Case no.

Patient identity
Husband Identity
Name : Mrs. E
Name : Mr. S
Age : 49th years old
No. MR : 01016261 Age : 53 years old
Addres : Tiku, Addres : Tiku, Pariaman
Pariaman Occupation : Farmer
Admission date : June 10th 2018

A 49 years old patient was admitted to the Gynecology Ward room of Dr. M. Djamil Central
General Hospital on june 10th 2018 at 19.30 pm, reffered from Emergency room Dr. M.
Djamil Central General Hospital with diagnosed Uterine myom + severe anemia.
Present Illness History:
• Previously, the patient reffered from emergency room Lubuk Basung
Hospital with diagnosed AUB due to uterine myom + severe anemia (Hb :
4,8 g/dl).
• Bleeding from vagina (+) since 2 weeks ago, bleeding happens out of
menstrual period, 4 - 5 times change pads daily.
• Felt mass in abdomen was (+) since 6 month ago, the mass going bigger
untill as big as a kasti ball with abdominal pain (+)
• History of Post coital bleeding , dispareunia (-)
• History of body weigh decreasing extremely (-)
• History of fever, trauma, and fluor albus was (-)
• Menstruation History : menarche at 13 years old, irregular cycle, every
month which last for about 5-7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
• Last menstrual period: march 14th 2018
• Urination and defecation was normal
• Patient already married and have 5 children, the youngest age was 11
years old.
Previous Illness History
• There was no previous history of heart, lung, liver, kidney, hypertension and allergy.

Family Illness History

• There was no history of hereditary disease, contagious and physiological illness in the family
Marriage history : once in 1995
History of pregnancy/abortion/delivery : 5/0/5
1. 1996/male/3800 gram/aterm/spontaneous/by midwife/JKT/Alive.
2. 1999/female/3000 gram/aterm/spontaneous/by midwife/JKT/Alive.
3. 2001/male/3000 gram/aterm/spontaneous/by midwife/JKT/Alive.
4. 2001/male/3000 gram/aterm/spontaneous/by midwife/JKT/Alive.
5. 2007/female/3000 gram/aterm/spontaneous/by midwife/JKT/Alive.

History of formal education : Senior high school

History of Occupation : house wife
History of contraception : (-)
History of Habit : Smoke (-), Alcohol (-), Drugs (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 120/80 80 18 36,8

BW : 55 kg
BH : 155 cm
BMI : 22,21 kg/m2
UAC : 24 cm

Eyes Conjunctiva was subanemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment Gyn Record
Genitalia Gyn Record
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
 Gynecologic record
Abdomen
I : Seems enlargement like 6 month of pregnancy
Pa : a mass was palpable 2 finger below the umbilikal, solid
consistency, mobile, Tenderness (-), Rebound Tenderness (-), DM (-)
Pe : tympani
Au : Peristaltic sound was normal

Genitalia
I : V/U normal, bleeding from vagina (+)
Inspeculo
• Vagina : Tumor (-), Laceration (-), Fluxus (+) blood with dark red colour accumulate in
posterior fornix
• Portio : MP size equal an adult toe, Tumor (-), Laceration (-),
sondase + 12 cm, AF, OUE opened 1cm, there fluxus come out from canalis cervicalis
Bimanual VT
• Vagina : Tumor (-), laseration (-)
• Portio : MP equal an adult tumb, tumor (-),
laseration (-)
• CUT : Uterus was palpable 2 finger below
the umbilical
• AP : Soft right - left
• CD : Not protruted
Laboratory, june 10th 2018
Parameter Result Normal Range
Haemoglobine 4,3 gr/dl 9,5 – 15

Haematocryte 16 % 28 – 40

Leucocyte 9.670 /mm3 5,9 - 16,9.103

Trombocyte 245.000/mm3 146 - 429.103

APTT 28,3 30,3 – 40,5

PT 9,8 9.7 – 12.9

No. Parameter Results Normal range
1 Random blood glucose 135 mg/dl <200mg/dl
2 Ureum 15 mg/L 16 - 48
3. Creatinin 0,7 mg/dL 0,6 - 1,2
4. Calsium 7,9 mg/dl 8,1 – 10,4
5. Natrium 134 Mmol/L 136 – 145
6. Kalium 3,9 Mmol/L 3,5 – 5,1
7. Chlorida 107 Mmol/L 97 – 111
8. Total protein 5,5 g/dl 6,6 - 8,7
9. Albumin 3,6 g/dl 3,5 – 5,1
10. Globulin 2,2 g/dl 1,3 – 2,7
11. SGOT 18 u/l 00 - 32
12. SGPT 11 u/l 00 - 31
USG
USG
• Uterus anteflexi, size was bigger than normally 99,2 x 47,2 x 25,3 mm
• Endline was pushed to anterior
• A hipoechoic mass strictly defined, was visualized with size 2,6 x 2,5 cm
• Impression : Uterine Myoma
Diagnosis
P5L5 + uterine myoma + severe anemia
Management :
 Control GA,VS,Vaginal bleeding
 Cross match 3 kolf of PRC
 Informed consent
 Prepare for laparotomy
 Consult Cardiologist, Internist, anesthesiologist
Result Consultation
• Cardiologist consult answer
• Pro operation mioma uteri
• With Goldman risk indek.
• Risk of cardiovascular complication perioperative 0,1% (class I)
• Internist consult answer
• A/ Severe anemia due to multiple mioma uteri
• Suggestions : Transfusion until Hb ≥ 10 gr%
• - Cardiovascular risk : Goldman score II
• - Pulmoner risk : light
• - Metabolic risk : light
• - Faal hemostasis : good
• Advice : consult anesthesiologist
• Anesthesiologist consult answer
• Prinsip agree for operative
• ASA II
12/06/2018
S / Bleeding from the vagina (-), fever (-)
GC GA BP HR R T
O/
Moderate CMC 120/80 80 22 afeb

Abd : Mass (-), pain tenderness (-), rebound tenderness (-), DM (-)
Genitalia : PPV (-)
A/ P5L5 + uterine myoma + anemia with clinical improvement
P / Prepare for laparotomy
Th/
Inj. Cefotaxime 1gr
Laboratory, june 12th 2018
Parameter Result Normal Range
Haemoglobine 9,3 gr/dl 9,5 – 15

Haematocryte 30 % 28 – 40

Leucocyte 16.280 /mm3 5,9 - 16,9.103

Trombocyte 233.000/mm3 146 - 429.103

APTT 35,5 30,3 – 40,5

PT 10,2 9.7 – 12.9

13th june 2018 at 12.00 pm
• Laparotomy was performed, uterus size as big as a kasti ball,
mobile, solid. Impression : uterine Mioma
• Plan : total hysterectomy
• Total hysterectomy was performed

Diagnosis
• Post total hysterectomy o.i uterine myoma

Plan
monitoring post operation
Check routine lab 6 hours post op
Inj. Cefotaxime 2x1gr
Pronalgess supp On demand
Perawatan RR
• Patient with position semi fowler ± 12 jam post operation
• Controle KU, VS, PPV, balance cairan
• IVFD RL = 28 tts/menit
• Antibiotik : Cefotaxime 2 x 1 gr (selama 3 hari)
• Bila kesakitan beri pronalges supp
• Catheter
• Check Hb 6 hours post operation, if Hb < 10 gr%  transfusion until Hb ≥
10 gr%
• If meteorismus (+)/flatus (+)  drink a little
THANK YOU
Laboratory, may 18th 2018
Parameter Result Normal Range
Haemoglobine 10,1 gr/dl 9,5 – 15

Haematocryte 34% 28 – 40

Leucocyte 11810/mm3 5,9 - 16,9.103

Trombocyte 453000/mm3 146 - 429.103