagnosis and
Planning

CC :
Abdominal
Enlargement
Since 1
months ago os
complain her
stomach
become
bigger. Os go
to
gynecologist
and being said
that she have
a cyst. Os
then referred
to RSMH
Previous
illness:

Menstrual : Menarche 15 years old, last menstrual period

23/9/2016
Marrital : Obstetric : P0A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not
palpable, Tenderness (-), Free fluid sign (-), cystic mass size
15x18 cm upper border 4 finger below proc. Xyphoideus, left
border LMC sinistra, right border LMC dextra, lower border
symphysis
Inspekulo:
VT :
USG Confirmation :
- Uterus AF size and shape norma, Endometrial line (+) 0,3 cm,
stratum basalis reguler, endocervix and portio normal
- Visible cystic mass with papile papile size 1,4x1,1 cm and
1,6x1,4 cm there is no echointerna pictured, come from left
adnexa filing almost all of abominal cavity, with size that can
be measure by probe 155,4x11,3x15,8 cm probaly a cystic
ovarium neoplasma papiliferum permagna sinistra
- Right ovarium normal, size 3,0x1,5 cm
- Liver and Both renal normal
- Ascites (-)
Result:Cystic ovarium neoplasma with malignancy possibility
Laboratory Finding : -

Diagnosis:
Cystic ovarium
neoplasma
papiliferum sinistra
Planning :
Laparatomy VC
DPJD : RT

Mrs. Yesi Noviyan Sari/28/RA

Anamnase

Physical Examination and supportive

exam

CC : Prolong
Abdominal
Pain
Since 1
months ago os
complain
continously
abdominal
pain even
outside the
menstrual
period, the
pain feel like
tingling in her
abdomen,
vaginal
bleeding
history (-)
Previous
illness:

Menstrual : Menarche 14 years old, regular 28 days for 7

days,
Marrital : 1 times, 7 years
Obstetric : P1A2
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not
palpable, Tenderness (-), mass (-), Free fluid sign (-)
Inspekulo : Portio non livide, no cervical opening, fluor (+), fluxus (-),
E/L/P (-), sondae RF 6 cm
VT : Portio ellastic, no cervical opening, CUT normal, Adnexa
parametrium not palpable, no protution in cavum of Douglas

USG Confirmation :
- Visible uterine RF, size and shape normal with bump,
endometrial line 0,43cm
- Visisble a hipoechoic with demarcated border size 0,57x4,44
cm probably a myoma submucose
- Visible right ovarium with size 11,41x3,03 cm, visible a
polycystic right ovarium with size 2,11x2,84 cm
- Visible left ovarium with size 8,68x3,43 cm
Result : myoma submucose and right ovarium polycystic
Laboratory Finding :
Hb: 12,0; Eritrosit: 4,31; Leu: 5,2 ;Ht: 36; Trombo: 217000; DC:
0/2/63/30/5; PT: 14,4; APTT: 33,6

Diagnosis and
Planning
Diagnosis:
Myoma uteri
submucose
Planning :
Myomektomy
DPJD :

Mrs. Tri Handayani/34/UA

Anamnase

Physical Examination and supportive

exam

CC : Leaking
pee from
vagina
Since 6
months ago os
complain
leaking pee
from vagina,
os changing
tampoon 4-5
times/day. os
have a SC
operation
before in
muhammadiy
ah hospital
and leaking of
pee begin to
appear after
the operation
Previous
illness:

Menstrual : Menarche 14 years old, regular 28 days for 7

days,
Marrital : 1 times,
Obstetric : P1A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine not
palpable, Tenderness (-), mass (-), Free fluid sign (-),operation
scar good
Inspekulo : visible fistule in anterior vagina in13.00 size 1 cm, metylen
blue tes (+)
VT :visible fistule in anterior vagina in13.00 size 1 cm, metylen blue
tes (+)

USG Confirmation :
- Visible uterine RF, size and shape normal, endometrial line
0,25cm, homogen miometrium, endocervix and portion
normal
- Both ovarium norlmal
- Visible defect with size 0,55cm with fistulation from vesica
urinaria to vagina with reflux urine (+) probably a vesica
vagina fistule
Result : Vesica vagina fistule
Laboratory Finding :
Hb: 11,2; Eritrosit: 4,29; Leu: 6,7 ;Ht: 36; Trombo: 319000; DC:
0/3/58/35/4; PT: 12,2; APTT: 42,4; Ur: 19; Cr: 0,69

Diagnosis and
Planning
Diagnosis:
Vesica vagina
fistule
Planning :
Repair fistule
DPJD :