Case No.36

Name: Mrs. NAge: 45 years oldMR No.: 891065 Date: May 11th, 2015

History Taking :A 45 years old patient was admitted to the gynecology ward room of Dr. M. Djamil Central General Hospital on may 11th , 2015 with chief complain bleeding from vagina since 3 days ago, there is no bleeding now. The patient feels fatigue and weakness.

Present Illness History :

Abdomen enlarge since 1 years agoShe got a long and plenty menstruation, since 5 days ago, 4-5 times pads changing a day, no pain. Previously, her period was reguler every month, but since 1 years ago she got along and plenty menstruation, duration was 10-12 days, the duration 3-4 times pads changing a day. The doctor had been suggested the patient to got laparotomy, but the patient refused it. Abdomen enlarge didnt perceived by the patienPatient has been married 15 years and have 3 childrenLast menstrual period : May 08th, 2015No history of fever, trauma, flour albusPost coital bleeding history (-), dyspareunia (-)Decrease of weight body (-)Miction and defication was normal

Previous Illness History :There wasnt previous history of heart, lung, liver, kidney, DM, hypertension and drug allergy

Family Illness History :There wasnt history of hereditary disease, contagious and psychological illness in the family.

Marriage History: 1 x, 1990Pregnancy/Abortion/Delivery History: 3/0/3

Physical Examination :

BW : 48 kgBH: 150 cmBMI: 21,33 kg/m2

EyesConjunctiva was anemic, Sclera wasnt ictericNeckJVP 5-2 cmH2O, tyroid gland no enlargementChestH/L normalAbdomentGyn RecordGenitaliaGyn RecordExtremityEdema -/-

GAConsBPPRRRTMdtCMC100/70842037

Gynecologic Record :Abdomen:Iabdominal enlarge, Pa a solid mass was palpable 3 finger above SOP, mobile, pressure pain (-), rebound tenderness (-), DM (-) Pe dull above massAunormal peristaltic sound

GenitaliaI :V/U normal, no vaginal bleedingInspeculo :Vagina : Tumor (-), laceration (-), fluxus (-), Portio : NP, size equal to an adult thumb, tumor (-), laceration (-), fluxus (-) ,sondage curette bump(+).

VT bimanual :vagina: tumor (-)portio : MP, size equal to an adult thumb, move when the mass moved, closed OUECUT : as big as adult fistA/P : supple in left and right sideCD : not protruded

ResultNormal ValueUnitHemoglobine4,412-14g/dlLeukocyte10.3005,0-10,0103/mm3Trombocyte266.000150-400103/mm3Hematocryte1537,0-43,0%Erytrocyte2.830.0004,0-4,5/mm3MCV5482-92fLMCH1527-31PgMCHC1537-43%PT10,210,0-13,60secondAPTT34,529,20-39,40secondINR0,95< 1,2

USG (13/5/2015)

Ultrasound(13/05/2015)AF uterus with 12,0 x 7,1 x 6,6 cm in sizeEndometrial line was pushed to posterior sideAn hyperechoic mass from anterior corpus, 3,8 x 4,7 cm in size, feeding artery (+)Right ovary 4,7 x 2,4 cm in sizeLeft ovary 2,4 x 2,8 cm in sizeImpression: Uterine myoma

Diagnose : Uterine myoma+ severe anemia

Management :Control GA, VSInformed consent Consult to internist departementBlood transfusion

Plan: improvement general appearence

(18/05/2015 after general appearance improvement )

ResultNormal ValueUnitHemoglobine12,612-14g/dlLeukocyte4.7305,0-10,0103/mm3Trombocyte177.000150-400103/mm3Hematocryte3837,0-43,0%PT11,110,0-13,60secondAPTT35,529,20-39,40secondINR0,97< 1,2

Diagnose : Uterine Myom

Management :Control GA, VSInformed consent Consult to anesthesiologist

Plan :Laparotomy Hysterectomy

At 09.30 am laparatomy was perfomedwhen peritoneum was opened, there was rubbery mass as big as adult fist in size Impression: uterine myom. Left and right ovarian was normal.Total hysterectomy was performed.Blood during operation 150 ccDiagnosed :Post Totalhysterectomy o.i uterine myom

POST OP

ResultNormal ValueUnitHemoglobine1212-14g/dlLeukocyte15.9005,0-10,0103/mm3Trombocyte229.000150-400103/mm3Hematocryte3937,0-43,0%

Thank you