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Case Conference: Mrs - Kudasih, 47 Y.o, CM: C 927936

This case conference involves 47-year-old Mrs. Kudasih who presented with a chief complaint of menstrual pain. She has a history of uterine myoma and irregular menstruation. On examination, she was found to have an enlarged uterus resembling a baby's head. Laboratory tests and imaging including ultrasound and chest x-ray showed no abnormalities except for the enlarged uterus consistent with myomas. The diagnosis was uterine myoma and hypertension. The proposed treatment is a total abdominal hysterectomy and unilateral salpingo-oophorectomy.

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55 views18 pages

Case Conference: Mrs - Kudasih, 47 Y.o, CM: C 927936

This case conference involves 47-year-old Mrs. Kudasih who presented with a chief complaint of menstrual pain. She has a history of uterine myoma and irregular menstruation. On examination, she was found to have an enlarged uterus resembling a baby's head. Laboratory tests and imaging including ultrasound and chest x-ray showed no abnormalities except for the enlarged uterus consistent with myomas. The diagnosis was uterine myoma and hypertension. The proposed treatment is a total abdominal hysterectomy and unilateral salpingo-oophorectomy.

Uploaded by

bayu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Case Conference

May, 18th 2022

Mrs.Kudasih, 47 y.o, CM: C 927936


Department of Obstetric Gynecology
Faculty of Medicine, Diponegoro University
Kariadi Hospital, Semarang
2022
Clinical History
Chief complaint: Menstrual pain
History of patient illness: Patient complained about menstrual pain since 2
year ago. She went to Sunan Kudus Islamic Hospital and was diagnosed with
uterine myoma. Patient also complained of irregular menstruation, she got
prolonged menstruation for 2 months. She changed her pad until 10 times a
day. She also complained about abdominal enlargement. Decrease in appetite
and weight loss are denied. Her micturition and defecation is in normal state.
• History of Menstruation : 02/04/2022
• History of Marriage : 1x ~ 23 years
• History of Obstetric : P3A0 ~ youngest child 12 y.o
• History of Contraception : DMPA, last used at 2007
• History of previous illness : asthma (-), hypertension (+) since 2009,
uncontrolled, diabetes mellitus (-), heart disease (-)
• Prior surgery : pasca endometrial and endocervix ablation (21/4/2022)
General Status
General condition : compos mentis
Vital sign :
VS : BP : 174/96 mmHg RR: 18 x/menit
P : 81 x/menit T : 36,4’ C

Height : 150 cm Weight: 62 kg BMI: 27,55 kg/m2 (Overweight)

Eye : Pale palpebral conjungtiva (-/-)


Thorax : Heart : heart sound I-II regular
Lung : vesiculer +/+ Ronchi-/-, wheezing -/-,
Abdomen : bowel sound (+) normal, solid mass ~ baby’s head, mobile
Extremity : oedema -/-
-/-
Gynecological Status

Inspection : Fluxus (+) Fluor (-)


Vulva/Urethra : No abnormalities
Baby’s head Inspeculo
Vagina : No abnormalities
Portio : smooth~ thumb
Sondage : 6 cm, anteflexion, resistent
Vaginal Toucher
C. Uteri : ~ baby’s head
AP : No abnormalities
CD : bulging (-)
Profile
Laboratory
Hematology 20/04/22 Immunoserology
Hb 12.8 gr% HBsAg < 0.10
Leukosit 11.600 /mm3
Trombosit 414.000/mm3
Hematology 13/04/22 Coagulation
BG 86 mg/dl PPT 13.7 (15.1)
SGOT 16 U/L PTTK 26.4(29.8)

SGPT 18 U/L
Ureum 17 mg/dL Urinary Analize
Protein Negatif
Creatinin 0,99 mg/dL
Nitrit Negatif
Na 142 mmol./L
Bakteri 301 /uL
K 4,5 mmol./L
Cl 107 mmol./L
Chest X – Ray 13/04/2022

• Cor normal size


• No abnormality found on the
lungs
Electrocardiography

Normo sinus rhytm


Gynecology Ultrasound
• TRANSABDOMINAL
• Adequate bladder filling
• Uterus size 95.5x 85.1 x 10,16 mm, volume > 432.34 ml, EL(-),
Anteflexion, Irreguler countour, Inhomogenous texture. Whorl like
pattern size 64.6 x 38.1 mm, 2.92x2.94 cm, ring of fire (+)
• No hypoechoic or hyperechoic mass at both of adnexa
• No free fluid in Morrison pouch
Histopathology 27/04/2022
• Endocervix : non specific chronic
cervicitis
• Endometrium : irregular shedding
endometrii
Cardiologist
A/ Hypertension Heart Disease P/ Perindopril 5 mg/24 hours
Diagnose
• P3A0, 47 y.o
• Uterine myoma
• Hypertension Heart Disease
Procedure

• Total abdominal hysterectomy


• Unilateral salpingo oophorectomy
Thank You

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