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COT I

(1) Mrs. ASN/ 57 YO/ 1082139


Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC : Abdominal Menstrual : Menopause since 5 years ago Diagnosis:
enlargement Marrital : Married 1x, 42 years Cystic ovarium
Obstetric : P3A0 neoplasm
Since 3 months before suspected for
admission, patient has Prior operation : - malignancy +
been complaining about Physical examination : massive ascites
abdominal enlargement. BP : 120/80 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5ºC
Patient denied any General status : Normal Planning :
vaginal bleeding and Laparotomy VC
post coital bleeding. Gynecologic status :
Patient had normal Abdomen : Raised, tense, symmetrical, Fundal of uterine hard to assess, tenderness (-), Doctor in charge :
urinary routine and Free fluid sign (+) AM
bowel habits. Patient
experienced lost of Vaginal Speculum exam: Portio non livide, Closed OUE, Fluor (-), Fluxus (-), E/L/P (-),
appetite and weight loss. protrusion of Cavum Douglass

Previous illness: - Vaginal Toucher: Portio elastic, Closed OUE, CUT~hard to assess, tense right AP and Left
AP

Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the recty, MIL
(-)
(1) Mrs. ASN/ 57 YO/ 1082139
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :

Laboratory examination :
(2) Mrs. WIR/ 54 YO/ 1076265
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Abdominal enlargement Menstrual : Diagnosis:
Marrital : Bilateral solid ovarium
Since 1 month before Obstetric : neopkasm suspected
admission patient has been for malignancy +
complaining about Prior operation : ascites
abdominal enlargement Physical examination :
without vomitting and BP : 120/80 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5ºC Planning :
nausea. Patient experienced General status : Normal Laparotomy VC
loss of appetite and weight
lost. Patient had normal Gynecologic status : Doctor in charge :
urinary routine and bowel Abdomen : Raised, supple, symmetrical, mass (+), upper border – 4 fingers below processus IS
habits. Patient went to xyphoideus; lower border – symphisis; right border – right LMC; left border – left LMC
Bunda Hospital in Palembang
and had been told that she Vaginal Speculum exam: Portio non livide, Closed OUE, Fluor (-), Fluxus (-),E/L/P (-)
had tumor in her abdomnen
and planned to undergp Vaginal Toucher: Portio elastic, Closed OUE, CUT~normal, non tense right AP and Left AP, cervical
tumor excision operation. motion tenderness (-), no protrusion of Cavum Douglas
Patient then consulted to
Internal Division, got Chest Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the recty, MIL (-)
Xray with the result of fluid
in her lung.

Previous illness: -
(2) Mrs. WIR/ 54 YO/ 1076265
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus AF, enlarge shape and size, 11.8 x 7.1 x 6 cm in size
˗Cirumscribed irregular homogen solid mass in the cavum of uteri until cervix, 9.6 x 2.4 cm in size,
apparent vascularisation, suspected for endometrial malignancy in the cavum of uteri DD/
Submucosum myoma of uteri
˗Circumscribed irregular mass, 10.8 x 9 cm in size suspected for malignant right solid ovarium neoplasm
˗Circumscribed inhomogen solid mass, 6.9 x 7.1 cm in size suspected for malignant left solid ovarium
neoplasm
˗Ascites (+)
˗Liver and both kidney in normal condition

Conclusion: Suspected endometrial malignant mass in the cavum of uteri DD/ submucosum myoma of
uteri, suspected malignant bilateral solid ovarium neoplasm, ascites

Laboratory examination :
Na 138
(3) Mrs. WAL/ 47 YO/ 1076943
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Lower abdominal pain Menstrual : Menarche 15 YO, regular cycle, 28 days, first day of last period: 5/8/2018 Diagnosis:
Marrital :1 time, 30 years Dysmenorrhe e.c
Since 1 month before Obstetric : P1A0 uterus adenomypsis +
admission patient has been endometriosis cyst
complaining about lower Prior operation : Cyst Operation in 2012
abdominal pain. Patient Physical examination : Planning :
denied any abdominal mass BP : 120/80 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5ºC Total abdominal
and vaginal bleeding. General status : Normal hysterectomy
Patient had normal urinary
routine and bowel habits. Gynecologic status : Doctor in charge :
Patient experienced weight Abdomen : Flat, supple, symmetrical, fundal of uterine not palpable, tenderness (-), free fluid sign (-) AA-AT
lost but still have her
appetite. Patient had regular Vaginal Speculum exam: Portio non livide, Closed OUE, Fluor (-), Fluxus (-),E /L/P (-)
menstrual cycle and disagree
for any painful menstrual Vaginal Toucher: Portio elastic, Closed OUE, non tense right AP and Left AP
episode. Patient had been
operated for cyst excision in Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the recty, MIL (-)
Prabumulih Hospital in 2012.

Previous illness: -
(3) Mrs. WAL/ 47 YO/ 1076943
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus RF, nodulus, enlarge shape and size with hyperechoic mass on the anterior corpus with irregular
border, vascularisation (+) 3.4 c 2.78 cm in size appropriate with adenomyosis
˗Endometrial Line (+)
˗Homogen basal stratum
˗Circumscribed hypoechoic mass with internal echo inside, in the right adnexa 6.14 x 4.85 cm in size
appropriate with endomteriosis cyst
˗Circumscribed hypoechoic mass with internal echo inside in the left adnexa, 5.5 x 4.7 cm in size
appropriate with endometriosis cyst
˗Liver, spleen and both kidney in normal condition

Conclusion: uterus adenomyosis, bilateral endometriosis cyst, internal genitalia adhesion

Laboratory examination :
Hb 12.9 WBC9.900 Ht 39 PLT 349.000 INR 0.83 Alb 3.9 BSS 111 U 19 Cr 0.61 Na
145 K 3.9
(3) Mrs. WAL/ 47 YO/ 1076943
(3) Mrs. WAL/ 47 YO/ 1076943
(3) Mrs. WAL/ 47 YO/ 1076943
COT II
(1) Mrs. JUL/ 48 YO/ 955732
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC : Painful menstruation Menstrual : Menarche 13 YO, regular cycle, 28 days Diagnosis:
Marrital : Married 1x Cystic Ovarium
Patient went to FER Poly Obstetric : P0A0 Neoplasm
referred from ObGyn specialist
with the diagnosis of Planning :
dysmenorrhea e.c endometriosis Prior operation : - Operative
cyst. Patient had been operated Physical examination : Laparoscopy
before for cystectomy BP : 110/70 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5ºC
laparotomy e.c endometrosis General status : Normal Doctor in charge :
cyst with 6 series of tapros. HE
Patient adviced to undergo Gynecologic status :
Laparotomy HT procedure.
Abdomen : Flat, supple, symmetrical, fundal of uterine symphisis, mass (+) upper border
Previous illness: - – 3 fingers above symphisis; lower border – symphisis; right border – right LMC; left
border – left LMC.

Vaginal Speculum exam: -

Vaginal Toucher: Portio on the vaginal opening, CUT ~ 12 weeks, tense and limited right
AP, limited left AP, no protrusion of Cavum Douglasi
(1) Mrs. JUL/ 48 YO/ 955732
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Cystic mass, 10.7 x 9.2 cm in size suspected arise from ovarium ~ cystic ovarium neoplasm
˗Non visualized contralateral ovarium and uterus appropriate with HTSOU
˗Liver and both kidney in normal condition

Conclusion: Cystic ovarium neoplasm

Laboratory examination :
Hb 13.2 Ht 39 WBC7.8 PLT 315 Ca 9 Na 142 K 3.8 Cl 109 Ur 17 Cr 0.63LDH 190
AFP 3.15 CA 125 8
(1) Mrs. JUL/ 48 YO/ 955732
(1) Mrs. JUL/ 48 YO/ 955732
(1) Mrs. JUL/ 48 YO/ 955732
Thank You

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