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Case No.

Identity Diagnosis Procedure Assesment Threatment


PATIENT Anamesa Residif ovarian cancer suspected + ileus Laparotomi  debulking
Name : Mrs. R • Feeling mass going bigger on abdomen since 3 obstructif
Age : 56 years old month ago, pain (-) Dygest Surgeon
MR : 01044991 • The patient was already got operation on
Adress : other hospital oi ovarian cyst since 6 month Reseksi ileum + large to large anastomosis
Occupation : Housewife ago. The mass was not sent to patology
Education : Senior High School anatomi laboratorium. 15/5/19 09.30
• Bowel was irregularly since 2 weeks ago.
Flatus (+) Laparotomi was perform  looks a solid mass
HUSBAND • Mikturition was no complain on the pelvic cavity adhesive to rectum with
Name : Mrs. F • Patient was already threat for improvement of ileus obstructif  Debulking was perform and
Age : 35 years old general condition, and got transfusion 2 pack consult to digestive surgery department 
of PRC oi moderate anemia ( Hb : 8,4g/dl)
Adress : Pasaman resection and large to large anastomosis of
Occupation : Farmer ileum
Education : Senior High School Pemeriksaan Fisik
GA : mdrt Cons : Alert BP : 120/70 HR : 80 RR: 22
T : 36,8

Abd :
I : Distenstion (+) DC (+) DS (+) Cikatrik (+) linea
mediana
Pa: Felt a solid mass with irregular surface ,
fixated , the size was as big as baby’s head.
Perk : hypertimpani
Aus : BU (+) increase

Gen :
VT bimanual in normal limit

Penunjang
USG : suggest STGO IOTA rule 2
Laboratorium :
Hb/Ht/Leuko/Trombo :
11,2/35/11040/192.000
Ur/Cr/OT/PT : 36/0,8/16/7
CT Scan : -
foto
Operation report
PA Result
• Didn’t perform
USG
Laboratorium
Thanku

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