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Tri Supartini/48/UA
Anamnase
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:
Diagnosis and
Planning
Diagnosis:
Ca Cervix std IB
Planning :
Radical
hysterectomy
DPJD : RT
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
Diagnosis:
Adenomyosis
uteri
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 :
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:
Diagnosis:
Cystic ovarium
neoplasma
papiliferum sinistra
Planning :
Laparatomy VC
DPJD : RT
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:
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 :
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:
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 :