Mrs.

Ratna Dwi Yanti/11/RA

Anamnase

Physical Examination and supportive

exam

CC :
Abdominal
Enlargement
Since 1
months ago os
complain her
stomach
become
bigger. History
of nausea and
vommiting (-),
history of
difficulty in
micturition
and
defecation(+),
history of
fever (-),
history of pain
in the
abdomen (+),
then os go to
gynecologist
in baturaja
hospital and
being said
that she have

Menstrual : Marrital : Obstetric : P0A0

Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : bloated, no tense, simetric, Fundal of uterine hard to
examine, Tenderness (-), Free fluid sign (-), mass (+) size 12x11
cm upper border 4 finger below umbillicus, left border LMC
sinistra, right border LPS dextra, lower border symphysis, solid
and immobile
Inspekulo:VT :USG Confirmation :
- Uterus being push to anterior because of the mass,
myometrium homogen
- ,Endometrial line (+) 0,2 cm, endocervix and portio normal
- Visible solid mass with demarcated border size 10,7x12,8cm
with vascularization probably from ovarium matches the
picture of a solid ovarium neoplasma
- Right ovarium normam
- Liver and Both renal normal
- Ascites (-)
Result:solid ovarium neoplasma with malignancy possibility
Laboratory Finding : -

Diagnosis and
Planning
Diagnosis:
solid ovarium
neoplasma
Planning :
Laparatomy VC
DPJD : AT

Mrs. Muryani binti M. Ani Abas/40/UA

Anamnase

Physical Examination and supportive

exam

CC :
Dismenorrha
e and bump
in abdomen
Since 6
months ago os
complain
there is a
bump in her
abdomen,
1years ago os
complain
dismenorrhae
, pain begins
in the 1st and
2nd days of
period. Os
says that her
period cycle is
reguler, os
then come to
Puskesmas
and referred
to AK Gani
Hospital and
being
diagnosed as

Menstrual : menache 12 years old, regular, for 6 days, last

menstrual period 25/9/2016
Marrital : 1 times 4 months
Obstetric : P0A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : bloated, no tense, simetric, Fundal of uterine not
palpable, Tenderness (-), Free fluid sign (-), cystic mass (+) size
6x7 cm not fixated
Inspekulo : Portio non livide, no cervical opening, fluor (-), fluxus (-),
E/L/P (-),
VT : Portio ellastic, no cervical opening, CUT normal, Adnexa
parametrium no tense, no protution in cavum of Douglas

USG Confirmation :
- Uterus RF, shape normal, size increase, with bumo
- Endometrial line (+) 0,7 cm, endocervix and portio normal
- Visible hyperechoic mass with no demarcayed border in
corpus uteriisize 2,9x2,7 cm
- Visible a cystic mass with echointerna inside of it probably
from right ovarium size 2,3 cm
- Visible a cystic mass with echointerna inside of it probably
from left ovarium size 8,5x7,1 cm cm
- Internal genitalia clingy
Result:adenomyosis uterii, endometriosis cyst bilateral, and
internal genitalia clingy
Laboratory Finding : -

Diagnosis and
Planning
Diagnosis:
Susp cystic
ovarium
neoplasma
Planning :
Laparatomy VC
DPJD : AT

Mrs. Maryanti Binti H Sapnan/43/UA

Anamnase

Physical Examination and supportive

exam

CC : vaginal
bleeding
Since 1
years=s ago
os
complainvagin
al bleeeding .
History of a
bump in lower
abdomen (+)
become larger
overtime,
painless, post
coital bleeding
(-), micturition
and
defecation
normal, os
then go to
gynecolgist
and being said
that she have
myoma uterii
anf referred to
RSMH
Previous
illness:

Menstrual : Menarche 12 years old, regular 28 days , not

reguler in past year
Marrital : 1 times, 22 years
Obstetric : P2A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, Fundal of uterine palpable in
umbilical, Tenderness (-), mass (-), Free fluid sign (-)
Inspekulo : Portio non livide,, cervical opening, visible gray mass that
pushed OUE size 3x4 cm, E/L/P (-), sondae AF 9 cm
VT : Portio ellastic, cervical opening, palpable hard mass,, CUT 22
weeks, Adnexa parametrium not palpable, no protution in cavum of
Douglas
RT : anal sphincter tone normal, rectal ampulla empty, intralumen
mucuos (-), slick mucose

USG Confirmation :
- Visible uterine AF, size increase with bumps,
- Visisble 5 hipoechoic mass with demarcated border with
feeding artery all over it filling almost all the part of uterine
size between 4,7x5,76 cm probably myomatosus uterine
- Enlargement of cervix, visible hipo echoic mass with
demarcated borderwith feeding artery probably a uterine
myoma
- Both ovarium normal
Result : Myomatosis uterus and myoma cervix
Laboratory Finding :

Diagnosis and
Planning
Diagnosis:
Abdormal uterine
bleeding e.c L1
Planning :
Hysterectomy
DPJD :

Mrs. Corina binti Anas Rudin/30/UA

Anamnase

Physical Examination and supportive exam

CC :
menstrual
pain
Os come to
polyclinic with
dismenorrhae
in the 2nd of
period. Os had
regular period,
for 7 days, os
go to
gynecologist
and said that
she have
endometriosis
and referred
to RSMH
Previous
illness:

Menstrual : Menarche 12 years old, regular 28 days , for 7 days

Marrital : 1 times, 2 years
Obstetric : P0A0
Prior operation : Physical examination :
BP : 120/80 mmHg, HR : 82x/m, RR: 22x/m, T: 36,5C
General status : Normal
Gynecologic status :
Abdomen : flat, no tense, simetric, mass (+) upper border abpve
symphisis, left border LMC sinistra, right border LMC dextra, lower border
3 finger below symphysis, immobile
Inspekulo :
VT :
USG Confirmation :
Visible uterine AF, size increase with bumps,
Visisble hyoerechoic mass with demarcated border with variant size
(2,47x2,49cm, 1,36x0,93cm, 1,37x0,61cm) probably a adenomyosis
uterii
Visible hipoechoic mass wih no demarcated border with variant size
(1,17x0,67cm, 1,81x1,18cm, 1,43x1,10cm) with feeding artery
probably a intramural myoma
Visible cystic mass with echo interna from right ovarium size 12,3x8,1
cm probab a right endometriosis that cling to uterus wall and cling to
another cystic mass with ecointerna from left ovarium size 3,84x4,55
cm probably a left endometriosis cystic (kissing ovaries)
Hepar and both renal normal
Result : - Multiple intramural myoma
- Adenomyosis uterii
- Endometriosis cystic bilateral (kissing ovaries)
- Clingy of internal genitalia
Laboratory Finding :

Diagnosis
and
Planning
Diagnosis:
Adenomyosis
uterii +
mutltiple
intramural
myoma +
billateral
endometroaia
cystic
Planning :
Hysterectomy
DPJD :