Wednesday, May 16, 2012

case summary

Assalamualaikum... selamat hari rabu...

hari tu aku ade cakap nak hapdet summary case aku sepanjang buat treatment kat HUKM kan... 

ni aku salin je la eyh.. mane tahu bole jadi rujukan pada kawan-kawan..

1. Primary subfertility x 3 years secondary to Endometriosis and Oligospermia

Referred from Babdar Seri Putra Kajang for primary subfertility in 04/2011. Patient has been married for 2 years at the time, staying together with husband, and having regular sexual intercourse and was not on any contraceptions. Both patient and husband was investigated :-

HSG (14/06/2011) : Patent fallopian tubes bilaterally
Ovulatary HGS : Day 21 Progesterone - 9.6nmol/L (anovolutary)
Alfa-Fetoprotein : 99.34 (Increase)

She has complete 5 cycle of clomid : 50mg x 1 and 100mg x 4

Latest Scan on 28/03/2012
- Ovary : Right Cyst - Solid area with multiseptate noted (3.8x4cm)
- Uterine Fibroid - 3x2.5cm

Evisceration and Adhesiolysis with Myomectomy and left Ovarian Plication was done on 12/04/2012
Pre-op Diagnosis : Primary subfertelity x 3 years secaodary to endometriosis
Post-op Diagnosis : Left endometrioma with endometriosis stage 2 with uterine fibroid

Intra-op Findings :
-Peritoneal cavity normal
- Right Ovary normal size 2x2cm kissing with left endometrioma 5x4cm - multiloculated containing chocolate material, embedded posterior to uterus.
- Both tube are normal, free but delayed spillage on the right side, normal spillage seen on the left side, both tubes are adhered posteriorly to POD.
- Uterus at 8/52 size, Anteverted, noted subserosal fibroid 3x4cm at anterior uterus - Myomectomy done.
- Liver, bowels and amentum - normal.
- Uterosacral not thickened.
- POD not obliterated.
- Left Ovary plicated to posterior or uterus.
- EBL : 300ml

* IM Lucrin 375mg for 6 cycle.

Ok kawan-kawan ni report yang doc bagi sebelum keluar hospital hari tu.... tapi aku terkejut jugak sebab kat report tu doc tulis uterus aku ANTEVERTED, sebab sebelum ni doc cakap rahim aku retroverted... bulan 7 appointment ngan doc akan ku tanya...

1 comment:

yatt said...

good luck with your treatment dear :) insyallah saya doakan awak