Morbili dengan Komplikasi Bronkopneumoni dan Rinosinusitis pada Anak yang Sudah Divaksin MMR

EndometriomaGunawan AliSupervisor: dr. H. A. Djaenudin, Sp.OGPatients IdentityName: Mrs. S. S.Age: 49 years oldPhone number: 085814360366Address: Kompleks Pemadam, CiganjurAdmission date : Sunday, 9 Desember 2012Medical record no. : 30-33-54

History TakingAutoanamnesis, on 10 December 2012Chief complain: Left lower abdominal pain since 10 days ago.History of Present IllnessLeft lower abdominal painHospital admissionWent to internist ovarian cyst referred to Obs-GynUSG

persistentfelt tight, like giving birthdiscomfort after urinatingER UTIHistory of Past Illnesshypertensive urgencyTransient Ischemic AttackMenstrual HistoryMenarche: 16 years oldCycle: 1 month +/- 1 week, regularDuration: 7 daysVolume: > 5 padsDysmenorrhea: positive

Obstetrics HistoryObstetrics status: P3A0First child: Born 1989, male, spontaneous vaginal deliverySecond child: Born 1993, female, spontaneous vaginal deliveryThird child: Born 2002, male, spontaneous vaginal delivery

MiscellaneousContraceptiveIUD since 10 years agocontraceptive pills stopped due to high blood pressureHistory of Family Illnessno cancer history in familyLifestyledoesn't smoke, drink alcohol, or using illicit drugs Physical ExaminationThe patient looks moderately ill, and fully alertVital signs:Blood pressure: 140/90 mmHgPulse: 88 times per minute, regular rhythm, adequate filling, symmetric in four extremitiesTemperature: 36.2 0CRespiratory rate: 20 times per minute, regular rhythm

Physical ExaminationAbdomen:Inspection: flat, no scar, no striaePalpation : softpalpable mass on suprapubic region, 6 cm in diameter, elastic consistency, well-defined border suprapubic tenderness notedliver and spleen were not palpablePercussion: tympanic, dull in suprapubic regionAuscultation: normal bowel sound

Auxiliary TestsUSGmass in suprapubic region, 8 cm x 9 cmChest X-Ray: within normal limitECG: within normal limitLaboratory:WBC: 4.6 x 103/LCT: 4 menitBT: 2 menitDifferential count: B/E/BN/SN/L/M: 0/0/1/56/34/9

DiagnosisWorking diagnosis: Ovarian cystDifferential diagnosis:EndometriomaOvarian functional cystOvarian cancer

ManagementDiagnostic planLaparoscopyCA 125Histopathology examination of cyst

Therapeutic planLaparotomy and excision of cysIVFD RL 20 drips per minuteTramal inj 1 ampule prnCaptopril tab 3 x 25 mgAmlodipine tab 1 x 10 mgCatapres tab 2 x 0.15 mg

ManagementEducation PlanExplain about her condition, surgery procedure, surgery risks, and alternativesPrognosisad vitam : bonamad functionam: bonamad sanationam: bonamSurgery ReportName: Mrs. S. S.Type of surgery: laparotomyVital signsBlood pressure: 140/90 mmHgPulse: 88 times per minuteTemperature: 36.4 oCRR: 20 times per minuteSurgeon: dr. Bambang F. N., Sp.OGAnesthesiologist: dr. Sanggam, Sp.AnType of anesthesia: spinalPre-op diagnosis: ovarian cystPost-op diagnosis: endometriomaDate: 11 December 2012Time: 9.00 9.45 WIBDuration: 45 minutes

Surgery ReportPatient laid supine in spinal anesthesiaAseptic and antiseptic procedure was doneMedial incision was done on abdominal wallLeft ovarian cyst was explored, lesion was as big as adults fistAdhesion was separatedCyst ruptured, thick reddish fluid was dischargedCystectomy was doneUterine cavity was cleanedRight ovary was within normal limitAbdominal wall was closed, with catheter drainage attached

Literature ReviewDefinitionEndometrioma = chocolate cystmasses of endometrial tissue that implant on the surface of the rectum, sigmoid colon, appendix, cecum, or distal ileum and may invade locally into the muscularis, submucosa, and even mucosaPatofisiologiretrograde passage of menstrual blood or shedding from endometriosis implants deposit on the ovary progressive invagination of the ovarian endometrioma

Clinical ManifestationAssociated with endometriosis symptom:pelvic / lower abdominal paindysmenorrheapolymenorrheahypermenorrheadyspareuniadefecatory painpelvic massinfertilityrupture peritoneal sign and symptoms, fever

Clinical Manifestation6 8 cmcontain thick brownish blood (chocolate-like fluid)usually associated with adhesion to nearby structureusually bilateralDiagnosisClinical diagnosisAuxiliary tests:USG, characteristic finding: diffuse internal low-level echoeslaparoscopy Definite diagnosis pathologic analysis:endometrial glands and stromaerythrocytehemosiderinmacrophage containing hemosiderininflammatory cellsconnective tissueHemosiderin is most commonly found in macrophages and is especially abundant in situations following hemorrhage, suggesting that its formation may be related to phagocytosis of red blood cells and hemoglobin. Hemosiderin can accumulate in different organs in various diseases.Hemosiderin often forms after bleeding (hemorrhage).[1] When blood leaves a ruptured blood vessel, the red blood cell dies, and the hemoglobin of the cell is released into the extracellular space. White blood cells called macrophages engulf (phagocytose) the hemoglobin to degrade it, producing hemosiderin and biliverdin.24ManagementCyst drainageCyst drainage + ablation of cyst wallCyst excisisionINITIAL TREATMENT Progestins, danazol, extended-cycle com- bined oral contraceptives, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) agonists can be used for initial treatment of pain in women with suspected endometrio- sis. However, recurrence rates are high after the medication is discontinued. If initial therapy is unsuccessful, diagnostic laparos- copy can be offered to confirm the diagno- sis. Alternatively, empiric treatment with another suppressive medication is an option. Empiric therapy with a three-month course of a GnRH agonist is appropriate if initial treatment with oral contraceptives and NSAIDs is unsuccessful. It is important to explain to the patient that response to empiric therapy does not confirm the diagnosis of endometriosis. of a GnRH agonist is appropriate if initial treatment with oral contraceptives and NSAIDs is unsuccessful. It is important to explain to the patient that response to empiric therapy does not confirm the diagnosis of endometriosis.

25Thank you