Mrs.

Nuriba bt Zainuddin/49/UA
Anamnase

Physical Examination and supportive exam

CC : Vaginal
Bleeding
Since 2
months ago os
complain that
she had fresh
blood vaginal
bleeding, as
much as 4
times changing
underwear,
Abdominal
Pain (-)
Whittish
history (+), 18
days ago os
complain
vaginal
bleeding
decrease and
appear to be a
wane spotting
bleeding
outside
menstrual
cycle, whittish
history (-),
micturition and
defecation

Menstrual : Menarche 13 years old, reguler, 28 days cycle for 5 days

Marrital : 1 times, 25 years
Obstetric : P4A3
Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 80x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine palpated 2 finger
above umbilical, Tenderness (-), mass (-), Free fluid sign (-)

Inspekulo : Portio non livide, no cervical opening, fluor (-), fluxus

(+) not active bleeding, E/L/P (-)
VT :Portio ellastic, no cervical opening, movement pain of portio
(-), CUT in 15 weeks line, Right and Left AP tense, no protution in
cavum of Douglas

USG Confirmation :
Uterus Increase inl size and bumping.
Pictured
hyperechoic
with
no
demarcated
border
with
vascularization size 5,04x5,91 cm in corpus uterii probably an
adenomyosis uterii
Both ovaium normal

Result : Adenomyosis Uterii

Laboratory Finding:

Diagnosis and
Planning
Diagnosis:
Susp
endometriosis
Planning :
LEETZ
DPJD : AT

Mrs. Nandra Helyani/51/UA

Anamnase
CC : Vaginal
Bleeding
Since 3
months ago os
complain
vaginal
bleeding, dark
red blood as
much as 2
times changing
underwear,
then os go to
gynecologist
and refers to
RSMH

Previous
illness:

Physical Examination and supportive exam

Menstrual : Menopause 3 years ago
Marrital : 1 times, 33 years
Obstetric : P1A0
Prior operation :
Physical examination :
BP : 100/80 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :

Diagnosis and
Planning
Diagnosis:
Ca.
Endometrium
stadium IB

Planning :
Laparatomy
Abdomen : flat, no tense, simetric, Fundal of uterine palpated half surgical staging
between umbilical and pubic symphisis, Tenderness (-), mass, Free fluid
sign (-)
DPJD : AT
Inspekulo: Portio irreguler, fragile, easy to bleed, mass (+) exophylic
2x3 cm,
VT :Portio irreguler, mass (+) exophylic 2x3x3 cm, fragile, easy to bleed
Right and Left AP no tense, no protution in cavum of Douglas
RT : anal sphincter tone normal, rectal ampulla empty, intralumen
mucuos (-), Right and Left CFS 100%, CUT 16 weeks

USG Confirmation :

Uterus AF size14,5x8,9 cm cavum uterii fil with liquid.

Both ovarium normal

Pictured hematosalphing in tuba

Liver and both renal normal

Result : Hematosalphing + Hematocyst

Laboratory Finding:
Hb: 13,5; Eritrosit: 5,22; Leu: 8,1 ;Ht: 42; Trombo: 324000; DC:
0/4/50/38/8; PT: 13,7; APTT ; 28,6 Alb: 4,5 , Ur: 25; Cr:0,68; Na:
143; Cl:109; CA125 :13,24

Mrs.Julailah bitni Saharuddin/42/RA

Anamnase

Physical Examination and supportive exam

CC :
Menstrual
pain
Os complain a
menstrual pain
in 1 and 2
daysof
menstruation
that disturbing,
her daily
activity, os
already feeling
this pain from
1 years ago, os
go to midwife
and got pain
reliever but her
complain
doesnt goes
away, loss of
appetite (+),
weight lost
(+), micturition
and defecation
normal,post
coital bleeding
(+), bleeding
outside
menstrual

Menstrual : Menarche 13 years old, irreguler,

Marrital : 1 times, 9 years
Obstetric : P0A0
Prior operation : - cyst operation in 2007
Physical examination :
BP : 120/80 mmHg, HR : 80x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine palpated,
umbilical-symphisis, bumps with upper border umbilicalsymphisis, right border LAA dextra, left border LMC sinistra, mobile
(-) Tenderness (-), Free fluid sign (-)
Inspekulo : Portio pushed to anterolateral sinistra, fluor (-), fluxus (+)
not active bleeding, E/L/P (-), sondae 4 cm there is a restrain AF
VT: Portio pushed to anterolateral sinistra, no cervical opening, CUT
18 weeks, no protution in cavum of Douglas, Right and Left AP no
tense
RT : anal sphincter tone normal, rectal ampulla empty, intralumen mucuos
(-), Right and Left CFS 100%, CUT 18weeks

USG Confirmation :
- Uterus retroflexed, size enlargment irregular, Endometral line
(+),
- Pictured Hyperechoic mass with demarcated border irregular,
filling all surface of corpus uterii, probably from adenomyosis
diffuse type
- Pictured hiporechoic cystic mass in right adnexa with echo
internal inside it., size 4,2x3,6 cm probably from endometriasis
cyst dextra
- Left ovarium visual

Diagnosis
and Planning
Diagnosis:
Adenomyosis
diffuse type,
right ovarium
endometriosis
cyst
Planning :
Laparatomy
Hysterectomy
DPJD : KY

Mrs.Rokiah bt Ruslan/39/RA
Anamnase

Physical Examination and supportive exam

Diagnosis and
Planning

CC : Bump
in abdomen
that become
bigger
Since 3 years
ago os
complain a
bump in her
stomach
become
bigger in
time,. History
of vaginal
bleeding (-),
micturition
and
defecation
normal ,
irregular
menstrual
period (+) os
had been
operated
twice before
because of
cystic in 2006
and 2007,

Menstrual : Marrital : 1 times, 18 years

Obstetric : P0A0
Prior operation : - cyst operation in 2006 and 2007
Physical examination :
BP : 120/80 mmHg, HR : 80x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : bloated , tense, simetric, Fundal of uterine hard to
examine, Tenderness (-), mass(+) with size 15x20cm, immobile,
free fluid sign (-)
Inspekulo : portio non livide, no cervical opening, Sondae 6 cm
VT: Portio ellastic, no cervical opening, AP sinistra tense, right AP
no tense, no protution in cavum of Douglas

Diagnosis:
Solid ovaium
Neoplasma susp
maligancy

RT : anal sphincter tone normal, rectal ampulla empty, intralumen

mucuos (-)

USG Confirmation :
- Uterus shaped and size normal, Endometral line (+),
- Pictured Hyperechoic eith echo interna inside of it, probably
from ovarium with size 18x11 cm
- Liver and both gall bladder normal
- Result: Endometriosis cyst dd/ Cystic ovarium neoplasma
uniloculare non papiliferum
Laboratory Finding:
-

Planning :
Laparatomy VC
DPJD : KY

Mrs.Yulisa bt H. Abdullah Biran/41/UA

Anamnase
CC : Os
referred
from
gynecologist
Os came with
referred letter
from dr. Rizal
Sanif
Sp.OG(K) with
diagnosis
ovarium cystic
+ Ca
mammae. 2
weeks ago os
come to
gynecologist
for the third
time ca cervix
vaccination.
Os doing USG
examination
and being said
that she had
ovarium
cystic. Os then
suggested to
go to RSMH,

Physical Examination and supportive exam

Menstrual : Menarche 13 years old, reguler, 28 days cycle for 3-5
days

Diagnosis and
Planning
Diagnosis:
Cystic ovaium
Neoplasma

Marrital : 1 times, 15 years

Obstetric : P2A0
Prior operation : - cyst operation in 2006 and 2007
Planning :
Physical examination :
HT-SOB
BP : 110/70 mmHg, HR : 88x/m, RR: 20x/m, T: 36,5C
General status : Normal
DPJD : RS
Gynecologic status :
Abdomen : flat , no tense, simetric, Fundal of uterine not palpated,
Tenderness (-), mass(-), free fluid sign (-)
Inspekulo : portio non livide, slick mucose, no cervical opening,
flour (-), fluxus (-), E/L/P (-)
VT: Portio ellastic, no cervical opening, AP no tense, no protution in
cavum of Douglas, CUT normal

USG Confirmation :
Laboratory Finding:
Hb: 13,1; Eritrosit: 4,13; Leu: 8,1 ;Ht: 39; Trombo: 226000; DC:
0/3/65/28/4; PT: 12,6; APTT ; 32,8 SGOT: 25; SGPT: 26; Ur: 16; Cr:
0,58; Ca: 9,8; Na: 145; K: 3,9 CA 125: 7,11

Mrs. Mey Susianawati/37/UA

Anamnase
CC : Vaginal
Bleeding
Os came to fertility
and gynecology
outpatient care with
vaginal bleeding os
had been operated
HDLO in April,12
2016 with diagnosed
multiple polyp cervix
+ hyperplasia
endometrium +
Hydrosalphing
bilateral + patent
tuba billateral with
PA rsult : endocervix
tissue with no
remarkable disorder
and polyp
ensdometrium
functional with
benign hyperplasia
endometrium, 2
months after
operation os
comeback with
prolong
menstruation
reached 3 weeks
tops, as much as 3
times changing
tampoon a day, os

Physical Examination and supportive exam

Menstrual : Menarche 13 years old, reguler, 28 days cycle for 5
days

Marrital : 1 times, 12 years

Obstetric : P2A0
Prior operation :
Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 20x/m, T: 36,5C
General status : Normal
Gynecologic status :

Diagnosis and
Planning
Diagnosis:
Abnormal
uterine bleeding
ec M1 Suspect
malignancy

Planning :
Histerescopy
Abdomen : flat, no tense, simetric, Fundal of uterine not palpable,
DnC
Tenderness (-), mass, Free fluid sign (-)
Inspekulo: VT : RT : -

USG Confirmation :
Uterus AF shape and size normal 5,2x2,5x4,0cm
Endometrial line thickness uk 0,9cm with increase of
vascularization RI:0,493
Right ovarium size 3,31x2,23 cm pictured follicle

Left ovarium size 2,99x1,99 cm pictured follicle

Result : Endometrium thickness with description increase
in vascularization, susp malignancy endometrium dd/ polyp
endometrium

Laboratory Finding:
Hb: 11,6; Eritrosit: 4,14; Leu: 6,5 ;Ht: 37; Trombo: 359000; DC:
0/3/67/23/7; PT: 12,5; APTT ; 31,2 Alb: 4,4 , Ur: 17; Cr:0,63;
Na: 140; K:3,8; CA125 :9,78

DPJD : AT

Pathology Anatomy
Macros :
Endocervix :some pieces of fragmented tissue with volume less than 3 cc, with brown-ish
color, most of it is a blood clot
Endometrium : some pieces of fragmented tissue with volume less than 3 cc with brownish color most of it is a blood clot
Micros:
1. Preparat from the clinical expertise come from endocervix, found endometrium tissue
formed polypoid coated by 1 layer collumner epithelial, in subephitelial found
endometrium gland forms tubular half of them notched coated by 1 layer of collumnar
ephitelial, surround by solid endometrium struma some of it have bleeding area fill with
inflamatory cell limphosit and plasma cell, also pictured a fragmented squamous
complex ephitelial and a little endocervix racemous gland coated by 1 layer secretory
collumnar epithelial between them there is a bleeding area and blood clot, not found
any malignancy sign in this preparat
2. Preparat from the clinical expertise come from endometrium found endometrium tissue
formed polypoid coated by 1 layer collumner epithelial, in subephitelial found
endometrium hyperplasia form tubuler half of them notched coated by 1 until some
layer of collumnar ephitelial with some focus light atypic cell surround by edmatic
endometrium struma, solid, and predesidua with some diiatated and hyperemi
vascular, not found any malignancy sign in this preparat