 Name : Mrs.

Z
 Age : 45 years old
 MR No. : 952523
 Date : 16-01-2016
Chief Complain :
 A 45 years old patient was admitted to the
gynaecology ward Room of Dr. M. Djamil
Central General Hospital on August 23rd 2016
at 15.00 am referred from polyclinic with
diagnosed multiple myom
 Abdominal enlargement since 3 month ago
 The patient had vaginal bleeding since 3 month ago,
which an amount 1-2 pad change per day
 History of fever, trauma and fluor albus was denied
 History of post coital bleeding and dispareunia was
denied
 History of loss of appetite and drastically decrease of
weight was denied
 No complain of miction or defecation disturbance
 Last menstrual period : August 10 th 2016
 Menstrual history : : menarche at age 13, irregular siklus
, which an amount of 3-4 pad change per day, pain (-)
 Patient already married for 28 years and have 2 children.
Previous Illness History:
 There was no previous history of heart, liver,
kidney and hypertension.
 History of DM since 2 years ago, controlled

Family Illness History:

 There was no history of hereditary disease,
contagious and psychological illness in the
family.
 GA : moderate
 Cons : cmc
 BP : 130/80 mmHg
 PR : 82x/min
 RR : 20x/min
 T : 37 °C
 Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric
 Neck : JVP 5-2 cmH2O, thyroid gland no enlargement
 Chest : H/L normal
 Abd : GR
 Gen : GR
 Extr : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
 Gynecology Record:
Abdomen
 I : Abdomen doesn’t seem enlarge
 Pa : a solid mass was palpated between umbilical- SOP,
irregular, mobile,
Tenderness (-), Rebound Tenderness (-), DM (-)
 Pe : tympanic
 A : peristaltic sound (+)

Genitalia :
Inspection : v/u N
Inspeculo : Vagina : tumor(-), lacerration(-), fluxus(-)
Portio : MP,tumor(-),lacerration(-), fluxus(-) , closed OUE
VT Bimanual :
 Vagina : tumor(-)
 Portio : MP, tumor(-),Closed OUE
 CUT : AF, size as big as an adult fist
 AP : relax both lef and right side
 CD : not protrude
No. Parameter Results Normal range

1 Haemaglobin 11,3 g/dl 12.-14

2 Haematokrit 34 % 37-43

3. Leucocyte 6.160/mm3 5-10

4. Trombocyte 427.000/mm3 150-400

5.
PT 9,9 9,5-13,4
6.
APTT 24,6 22,9-38,1
7.
Blood glucose 137 <200
 Uterus AF, size and shape were bigger than
normal, size 14,9 x 7,6 x 8,6 cm
 There’s hiperechoic mass clear border I : at
fundal size 5,7 x 5,7 cm feeding artery +
 There’s hiperechoic mass clear border II : at
intracaviter size 8,9 x 5,5 cm feeding artery +
 Right ovarian : 2,0 x 2,2 cm
 Left Ovarian : 1,4 x 1,6 cm

Impression :
• Multiple myom
Diagnose:
Multiple myoma

Advice:
 Control GA, VS
 Informed consent

Plan:
Laparatomy
 After the peritoneum was opened then after perform
exploration of internal genitalia, found the uterus bigger
than normal. Palpated smooth uterus with dense and
chewy consistency as big as an adult fist. adhesion (-)
impression : multiple myoma.
 Both adnexa and ovarian within normal limit.
 Plan supravaginal hysterectomy
 Supravaginal Hysterectomy was performed.

Diagnose :
Post supravaginal hysterectomy on indication multiple
myom
•P/ Admission post operation in HCU
Control GA, VS, vaginal bleeding, Intraabdomen
bleeding.
cefotaxime 2 x 1 gram iv
Laboratory post operation
No. Parameter Results Normal range

1 Haemaglobin 12,5 g/dl 12.-14

2 Haematokrit 35 % 37-43

3. Leucocyte 16.170/mm3 5-10

4. Trombocyte 384.103/mm3 150-400