Ovarian cyst

Case No.
Patient’s ID

Name : Mrs. Y
Age : 28 yrs
Address : Pasaman
MR Number : 82 59 34
Time of admission : April 28th, 2013
Anamnesis

A 28 years old patient was admitted to

The General Hospital of Dr. M. Djamil
Padang on April 23th, 2013 at 03.3 am,
referred from RSUD Pasaman Barat with
diagnosed ovarian cyst
 Present Illness History
 Swollen in stomach since 1 year ago, bigger more and more,
initially equal to adult fist and now equal to baby’s head, pain
was denied
 Blood leakage from vagina outside menstrual periode was
denied
 Post coital bleeding history (-), dispareunia (-)
 Patient was married with 3 children, smallest age was 1years
 Nausea (-), vomit (-) and decrease of body weight
 Urinary and bowel was normal
 Menstruation history: Menarche at 13 years old, its cycle was
reguler for lasth 3 months, once a month, 5-7 days in duration
with 2-3x pad change/day without pain.
 Previous Illness History
 There was no history of cardiac disease, lung
disease, liver disease, renal disease, diabetes
mellitus, hypertension, nor allergy.

Familial Illness History

 There was no history of any hereditary, contagious,
or psychiatric disorder.
 Marriage history: married once in 2004

Obstetric history : Pregnancy/Abortion/Delivery: 3/0/3

1. In 2005, female, 3200 gr, term, spontaneous,
midwife,alive
2. In 2010, male, 3600 gr, term, spontaneous,
midwife,alive
3. In 2012, female, 3400 gr, term, spontaneous,
midwife,alive

Educational history : Senior High School graduate

Occupational history : housewife

History of family planning : contraception injection every 3

month

Immunization : (-)
 Physical Examination

GC Cons BP HR RR T BW BH BMI

Mdt CMC 120/90 82 20 37° 45 150 20,4

Eyes : conjunctiva was not anemic, sclera was not icteric

Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Thorax : Heart & lung were in normal limit
Extremity : oedema -/-, PF +/+, PT-/-
 GYNECOLOGY RECORD

Abdomen

 Inspection : Seemed enlarged in accordance with

preterm 7 month pregnancy, cicatrix (-)
 Palpation : mass was palpabled at 2 finger above
umbilicus, round shape, cystic consistency, mobile,
pressure pain (-), tenderness pain (-), DM (-)
 Percution : deaf above mass
 Auscultation : peristaltic sound was normal
Genitalia: I: V/U normal, Vaginal bleeding (-)
Inspeculo
Vagina: Tumor (-), laceration (-), Fluxus (-)
Portio: MP, equal to adult fist,tumor (-), laceration (-),
fluxus (-), OUE was closed, sondase : AF, 7 cm in size.
Bimanual VT:
Vagina: tumor (-)
Portio : MP, equal to adult fist, tumor (-),
motion less when mass moved, OUE was
closed, motion pain (-)
CUT : AF, equal to chicken egg
A/P : weaken right, under pool mass was
palpabled at left adnexa
CD : not protruded
 Laboratory Finding

Parameter Result Normal Value Unit

Haemoglobin 11,3 12.00-14.00 g/dl

Leukocyte 8300 5.00-15.00 103/mm3

Eritrocyte 4,1 4.00-5.00 106/µl

Thrombocyte 355 150.00-400.00 103/mm3

Hematocrit 32 35.00-43.00 %

MCV 86 82-92 fL

MCH 30,9 27-31 Pg

MCHC 35,7 32-36 g/dl

APTT 30,1 27-32 Pg

PT 12,4 10-14 g/dl

 Laboratory Finding

Parameter Result Normal Value Unit

SGOT 46 <50 g/dl

SGPT 51 <50 103/mm3

Total protein 7,5 4.00-5.00 106/µl

Albumin 4,24 3,5-4,5 103/mm3

kreatinin 0,92 <1 %

GDS 86 <150 fL

Ca 125 30,9 >50 Pg

 Urinalisis

 Protein :-
 Glukosa :-
 Leukosit : 1-2/LPB
 Eritrosit : 0-1/LPB
 Silinder : -/LPK
 Epitel : Gepeng +
 Bilirubin :-
 Urobilinogen : +
Diagnosis :

• Left Ovarian cyst

Management :

• Control general condition, vital sign, acut

abdomen signs
• Antibiotics (Skin test)
• Preparation of blood transfusion (Crossmatch)
• Consult to OR and anesthesiologist
• Informed Consent

Planning : elective laparatomy

At April 25th 2013 12.40 AM : laparatomy was performed

After peritoneum was opened, mass was palpabled fulfill cavum

abdomen, cystic consistency, equal to baby’s head, reddish
brown color, surface flatten.
Exploration was done and mass came from left ovarian, equal to
baby’s head, surface flatten, cystic consistency, torsion (+), right
ovarian was normal
Impression : torsion left ovarian cyst
Plain/ left salphingooovarectomy
Left salphingooovarectomy was performed  PA
Bleeding was ± 200 cc
Diagnosis :
• Post left salphingooovarectomy oi torsion left
ovarian cyst

Management :
• Post surgery observation
Thank You..