CHAPTER II

CASE
I.

II.

Identity
Name
Age
Occupation
Address
Education
Marital Status
Religion
Date of Admission

: Mrs. Elita
: 31 years old
: Housewife
: Kp Cigarung 01/09
: Senior high school
: Married
: Moslem
: August 8th 2016

History
A. Chief Complaint
Lower abdominal pain

B. History of Present Illness

Patient complains about 4 months pregnancy with pain and a lump in lower abdomen
since a week ago. Patient also complaints hypomenorrhea with dysmenorrhea since a
year ago before the patient getting pregnant.
C. History of Past Illness
History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of urinary tract/kidney disease
History of trauma
History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

D. Family History
Patient didnt have family history of tumor and malignancy
E. History of Menstruation
Menarche

: 13 years old
2

Menstrual Cycle

: 27 days, regular with duration of 6 days, changed 2 pads a

day ( 60 cc)
Dysmenorrhea
Last menstrual

: (-)
: 4 months ago, with duration of 7 days

F. Contraception History
Patient using contraception implant for 3 years before her pregnancy.
G. Marital History
Patient is married for 10 years with her first husband.
H. Obstretric History
No
1

Years
1997

Gestational Age
9 month

Labor
History
Spontaneous

Sex
Male

Birth

Breast

Weight
2900

Feeding
1 year

grams
III.

PHYSICAL EXAMINATION

General condition
: Moderate
Level of consciousness
: Composmentis
Vital Sign
Blood Pressure
: 110/70 mmHg
Heart Rate
: 79 beats per minute
Respiratory rate
: 18 times per minute
Temperature
: 36,1C
Height
: 154 cms
Weight
: 55 kgs

A. General Examination
Eyes
: Anemi conjunctiva -/-; Icteric sclera -/ Mouth
: Wet oral mucosal membrane
Thorax
Heart
: Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
Lung
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-, crackles -/ Mamae
: Aerola hyperpigmentation, nipple retraction -/-, breast milk -/ Abdomen
Inspectio
: Convex on suprapubic, lump on regio illiaca dextra
Palpation
: Tenderness (+) on suprapubic, uterus with tender and

solid consistency and enlargement (2 fingers below

umbilicalis), surface is enlarged uniform in a single
fibroid.

Ovarian Cyst

Percussion
Auscultation
Ekstremitas
: Edema

: Dull on suprapubic
: Bowel sounds (+)
,
CRT < 2 seconds
- - -

Gravida 15-16
weeks

B. Status Obstetrikus
Fundus uteri
: 3 fingers from umbilical
Fetal heart rate
: 140 times per minute
Uterus contraction
: (-)
C. Gynecologic Examination
Inspection
Vulva : Within normal limits, mass (-), ulcer (-), hyperemia (-)
Vagina : Within normal limits, mass (-), ulcer (-), hyperemia (-)
Inspeculo
Vagina : Erotion (-), bleeding (-), mass (-), inflammation (-)
Portio : Erotion (-), fluxes (-), fluor albus (-), bleeding (-), mass (-),
inflammation (-)
VT Bimanual
Vulva
: Pain (-), Mass (-)
Vagina
: Pain (-), Mass (-)
Portio
: Pain (-), Mass (-)
Uteri corpus
: Uteri in gravida 15-16 weeks
Adnexal
: Lump in right ovary the size of an egg
IV.

Laboratory Examination
Type
HEMATOLOGY
Hemoglobin
Leukocyte
Hematocrit
Eritrocyte
Platelets
Erytrocytes Index
MCV
MCH

Result

Unit

Normal Value

* 7.4
* 24,900
* 23
* 3.7
* 338,000

g/dL
/L
%
/L
/L

1214
4,00010,000
3747
3.85.2
150,000450,000

* 62
* 20

fL
pg

80100
2634
4

MCHC
Imunoserologi
HIV Kualitatif
Kidney Function
Colour
Clarity
pH
Specific gravity
Leukocyte
Nitrit
Protein
Glucose
Ketones
Urobilirubin
Bilirubin
Eritrocyte
Urinalysis
Leukocyte
Eritrocyte
Epithelial cells
Casts
Crystals
Bacteria
Pregnancy

V.

33

g/dL

3236

Non reactive

Non reactive

Yellow
Turbid
5.0
1.020
Negative
Negative
Negative
Negative
Negative
Normal
Negative
Negative

cell/dL

Yellow
Clear
4.68.0
1.0051.03
Negative
Negative
Negative
Negative
Negative
<1
Negative
Negative

/hpf
/hpf
/lpf
/hpf
/hpf
/lpf

<6
<3
115
Negative
Negative
Negative

8-12
3-6
Positive (+)
Negative
Negative
Negative
Positive

cell/L
cell/dL
mg/dL
mg/dL
mg/dL

Imaging
Transabdominal sonography (TAS) August 9th 2016: found an unilateral cyst in the right
ovary with the diameter of 3.5 x 2.6 cm

VI.

Resume
G2P1A0 31 years old on 4 month pregnancy came with chief complaint of pain in
the lower abdomen since a week ago. Patient also complaints hypomenorrhea with
dysmenorrhea since a year ago before the patient getting pregnant.
On physical examination, blood pressure was 110/70 mmHg, heart rate was 79 bpm,
respiration rate was 18 times per minute, and temperature was 36,1 C. Palpated mass in
regio iliaca dextra with size 3-4 cms, flat surface, cystic consistency and mobile with no pain
if moved. Laboratory test showed 7,1 g/dL hemoglobin.

VII.

Differential Diagnosis
- Ovarian cyst
5

VIII.
IX.

X.

Torsion ovarian cyst

Endometriosis cyst
Malignancy suspicion

Working Diagnosis
G2P1A0 31 years old gravida 15-16 weeks with ovarian cyst
Planning
Conservative treatment
Premaston 3x1 PO
Dextrose 5% infuse
Asamefenamat 3x1 PO
Transabdominal sonography (TAS)
Follow Up
Date
August 8th

Subjective
Pain in the

Objective
BP: 100/60
HR: 83 bpm
RR: 21 times/min
Temp: 37,1
Hb: 7,1

Assessment
G2P1A0 31

2016
12pm

right lower

August 9th

Pain in the

BP: 90/60 mmHg

G2P1A0 31

2016
07am

right lower

HR: 85 bpm

years old

abdomen

RR: 20 times/min

gravida 15-16

Temp: 37,5

weeks with

abdomen

years old
gravida 15-16
weeks with
ovarian cyst

ovarian cyst

XI.

Planning
- Observe the vital

August 10th

Pain in the

BP: 100/60 mmHg

G2P1A0 31

2016
07am

right lower

HR:78 bpm

years old

abdomen

RR: 18 times/min

minimal

Temp: 35,8
Hb: 8,9 g/dL

signs
Premaston 3x1
Dextrose 5%
Asamefenamat 3x1
PRC Blood

transfusion
- Observe the vital
-

signs
Premaston 3x1
Dextrose 5%
Asamefenamat 3x1
Blood transfusion
Transabdominal

Sonography
- Observe the vital

signs
- Premaston 3x1
gravida 15-16
- Dextrose 5%
weeks with
ovarian cyst

Prognosis
Quo ad vitam
: Bonam
Quo ad functionam : Bonam
6

Quo ad sanationam : Bonam