Mrs.

Dian Ekasari/44/UA
Anamnase Physical Examination and supportive exam Diagnosis
and Planning
CC : Abdominal Menstrual : Menarche 13 years old, reguler, 28 days cycle for 7 Diagnosis:
Enlargement days cystic ovarium
Since 4 months Marrital : 1 times, 4 years neoplasma
ago os somplain Obstetric : P1A0 multiloculare
that her stomach Prior operation : - susp
become bigger Physical examination : malignancy
BP : 120/70 mmHg, HR : 86x/m, RR: 22x/m, T: 36,0C
painless, history of with DLI
General status : Normal
vaginal bleeding Gynecologic status :
(-), whittish Abdomen : bloated, tense, simetric, Fundal of uterine not palpablel, Planning :
discharge (-), Tenderness (-), mass (+)cystic mobile size 28x25 cm, upper border 2 Laparatomy
Irregular finger below proc xypoideus, lower border symphisis, right border VC
menstrual cycle LAA dextra, left border LAA sinistra, Free fluid sign (-)
history, then os Inspekulo: Portio non livide, no cervical opening, fluor (+), fluxus (-) ,
E/L/P (-)
DPJD : AT
come to AK Gani VT :Portio ellastic ,CUT normal, Right and Left AP n tense, palpable
hospital and being mass size 28x25 cm no protution in cavum of Douglas
said that she have RT : anal sphincter tone normal, rectal ampulla empty, intralumen
a fluid and cyst, os mucuos (-), palpable lower pool of tumor, right and left AP tense
then referred to palpable mass size 28x25 cm
RSMH, USG Confirmation :
- Uterus AF shape and size are normal , endometrial line (+),
1 weeks ago os
endometrium thickness is 0,74 cm
come to oncology - Pictured cystic mass mucin type, with septum, size 29x25 cm in
outpatient adnexa)
department and - Hepar, lien and both renal normal
scheduled - Ascites (+)
operation in Results :cystic ovarium neoplasma multiloculare mucin type
february 2017, 1
days ago os
 Mrs. Emi Kustini/33/UA
Anamnase Physical Examination and supportive exam Diagnosis
and Planning
CC : Abdominal Menstrual : Menarche 12 years old, reguler, 28 days cycle for 7 Diagnosis:
Enlargement, days cystic ovarium
and dispneu Marrital : 2 times, 7 years and 2 years neoplasma
Os before had Obstetric : P3A0 multiloculare
been diagnosed by Prior operation : - susp
cystic ovarium Physical examination : malignancy
BP : 120/70 mmHg, HR : 86x/m, RR: 22x/m, T: 36,0C
neoplasma
General status : Normal
multiloculare Gynecologic status : Planning :
dextra susp Abdomen : bloated, tense, simetric, Fundal of uterine not palpablel, Laparatomy
malignancy, and Tenderness (+), mass hard to examine, Free fluid sign (+) VC
being shveduled Inspekulo: Portio non livide, no cervical opening, fluor (+), fluxus (-) ,
to operate in 19 E/L/P (-) DPJD : AT
desember but VT :Portio ellastic , slick mucose, CUT normal, Right and Left AP n
tense, no protution in cavum of Douglas
since 1 weeks ago RT : anal sphincter tone normal, slick mucose rectal ampulla empty,
os feel her intralumen mucuos (-),, right and left AP tense
stomach become USG Confirmation :
bigger and - Uterus AF shape and size are normal, floated because of ascites
shortness of - Pictured cystic lobuller, with septum, with solid part, size
breathing, loss 14,5x11,6 cm in right adnexa probably a cystic ovarium
neoplasma multiloculare dextra with malignancy not yt to be
appetite (+),
step aside (RI :0,22)
weight loss (+), - ;eft ovarium normal
micturition and - Hepar, lien and both renal normal
defecation normal - Ascites (+)
Previous illness: Results :cystic ovarium neoplasma multiloculare dextra susp
malignancy and ascites