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Uterine Myoma Case Study 2022

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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63 views18 pages

Uterine Myoma Case Study 2022

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.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

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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