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CHIEF REPORTFriday, April 10 2015OBSTETRICS AND GYNAECOLOGY REPORT
Elective Operation Chief
Dr. AlvilusiaDr. Hariya Romiya
Obstetric Inpatient Chief Dr. Lydia OctaviaDr. Erliyanna Tolu SaputriDr. Oktrivianus Sanjaya
Gynecology Inpatient Chief Dr. Jamatul FirdausDr. WahyudiDr. Emiruddin Sunny
Obstetric Outpatient Chief Dr. Rodiani Dr. Hendra Sugama Saputra
Gynecology Outpatient Chief Dr. Agung HaryadiDr. Meita Esthi Harumi
Emergency Room Chief Dr. Wirahadi SatriaDr. Fista Divi Amesia
I. ELECTIVE OPERATION REPORTMonday, April 6th, 2015 until Wednesday, April8th, 2015
Operation Room Chief:Dr. HariyaRomiza: 3patientsDr.Alvilusia: 3patientsTotal:6patients
NoDateIdentityPre-operative DiagnosisIntraoperativeManagementPost- operative Diagnosis
dr.HariyaRomiza
1.06-04-2015Mrs. AIN /35/ UA/NS
G2P1A038 weeks gestational age not inlabor with prior CS 1x (due totwin pregnancy) SLF transverse lie
Pfannenstiel incisionUterine size~ 38 weeks gestationFemale life baby was born, BW 3300 g ,BL 49 cm, AS 8/9 FTAGAPlacenta was delivered completely, PW 510 g, UCL 48 cm , diameter 19x20 cmMother and baby was in good conditionLSCS(648.6)P2A0post LSCS due to transverse lie
2.06-04-2105Mrs.END/37/P5A1/RA/AF
VIDRectocele grade II (N81.6)Suprapubic incision 2cmUterus was in normal limitIdentified both of tubePerforned Pomeroy tubal ligationLongitudinal incision at posterior vaginal to perineal lateral 2cm from midlineVaginal perineomucocutan seperated from rectovagina fasciaDisection vaginal perineomucocutan and suture vaginal mucous Suture vaginal perineomucocutan Pomeroy tubal ligation (26.51) + posteriorcolporaphy(70.5)
Post posteriorcolporaphyoi. rectocele grade II (N81.6) + post pomeroytubal ligation(26.51)
3.08-04-2015Mrs.JUA/79/P6A0/RA/ISVIDUterine prolaps grade II + cystocele grade II(N81.3 + N81.4)Uterus size normalBoth ovaries and tubes were within normal limitPerformed total hysterectomyPerformed methylene blue test to bladder no leakagePerformed anterior colporaphyVaginal stump hanged to uterosacral ligamentLAVH + anterior colporaphy(70.5)Post LAVH + anterior colporaphyoi. Uterine prolaps grade II + cystocele grade II(N81.3 + N81.4)
ELECTIVE OPERATION PLANNINGSaturday, April11st, 2015 Tuesday, April15th, 2015
NoDateIdentityDiagnosisPlanningOperatorAssistant IAssistant IIPreOp
1.13-04-15Mrs.Sat/45/P0A0/UAAUB ec susp L1HysterectomyKY-ERLOMIRISLAT
2.14-04-15Mrs.Nur/35/ PoAo/RAUterine AdenomyosisAdenomyosis resectionISOMIMRZLAT
3.14-04-15Mrs.Non/64/P3A0/RACervical cancer stage II B post NAC 3rd seriesRadical hysterectomyISOMIRISKML
NOASSESMENTVALUE MAXNAMENotes
dr.Hariya Romiza
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
NoDateIdentityPre-operative DiagnosisIntraoperativeManagementPost- operative Diagnosis
Dr. Alvilusia
1.07-04-2015Mrs. HER/32/P5A1/UA/ AA-LYD
PICAUBec L1(N93.9)Exploration uterine with bumpy surface size ~ 16 weeksRight and left ovarian were in normal limitPerform total abdominal hysterectomyUterine incised C/intramural myoma size 6cm, 2cm, , 2 cm, 1,5 cm, 2 cmTotal Abdominal Hysterectomy (68.4)Post Total Abdominal Hysterectomy due to multiple uterine myoma(D25.1)
2.07-04-2015Ms. LIZ/RA/19/RS-RIS
PICCyst ovary neoplasm malignancy was suspected(N83.29) Mediana incisionThere was ascites liquid 500 cc at abdominal cavityperform citology Uterus was in normal limitLeft ovarian and tube were in normal limitThere was cystic mass greyish white size 10x20x5 cm derived from right ovarian rupture (+) perform frozen section C/ malignant mucinous tumorRight pelvic lymphadenectomy, partial omentectomy, appendectomy Conservative Surgical staging (162.9)Stage IC Ovarian Cancer was suspecteed(C56.9)
3.06-04-2015Mrs. ISM/40/P4A0/RA/ATPIC
Endometrial hyperplasia(N85.00)Performed sondage, uterus AF 9 cmUterus size 14 weeksBoth ovaries and tubes were within normal limitPerformed total hysterectomyPerformed methylene blue test to bladder no leakageLAVH (68.51)Post LAVH due to endometrial hyperplasia(N85.00)
ELECTIVE OPERATION PLANNINGSaturday,April11st, 2015 Tuesday,April15th, 2015
NoDateIdentityDiagnosisPlanningOperatorAssistant IAssistant IIPreOp
1.11-04-15Mrs.Adu/53/P5A1/UAAUB ec L1 HysterectomyAFJUSVILLAT
2.11-04-15Mrs.Das/47/P0A0/RAOvarian cancer inadequate staging Surgical stagingATVILRISKML
3.13-04-15Mrs.Yan/56/P2A0/UACyst ovarian neoplasm with solid part malignancy was suspectedLaparotomy FSATVILMRZKML
NOASSESMENTVALUE MAXNAMENotes
dr.Alvilusia
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
3
II. OBSTETRICS INPATIENTS REPORTS Sunday, April 5th 2015 until Wednesday, April 8th , 2015 Physiological Patients: 2 cases Pathological Patients : 7 cases Total : 9 cases
Chief Obstetrics Inpatient dr. Oktrivianus Sanjaya : 3 cases dr. Erliyanna Tolu Saputri : - cases dr. Lydia Octavia : 4 cases PROM: 1 casesAntepartum haemorrhage : 1 casePreterm: 1 caseBreech presentation: 1 caseProlonged 2nd stage: 1 casePlacentae incarcerated: 2 casesTOTAL: 7 cases
NoInitialAgeDiagnosisTreatmentPhysician
1.WAN25Incarcerated placentaeBrandt Andrew Manouvre
COR
2.WAR22PretermSpontaneous delivery(80.0)RZM
3.ROD41Breech presentationSpontaneous brachtRZM
4.LUS19Ante Partum Hemorrhage( O46.9)Expectative TMS
5.DIA25Prolonged 2nd stageVaccuum extractionRZM
6.NEL32Incarcerated placentaeBrandt Andrew Manouvre
COR
7.MAR21PROMSpontaneous delivery(80.0)TMS
MATERNAL MORTALITYNo.InitialAgeDiagnosisTreatmentPhysician
------
dr. Oktrivianus Sanjaya
1.06-04-1504:25 PMBrandt Andrews Manouvre Mrs.WAN/25/UA/SWA/COR
D/ P1A0 post spontaneous delivery 3 hours (outside) with early PPH cb incarcerated placentae
08-04-1506:00 AMD/ P1A0 post Brandt Andrew Manouvre due to Incarcerated placentae (day 2)
M/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother was discharged
2.06-04-1507:35 PMPreterm spontaneous delivery Mrs.WAR/22/RA/SWA/RZM
D/ G2P1A0 35 weeks of gestational age inlabour 2nd stage SLF cephalic presentation
08-04-1506:00 AMD/ P2A0 post preterm spontaneous delivery day 2 Female life baby was born with BW : 2300 g BL : 44 cm
Balard score:34-36 weeksM/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother and baby were discharged
3.08-04-1504.30 WIBSpontaneous bracht Mrs.ROD/41/RA/NIL/RZM
D/ G2P0A1 37 weeks of gestasional age inlabor 1st stage active phase SLF breech presentation
09-04-1506:00 AMD/ P1A1 post spontaneous bracht (day 1) Female life baby was born with BW : 2700 g BL : 48 cm
M/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother and baby were discharged
NOASSESMENTDr. Oktrivianus SanjayaVALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
dr. Lydia Octavia
105-04-158:51 AMExpectative Management Mrs.LUS/19/UA/VIL/TMS
D/ G1P0A0 34 weeks of gestational age not inlabour with antepartum haemorrhage c.b total placentae previa, SLF cephalic presentation
USUS confirmation (NS):C/ 34 weeks gestational age SLF cephalic presentation with total placentae previa + BPP 10
09-04-1507:00 AMD/ G1P0A0 34 weeks of gestational age not inlabour with antepartum haemorrhage c.b total placentae previa SLF cephalic presentation (day 4)
M/ Expectative management Nifedipine 10 mg/ 6 hours p.o Cefadroxil 500 mg/ 12 hour
Mother and baby were in good condition
2.05-04-1504:00 PMVacum Extraction due to prolonged 2nd stage (outside) Mrs.DIA/25/RA/ASA/RZM
D/ G1P0A0 39 weeks of gestational age inlabour with prolonged 2nd stage (outside) + SLF cephalic presentation
07-04-1506:00 PMD/ P1A0 post vacum extraction due to prolonged 2nd stage (outside) day 2 Female live baby, BW 3000 g, BL 51 cm
M/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother and baby were discharged
3.06-04-201504:08 AMBrandt Andrew Manouvre Mrs.NEL/32/RA/ASR/COR
D/ P3A0 post spontaneous delivery 3 hours (outside) with early PPH cb incarcerated placentae
08-04-1506:00 AMD/P3A0 post brandt andrew manouvre due to incarcerate placenta (day 2)
M/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother were discharged
4.08-04-1503:30 AMSpontaneous delivery Mrs. MAR/21/UA/NIL/TMS
D/ G2P1A0 37 weeks of gestasional age inlabor 1st stage active phase with history of ROM 13 hours SLF cephalic presentation
09-04-1506:00 AMD/ P2A0 post spontaneous delivery (day 1) Female life baby was born with BW : 2800 g BL : 45 cm
M/ Cefadroxil 500 mg/ 12 hour PO Mefenamic acid 500 mg / 8 hour PO Roborantia
Mother and baby were in good condition
NOASSESMENTDr. Lydia OctaviaVALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
III. GYNAECOLOGYCAL INPATIENT REPORT Thursday, April 2nd, 2015 until Wednesday, April 8th, 2015 Gynaecological Inpatient Chief dr. Emiruddin Sunny: 3 patientsdr. Wahyudi: 2 patients dr . Jamatul Firdaus: 3 patientsTotal patients: 8 patients
Dr. Emiruddin Sunny
1.06-04-15ChemotherapyMrs. MIR/42/P0A0/RA/MUL
11:38 AMD/ Stage IVA cervical cancer with partial response (C53.9)
M/ Chemotherapy Gemcitabine-oxaliplatin 1s tcourse
Pathology: Moderately differentiated papillary squamous cell carcinoma cervix with angioinvasion
2.05-04-15Plan for laparotomy FSMrs.NUR/36/P4A0/UA/MUL
01:38 AMD/ Cystic ovarian neoplasm malignancy was suspected + mild anemia
USM/ Blood transfusion
P/ Laparatomy FS
3.07-04-15Plan for laparotomy FSMrs.CIK/55/P1A0/UA/MUL
07: 38 PMD/ Solid ovarian neoplasm malignancy was suspected + mild anemia
USM/ Blood transfusion
P/ Laparatomy FS
NOASSESMENTVALUE MAXNAMENotes
dr.Emirudi Sunny
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
Dr. Wahyudi
1.05-04-15MedicinalisMrs.EMI/37 /UA/NRM
17.40 PM
D/ G4P3A0 9 weeks gestational age with threatened abortion
Hb : 12.6 g/dLT/ : - Amoxicillin 3x500 mg - Luminal 3x30 mg - P/ US Confirmation
USUS confirmation (NS) :C/ 10 weeks gestational age SLF intrauterine
2.04.04.15Chemotherapy (V58.1) + Plan for radical hysterectomy Mrs.NON/64/P8A0/RA/FOR
03.45 PM
D/ Stage II B cervical cancer post Neoadjuvant Chemoyherapy Paclitaxel-Carboplatin 2th course
M/ Neoadjuvant Chemoyherapy Paclitaxel-Carboplatin 3rd course
P/ Radical hysterectomy
Pathology : Moderately differentiated non keratinizing squammous cell carcinoma cervix with no lymph vascular invasion
NOASSESMENTVALUE MAXNAMENotes
dr.Wahyudi
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
Dr. Jamatul Firdaus
1.04.04.15Chemotherapy (V58.1) + Plan for radical hysterectomy Mrs.NON/64/P8A0/RA/FOR
03.45 PMD/ Stage IIB cervical cancer
M/ Paclitaxel-Carboplatin chemotherapy 3rd course
Pathology : Moderately differentiated non keratinizing squammous cell carcinoma cervix with no lymph vascular invasion
2.06.04.15Chemotherapy Mrs. CAS/36/P2A0/RA/FOR
02.00 PMD/ Ovarian cancer inadequate staging + post colostomy + fistula enterocolon + Mild anemia
Hb : 9g%M/ General condition improvement Stoma care PRC transfusion
P/ Chemotherapy
Pathology : Mucinous cystadenocarcinoma ovarii which has been metastases to omentum
3.07.04.15Chemotherapy Mrs. NIS/55/P2A0/RA/FOR
02.00 PMD/ Cervical cancer stage IIB
P / NAC Paclitaxel - Carboplatin 1st course
Pathology : Moderatelly differentiated non keratinizing squammous cell carcinoma on cervical biopsy
Gynaecologi Chief on DutyMonday, April 6th 2015 at 02 .00 PM Tuesday, April 7th 2015 at 07.00 AMConsultant on duty : dr. Awan Nurtcahyo, SpOG(K)
NOASSESMENTVALUE MAXNAMENotes
Dr. Jamatul Firdaus
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
11
12
IV. OBSTETRICS OUTPATIENT REPORTThursday, April 2nd, 2015 until Wednesday April 8th, 2015
Obstetric outpatient chief :dr. Rodiani: 7 patientsdr. Hendra Sugama Saputra: 7 patientsTOTAL : 14 patients
DATEVISITEPATIENT
ObstetricLactation & puerperalFamily PlanningObstetricLactation & puerperalFamily Planning
April 2nd416416
April 3rdHoliday
April 4th103103
April 5thHoliday
April 6th531531
April 7th368368
April 8th133133
TOTAL141321141321
1. dr. Rodiani
OBSTETRIC CASE
NoInitialAgeAddDiagnosisICD CodeTreatment/PlanPhysician
1DIA33UA
USG2P1A0 33 weeks gestational age not inlabor SLF cephalic presentation
32 weeks gestational age SLF cephalic presentation Z.34Folic acid 1x400g Recontrolled within 2 week
FCH ROD
LACTATION AND PUERPURAL
No.InitialAgeAddDiagnosisICD CodeTreatment/PlanPhysician
1TET32UAP1A1 post LSCS due to impending eklampsia and breech presentation082.1RoborantiaROD
2WID23UAP1A1 post LSCS due to impending eklampsia082.1RoborantiaROD
FAMILY PLANNING
No.InitialAgeStatus(New/Old)/DateDiagnosisContraceptionPhysician
1HER36April 1st 2015P7A1 post incomplete abortion day 1 O03.4IUDZ97.5BOY-ROD
2RIA26April 1st 2015P3A0 post spontaneous bracht day 1652.2IUDZ97.5BOY-ROD
3RIA28April 1st 2015P2A0 post spontaneous preterm delivery day 1 O60IUDZ97.5BOY-ROD
4ELY28April 1st 2015P1A0 post LSCS due to fetal distress day 1656.8IUDZ97.5BOY-ROD
Obstetrical Chief on DutyTuesday, April 7th, 2015 at 02.00 AM Wednesday, April 8th, 2015 at 07.00 AM Consultant on duty : Dr. H. Rizal Sanif, Sp.OG(K)
1.07.04.15Conservative management Mrs. RIS/24/UA/NIL
02:30 PMD/ G2P1A0 32 weeks of gestasional age with threatened preterm labor SLF cephalic presentation
Hb 11.0 gr/dlWBC 11.9 103/mm3
IT : 2M/ Conservative management Observed vital sign, FHR, contraction IVFD RL gtt xx/minute Laboratory examination Ceftriaxone inj 1 g/12 hour IV (ST) Deksamethason inj 6 mg/12 hour IV (2 days) Nifedipine 10 mg/6 hour po Vaginal swab
08.04.15P/ US confirmationUS (AK) :C/ 32 weeks gestational age SLF cephalic presentation+ cervical length 4,4 cm
2.08.04.15LSCS due to Severe Preeclampsia + Condiloma Acuminata Mrs.RIN/20/UA/RS-GUH
03.00 AMD/ G1P0A0 37 weeks of gestasional age with severe preeclampsia and condiloma acuminata not in labor SLF cephalic presentation
GI : 6 Hb : 10.8 g/dlPIC
M/ Stabilitation 1-3 hours Observed vital sign, FHR, contaction IVFD RL gtt xx/minute Catheter Laboratory examination MgSO4 inj protocol Nifedipine 10 mg/8 hour po Evaluation with gestosis task Consult to Internal and ophtalmology department
P/ Abdominal delivery after stabilization Consult to consultant on duty agree for abdominal delivery
10.30 AMMale life baby was born, BW 2600 g, BL 47 cm, A/S 8/9 FT AGA
10.33 AMPlacenta was delivered completely, PW 400 g, UCL 46 cm 16x17 cm
The mother and baby were in good condition
3.08.04.15Spontaneous bracht Mrs.ROD/41/RA/NIL
02:15 AMD/ G2P0A1 37 weeks of gestasional age inlabor 1st stage active phase SLF breech presentation
M/ Observed vital sign, FHR, contaction IVFD RL gtt xx/minute Laboratory examination
P/ Vaginal delivery
04:25 AMD/ G2P0A1 37 weeks of gestasional age inlabor 2nd stage SLF breech presentation
M/ Conduct the labor
04.30 AMMale life baby was born, BW 2700 g, BL 48 cm, A/S 8/9 FT AGA
04.35 AMPlacenta was delivered completely, PW 400 g, UCL 50 cm 17x18 cm
The mother and baby were in good condition
4.08.04.15Spontaneous delivery Mrs. MAR/21/UA/NIL
03.30 AMD/ G2P1A0 37 weeks of gestasional age inlabor 1st stage active phase with history of ROM 13 hours SLF cephalic presentation + olygohydramnious
Hb : 11.5 g/dLM/ Observed vital sign, FHR, contraction IVFD RL gtt xx/minute Laboratory examination Ceftriaxone inj 1 g/12 hour IV (ST) Evaluation with partograph WHO modification (Active phase)
P/ Vaginal delivery
05.10 AMD/ G2P1A0 37 weeks of gestasional age inlabor 2nd stage with history of ROM 14 hours SLF cephalic presentation + olygohydramnious
M/ conduct the labor
05.15 AMFemale life baby was born, BW 2800 g, BL 45 cm, A/S 8/9 FT AGA
05.20 AMPlacenta was delivered completely, PW 500 g, UCL 50 cm 17x18 cm
The mother and baby were in good condition
5.08.04.15Spontaneous delivery Mrs. SIT/32/UA/NIL
01.30 PMD/ G3P1A1 38 weeks of gestasional age inlabor 1st stage active phase with history of ROM 3 days SLF cephalic presentation
M/ Observed vital sign, FHR, contraction IVFD RL gtt xx/minute Laboratory examination Ceftriaxone inj 1 g/12 hour IV (ST) Accelaration with oxytocin drips Evaluation with partograph WHO modification (Active phase)
P/ Vaginal delivery
02.40 AMD/ G3P1A1 38 weeks of gestasional age inlabor 2nd stage with history of ROM 3 days SLF cephalic presentation
M/ Conduct the labor
02.50 PMMale life baby was born, BW 3000 g, BL 48 cm, A/S 8/9 FT AGA
02.55 PMPlacenta was delivered completely, PW 500 g, UCL 45 cm 18x19 cm
The mother and baby were in good condition
6.08.04.15Expectative management Mrs. DEV/36/UA/NIL
06.30 AMD/ G2P1A0 35 weeks of gestasional age not inlabor with prior CS 1x + severe preeclampsia + epistaxis SLF cephalic presentation
M/ Stabilitation 1-3 hours Observed vital sign, FHR, contaction IVFD RL gtt xx/minute Catheter Laboratory examination MgSO4 inj protocol Nifedipine 10 mg/8 hour po Evaluation with gestosis task Consult to Internal and ophtalmology department Consult to ENT department
P/ Maturation of lung for 2 days
M/ Expectative
08.04.15US (AK) :C/ 35 gestational age SLF cephalic precentation
08.04.15ENT department :A/ Epistaxis e.c severe preeclampsiaM/ anterior sufratule tamponade 4/3Analgetic and antibioticJoint Care with Rhinology ENT Subdivision
7.08.04.15LSCS due to Prior LSCS 1 x and PROM Mrs.SEL/28/UA/RS-ROD
04:00 AMD/ G2P1A0 40 weeks of gestasional age with prior LSCS 1 x (o.i unripe cervix) + PROM 6 hours not in labor SLF cephalic presentation
US ES (MUL)C/ 40 weeks of gestational age SLF cephalic presentation
M/ Observed vital sign, FHR, contaction IVFD RL gtt xx/minute Laboratory examination Ceftriaxone Inj. 1 g/12 hour ivP/ Abdominal Delivery
Consult to consultant on duty agree for abdominal delivery
05.40 AMMale life baby was born, BW 2900 g, BL 46 cm, A/S 8/9 FT AGA
05.45 AMPlacenta was delivered completely, PW 500 g, UCL 50 cm 17x18 cm
The mother and baby were in good condition
NOASSESMENTdr. RodianiVALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
2 dr. Hendra Sugama Saputra
OBSTETRIC CASE
No.InitialAgeAddDiagnosisICD CodeTreatment/PlanPhysician
1SRI37UA
USG2P1A0 39 weeks gestational age not inlabor SLF cephalic presentation
39 weeks gestational age SLF cephalic presentationZ.341x400g Recontrolled within 1 week
FCH SUG
LACTATION AND PUERPERAL
No.InitialAgeAddDiagnosisICD CodeTreatment/PlanPhysician
1MAR20UAP1A0 post SSTP a.i transverse lie082.1RoborantiaSUG
FAMILY PLANNING
No.InitialAgeStatus(New/Old)/DateDiagnosisContraceptionPhysician
1NEL32April 6th 2015Post Brandt Andrew Manoeuvre day 175.4 IUDZ97.5SUG
2WAN26April 6th 2015P1A0 post spontaneous delivery (outside) 3 hours + post Brandt Andrew Manoeuvre day 175.4IUDZ97.5SUG
3WAR23April 6th 2015P2A0 post spontaneous delivery day 1 O80.0IUDZ97.5SUG
4WIN16April 6th 2015P1A0 post spontaneous delivery day 1O80.0IUDZ97.5SUG
5YUL28April 1st 2015P1A0 post LSCS o.i uterine inertia day 6661.2IUDZ97.5SUG
NOASSESMENTdr. Hendra SugamaVALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
V. GYNECOLOGY OUTPATIENT REPORT Thursday, April 2th, 2015 until Wednesday,April 8st, 2015Gynaecological Outpatient Chiefdr. Agung Haryadi: 5 patientsdr. Meita Esthi Harumi: 6 patientsTotal: 11 patients
DATEPATIENTVISITE
GynecologyOncologyEndocrinologyUrogynecologyGynecologyOncologyEndocrinologyUrogynecology
Apr 2nd----5234-
Apr 3rd----2247-
Apr 4st-----169-
Apr 6st-71-12210-
Apr 7st--1-1288-
Apr 8st--2-12261
Total----11135441
Dr. Agung Haryadi
1.06.04.15Ms. SUR/45/RA
Stage IB endometrial cancer (C53.9)Chemotherapy Paclitaxel-Carboplatin 1st course (V58.1)NIS
Pathology : Malignant mesodermal mixed tumor at uterus
2.07.04.15Mrs. DAH/50/P5A1/UAStage IIIB cervical cancer (C53.9)Chemoradiation Paclitaxel-Carboplatin 2nd course (V58.1)FIT
Pathology : Well moderatelly differentiated squamous cell carcinoma cervix with solid limfoplasmasitic and limfovaskuler invasion
3.07.04.15Mrs. ZUR/45/P2A1/UA
Stage IIIB cervical cancer (C53.9)Chemoradiation Paclitaxel-Carboplatin 4th course (V58.1)FIT
Pathology : Moderate differentiated non keratinizing squamous cell carcinoma cervix, limfovascular invasion
4.07.04.15
USMs.RAH/24/UA
Right ovary endometriosis cyst(N80.1)Operative laparoscopy(54.21)PUT
5.08.04.15
USMrs. AST/47/P3A0/RA
Leiomyosarcoma (C53.9)Surgical staging (68.49)NIS
Pathology : Leiomyosarcoma
Gynaecologi Chief on DutyWednesday, April 8th 2015 at 02 .00 PM Thursday, April 9th 2015 at 07.00 AMConsultant on duty : dr. H. Irawan Sastradinata, SpOG(K)
1.08.04.15General condition improvement Ms. DIL/13/RA/RSP
D/ Carcinoma ovary stage III C with progressive disease metastatic was suspected
US ER (SMS) :
M/ - Observed vital signIVFD RL : D5 1 : 1 xx drops/mLaboratory examinationsThorax X-Ray
P/ - US ConfirmationConsult to internal Department
Dr. Meita Esthi Harumi
1.07.4.15Mrs. NIS/49/P8A0/RA
Stage IIB cervical cancer (C53.9)NAC Paclitaxel-Carboplatin 1st course(V58.1)FIT
Pathology : Moderatelly differentiated non keratinizing squamous cell carcinoma cervix
2.07.04.15Mrs. JUR/32/P1A0/RA
Stage IIIC ovarian cancer(C56)Chemotherapy Docetaxel-Carboplatin 1st course (V58.1)FIT
Pathology : Low grade serous papillary adenocarcinoma right ovarian with atypical proliperative serous tumor with right ovary microinvasion and there was malignant cell at ascites fluidTeratoma cystic matur with multiple cyst at bilateral ovarian folicelThere was no tumor mass at peritoneum, omentum and mesocolon
3.07.04.15Mrs. MAY/58/P4A0/UA
Residive ovarian cancer (C53.9)Chemotherapy Gemcitabine-Oxaliplatin 4th course (V58.1)NIS
Pathology : High grade serous carcinoma ovarian (cystadenocarcinam serosum papilliferum multiloculare)
4.07.04.15
CurveHcg : 52788
Mrs. LIN/41/P4A0/UAGTN stage I FIGO score 7 (C54) Chemotherapy Methothrexate-Etoposide 1st course (V58.1)NIS
Pathology : hydatid mole, mild proliferation thropoblast
5.08.04.15
USMs.ERN/29/UA
Right ovary endometriosis cyst(N80.1) Operative laparoscopy(54.21)PUT
6.08.04.15
USMrs. MAY/29/P0A0/RA
Left ovary endometriosis cyst + Primary infertile 10 years(N80.1)HDLO(54.21) (68.12)PUT
Dr. Meita Esthi Harumi
1.07.4.15Mrs. NIS/49/P8A0/RA
Stage IIB cervical cancer (C53.9)NAC Paclitaxel-Carboplatin 1st course(V58.1)FIT
Pathology : Moderatelly differentiated non keratinizing squamous cell carcinoma cervix
2.07.04.15Mrs. JUR/32/P1A0/RA
Stage IIIC ovarian cancer(C56)Chemotherapy Docetaxel-Carboplatin 1st course (V58.1)FIT
Pathology : Low grade serous papillary adenocarcinoma right ovarian with atypical proliperative serous tumor with right ovary microinvasion and there was malignant cell at ascites fluidTeratoma cystic matur with multiple cyst at bilateral ovarian foliceleThere was no tumor mass at peritoneum, omentum and mesocolon
3.07.04.15Mrs. MAY/58/P4A0/UA
Residive ovarian cancer (C53.9)Chemotherapy Gemcitabine-Oxaliplatin 4th course (V58.1)NIS
Pathology : High grade serous carcinoma ovarian (cystadenocarcinoma serosum papilliferum multiloculare)
4.07.04.15
CurveHcg : 52788
Mrs. LIN/41/P4A0/UAGTN stage I FIGO score 7 (C54) Chemotherapy Methothrexate-Etoposide 1st course (V58.1)NIS
Pathology : hydatid mole, mild proliferation thropoblast
5.08.04.15
USMs.ERN/29/UA
Right ovary endometriosis cyst(N80.1) Operative laparoscopy(54.21)PUT
6.08.04.15
USMrs. MAY/29/P0A0/RA
Left ovary endometriosis cyst + Primary infertile 10 years(N80.1)HDLO(54.21) (68.12)PUT
Obstetric Chief on DutyWednesday, April 8th 2015 at 02 .00 PM Thursday, April 9th 2015 at 07.00 AMConsultant on duty : dr. H. Irawan Sastradinata, SpOG(K)
(-)
VI. EMERGENCY ROOM REPORTMonday, April 6th, 2015 until Wednesday, April 8th, 2015
OBSTETRICSPhysiological patient: - casePathological patient: - case
GYNAECOLOGY/ONCOLOGY Gynecology patient: 1 case Oncology patient: - case
Emergency Room ChiefsDr. Fista Divi Amesia: - caseDr. Wira Hadi Satria: 1 caseTotal: 1 case
OBSTETRIC NSR/MAFNoIDAgeDiagnosisTreatmentPhysician
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GYNAECOLOGY/ONCOLOGY NSR/MAF-NoIDAgeDiagnosisTreatmentPhysician
1.Mrs. LIN32D/ Post coital bleeding(N.93.0) Suture laceration( 665.4)WRA
Dr. Wira Hadi Satria
107-04-2015Suture lacerationMrs. LIN/ 38/UA/MAF
10.45 AMLaceration at back of vaginal wall at 3 aclock 3 cmD/ Post coital bleeding c.b laceration vaginal posterior lateral
Hb : 12 g/dLM/ Suture laceration Amoxycilin 500mg/ 8 hours Mefenamic Acid 500 mg/ 8 hours
The patient was discharge
NOASSESMENTdr. Wira Hadi Satria VALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
Dr. Fista Divi Amesia
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Gynecology Chief on duty: Dr. Fista Divi AmesiaTuesday, April 7th, 2015 at 02.00 PM - Wednesday, April 8th, 2015 at 07.00 AMConsultant on duty: Dr. H. Rizal Sanif, SpOG (K)
1.07.04.15MedicinalisMrs. SUS/62/P1A0/UA/RIS
04:00 PMD/ AUB cb M1 was suspected with moderate anemia
Hb 7.6 g/dlUS Confirmation :Uterine RF sized 6,08 x 2,68 mmBoth ovaries dificult to identified, atrophy was suspectedC/ there is no abnormality at internal genitalia
M/ Observed vital sign, bleeding IVFD RL gtt XX/minute Laboratory examination Ceftriaxone Inj 1 g/12 hour IV Tranexamat acid 500 mg/8 hour IV PRC tranfusion
2.07.04.15Curettage due to incomplete abortionMrs. MAH/27/P2A0/UA/NIL
09:10 PMD/ Incomplete abortion
M/ Observed vital sign, bleeding IVFD RL gtt XX/minute Laboratory examination Ceftriaxone inj 1 g/12 hour IV (ST)
P/ Curettage
01.00 AM blood and tissue 10 cc
3.07.04.15Plan Laparotomy + FS Mrs. CIK/54/P1A0/RA/RIS
09:30 PMD/ solid ovarian neoplasm with cystic part malignancy was suspected + dehidration low intake + mild anemia
Hb : 9,0 g/dlUS Confirmation:Uterine hard to identifiedThere was solid mass with cystic part, multiloculare , papil (-) sized 50 x 50 cm that posible from ovariesIntramass blood flow (+)C/ solid ovarian neoplasm with cystic part malignancy was suspected
M/ Rehydration with IVFD RL 500 cc flush in 8 minutes with maintanance RL gtt XXX/mnt Laboratory examination , tumor marker Thorax X-Ray
P/ Laparotomy + FS
NOASSESMENTdr. Fista Divi AmesiaVALUE MAXNotes
1Report technique30
2Paper acknowledgment35
3Honesty35
Mean100
Mengetahui , Konsulen
Dr. H. Rizal Sanif, SpOG (K)