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)