II.

GYNAECOLOGYCAL INPATIENT REPORT

Thursday, April 17
th
, 2014 until Wednesday April 23
th
, 2014

Gynaecological Inpatient Chief:
dr. Adrin M. Harahap : 4 patients
dr. Albert L. Tobing : 4 patients
dr. Wahyu Pranata : 4 patients
dr. Edo Brendo Stevano : 5 patients
dr. Syifa Alkaf : 4 patients
dr. Bertha Octarina : 5 patients
Total patients : 26 patients


dr. Adrin M. Harahap
GYNAECOLOGY WARD DAS-SMA-LIN/SUG
1. 17.04.14
Chemoradiation Mrs.PUT/48/P
9
A
0
/RA/LAS
10.18 AM
M/ Stage IIIB cervical cancer C53.9

D/ Chemoradiation Paclitaxel Carboplatin 2
nd
course

Pathology result : poorly diffrentiated adenosquamosa carcinoma


2. 21.04.14
Adjuvant Chemotherapy Mrs. TUK/53/P
2
A
0
/RA/LAS
09.04 AM
D/ Stage IIIC ovarian cancer C56

M/ Chemotherapy paclitaxel-carboplatin 1
st
course
1. 22.04.14 Right salfingectomy oi. Rupture of right tube pars ampullaris
Mrs. ARG /23/UA/AMH

05.30 PM
Hb: 6,0 g/dl
D/ Difuse peritonitis cb. liver laceration + severe anemia

09.30 PM
Pregnancy test:
(+)
Intraoperative consult from Surgery departement:
There was 1500 cc blood, liver laceration and rupture of right tube pars
ampullaris

D/ Rupture of right tube pars ampullaris

M/ Right salfingectomy
Vital sign and bleeding observation
Antibiotic inj
Transfusion until Hb 8 g/dl
Joint care with Surgery Department

24.04.14 Follow up

Hb : 8,4 g/dL
Drain : 200 cc
Urine : 5
cc/kgBB/hour
Sens : CM HR : 98x/mnt
BP : 120/80 mmHg T : 36,5
0
C
ONCOLOGY WARD LAS-EST
08.04.14
Pathology result : high grade serous papillary carcinoma


3. 23.04.14
Chemotherapy Mrs.SUA/48/P
0
A
0
/RA/EST
09.53 AM
D/ Stage IIIC ovarian cancer C56

M/ Chemotherapy Paclitaxel-Carboplatin 3
rd
course
Pathology result : moderate diffrentiated endometrioid carcinoma at right
ovarian

ENDOCRINOLOGY, FERTILITY AND REPRODUCTION

UROGYNECOLOGY WARD


GYNAECOLOGY WARD DAS-SMA-LIN/SUG

1. 21.04.14
Chemoradiation Mrs. ROH/56/P
7
A
0
/RA/EST
11.19 AM
D/ Stage IIIB cervical cancer C53.9

M/ Chemoradiation weekly Paclitaxel Carboplatin 3
rd
course

31.08.13
Pathology result :
Cervical biopsy : poorly differentiated adenosquamous cell carcinoma at
serviks
2. 22.04.14
Adjuvant chemotherapy Mrs. MAS/40/P
1
A
0
/RA/LAS
09.51 AM
D/ Stage IC ovarian cancer C56

M/ Adjuvant chemotherapy BEP 4
th
course

Pathology result : adult granulosa cell tumour at right ovarian
-
- -
-
- -
dr. Albert L Tobing
1.
21.04.14 Laparoscopy cystectomy Mrs.SIT/21/P
0
A
0
/RA/SUG

08.24 AM D/ Endometriosis cyst

M/ laparoscopy Plan for cystectomy

24.04.14 Intraoperative:
- There was cystic white-greyish mass 4 x 3 cm derived from right ovary
- There were adhesion of the right adnexa with omentum and colon, and
left adnexa with posterior uterine wall
- The was Severe adhesion of the posterior uterine wall with Douglas
cavity

D/ Left ovarian functional cyst + Internal genital adeshion +
Endometriosis ASRM grade I
ONCOLOGY WARD LAS-EST


ENDOCRINOLOGY, FERTILITY AND REPRODUCTION

UROGYNECOLOGY WARD


dr. Wahyu Pranata
GYNAECOLOGY WARD DAS-SMA-LIN/SUG

ONCOLOGY WARD LAS-EST
1. 21.04.14 Adjuvant Chemotherapy Mrs. MAI/43/P
1
A
0
/RA/EST
11.45 AM D/ Stage IC ovarian cancer C56
M/ Chemotherapy Docetaxel-Carboplatin 2
nd
course
Pathology result : endometrioid carcinoma at left ovarian

2. 22.04.14 Chemotherapy Mrs. SRI/42/P
1
A
0
/UA/EST
10.00 AM D/ Stage IIIB cervical with inadequate therapy C53.9
M/ Chemotherapy paclitaxel-carboplatin 2
nd
course
Pathology result :
Keratinizing squamous cell carcinoma
FNAB : inguinal regio show carcinoma

ENDOCRINOLOGY, FERTILITY AND REPRODUCTION

- - -
1.
19.04.14 Colpocleisis + cervical amputation + cautherization
Mrs.PON/85/P
6
A
0
/RA/WRA

01.05 PM D/ Cystocele grade II + Rectocele grade II + caruncle of paraurethra

P/ Plan for transvaginal hysterectomy

22.04.14 Intraoperative:
- identifying the border of vesica, vagina and servix C/ cystocele grade
II and rectocele grade II
- Identifying mass at parauretrhra C/ caruncle of paraurethra

Foto D/ cystocele grade II + Rectocele grade II + caruncle of paraurethra
1.
21.04.14 Total abdominal hysterectomy Mrs. ROH/40/P
3
A
1
/RA/SUG

03.34 PM D/ Uterine myoma

US P/ Total abdominal hysterectomy

24.04.14 Intraoperative:
- uterine was 20 weeks

Foto D/ Uterine myoma
- - -
UROGYNECOLOGY WARD
dr. Edo Brendo Stevano
GYNAECOLOGY WARD DAS-SMA-LIN/SUG

1. 17.04.14
Neo adjuvant chemotherapy Mrs.KAR/46/P
2
A
0
/RA/EST
10.23 AM
D/ Stage IIB cervical cancer C53.9

M/ NAC Paclitaxel Carboplatin 2
nd
course
Pathology result : moderate differentiated non keratinizing squamosa cell
carcinoma

P/ Radical hysterectomy


2. 22.04.14
Adjuvant chemotherapy Mrs.PIN/27/P
0
A
0
/RA/EST

D/ Stage IIIC ovarian cancer inadequate treatment C56

M/ Adjuvant chemotherapy Gemcitabin-Oxaliplatin 4
th
course day VIII

12.11.06
05.02.14
Pathology Result :
Papillary ovarian adenocarcinoma
Mixed type cystadenocarcinoma


3. 22.04.14
Chemoradiation Mrs. RUS/49/P
4
A
0
/UA/LAS
1.
19.04.14 Total vaginal hysterectomy + anterior et posterior colporraphy
Mrs. MAH/62/P
7
A
0
/RA/WRA

08.00 AM D/ Cystocele grade II + Rectocele grade III + uterine prolaps grade II

M/ Total vaginal hysterectomy + anterior et posterior colporraphy
1.
23.04.14

Curettage oi. incomplete abortion
Mrs.ELI/27/P
2
A
0
/UA/DAS

01.38 AM D/ Incomplete abortion (O03.4)

M/ Curettage (68.1)

Blood and tissue 40 cc


2.
23.04.14 Plan for laparotomy
Mrs.RIS/26/P
2
A
0
/RA/SUG

09.35 AM
CEA : 0,85
ng/mL
Ca 125 :29,21
RI : 0,19
PI : 0,378
RMI 3 : 29,21
D/ Cyst ovarian neoplasm with solid part malignancy was suspected

US P/ laparotomy + FS
ONCOLOGY WARD LAS-EST
10.08 AM
D/ Stage IIIB cervical cancer C53.9

M/ Chemoradiation weekly paclitxel-carboplatin 4
th
course

Pathology result : adenosquamosa cell carcinoma

ENDOCRINOLOGY, FERTILITY AND REPRODUCTION

UROGYNECOLOGY WARD


dr. Syifa Alkaf
GYNAECOLOGY WARD DAS-SMA-LIN/SUG
1. 19.04.14 Laparotomy Mrs. MAR/29/P
1
A
0
/RA/SUG
08.22 AM
US
D/ Cyst ovarian neoplasm malignancy was suspected
21.04.14 Laparotomy
Intraoperative : there was greyish white mass sized 20x15x5 cm derived from
retroperitoneal cavity
Mass biopsion from digestive subdivision
D/ Retroperitoneal mass
P/ Refer to surgery Department

ONCOLOGY WARD LAS-EST
1. 21.04.14 Adjuvant chemotherapy
Mrs.SUH/50/P
0
A
0
/UA/EST
09.38 AM
US
D/ Endometrioid adenocarcinoma + bilateral inguinal lymph node
metastase
C54.1
M/ Chemotherapy paclitaxel-carboplatin 2
nd
course
18.03.14

Pathology result : carcinoma at both inguinal lymph node metastase

2. 22.04.14 Neo adjuvant chemotherapy Mrs.SUH/43/P
0
A
1
/RA/LAS
Ca 125 :368,5
AFP : 7,28
CEA : 14,42
D/ Solid ovarian neoplasm was suspected + myomatosus uterine + lung
metastase was suspected
US M/ Neoadjuvant chemotherapy paclitaxel-carboplatin 2
nd
course

ENDOCRINOLOGY, FERTILITY AND REPRODUCTION
- - -
- - -


UROGYNECOLOGY WARD


dr. Bertha Octarina
GYNAECOLOGY WARD DAS-SMA-LIN/SUG
1.
22.04.14 Plan for laparoscopic cystectomy + chromotubation
Mrs. FER/26/P
0
A
0
/RA/SUG

08.50 AM D/ Endometriosis cyst + Primary infertile 5 years

US P/ Laparoscopic cystectomy + chromotubation
ONCOLOGY WARD LAS-EST
1. 17.04.14
General condition improvement Mrs.SUA/61/P
7
A
0
/UA/EST
00.30 PM D/ Stage IIIC ovarian cancer inadequat therapy + liver metastase + drug
eruption cb? C56
M/ - General condition improvement
- Join care with gastroenterology subdivision

Pathology result : High grade serous carcinoma
23.04.14 Abdominal US result:
Liver and paraaortic lymph node metastase
D/ Stage IIIC ovarian cancer inadequat therapy with progressive disease +
drug eruption cb? C56
P/ Hemodialysis
Nefrostomy
Chemotherapy Gemcitabine-Oxaliplatin


2. 21.04.14
Chemotherapy Mrs.SIT/42/P
2
A
2
/UA/LAS
11.58 PM D/ Stage I Gestational trophoblastic neoplasia with progressive disease
C.58

M/ Chemotherapy Paclitaxel-Cisplatin 5
th
course

Pathology result : choriocarcinoma


4. 23.04.13
Neoadjuvant chemotherapy Mrs. TUM/58/P
4
A
0
/RA/EST
08.47 AM D/ Stage IIB cervical cancer
C53.9

M/ - Neoadjuvant chemotherapy Paclitaxel-Carboplatin 2
nd
course
1.
19.04.14 Plan for histerectomy Mrs.DEW/45/P
3
A
0
/UA/SUG

08.41 AM D/ uterine adenomiosis

US P/ Plan for histerectomy
- - -
- Consult to urology surgery department

P/ Radical hysterectomy
Pathology result : Nonkeratinizing squamous cell carcinoma moderately
differentiated

ENDOCRINOLOGY, FERTILITY AND REPRODUCTION
UROGYNECOLOGY WARD


Passed Away
- - -
- - -
1. 15.04.2014 General condition improvement
Mrs. RIK/34/P
1
A
0
/RA/EST-DEN
04.00 PM D/ Cervical cancer stage III B was suspected + severe anemia + CKD
stage V DD/ AKI stage III + dyspnue
Hb: 3,3 g%
Ureum 87
Creatinin 13,85
M/ IVFD RL gtt x/m
O2 5 l/m
Blood transfusion
Transamin inj. 3x1 amp iv
Ceftriaxone injection 2x1 g IV
P/ Biopsi
Clinical staging
Abdominal CT scan
BNO-IVP
Abdominal US
15.04.2014 Consult to Internal Department:
C/ - CKD stage V cb. Uropathy obstructive cb. Cervical cancer stage III B
was suspected.
DD/ AKI stage III cb. Uropathy obstructive cb. Cervical cancer stage
III B was suspected. CKD stage V cb. Uropathy obstructive cb.
Cervical cancer stage III B was suspected.
- Hypertention stage II
- Chronic anemia
Advice: Clonidin 3x0,15 mg tab
Folic acid 3x400 mg tab
Plan for hemodialysis
Join care with Renal and Hypertensive Subdivision Department
Laboratory examination
18.04.2014 D/ Cervical cancer stage III B was suspected + severe anemia + CKD
stage V + moderate anemia + dyspnue
Hb: 7,7 g% M/ IVFD RL gtt x/m

Control List
Date Vital Sign
April,21,
2014
Sens BP Pulse

RR T
07.00 AM Somnolen 80/50 130 28 36,5 Urine : 0 cc
07.15 AM Somnolen 80/50 115 28 36,5
07.30 AM Somnolen 80/50 115 28 36,5 Consult to Oncology
ward supervisor, dr.
Irawan S, SpOG(K):
Advice: Informed
consent
Ureum 112
Creatinin 17,64
O2 5 lpm
Blood transfusion
Transamin inj. 3x1 amp iv
Ceftriaxone inj. 2x1 gr iv
P/ Hemodialysis
19.04.2014 D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage
V + mild anemia + dyspnue + post hemodialysis + hyperkalemia
Hb: 9,2 g%
Ureum 84
Creatinin 14,04
Na : 142
K : 6,9
M/ Ca Gluconas inj 1 amp iv
P/ consult to urology surgery division


20.04.2014 D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage
V + mild anemia + dyspnue + hyperkalemia
Ureum 103
Creatinin 16,63
Consult to Urology department -> not yet assesed
P/ Nefrostomy
21.04.2014
03.00 AM
D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage
V + dyspnue + decrease of consciousness
Sens: somnolens
RR: 46x/m
M/ Close observation
IVFD RL gtt x/m
O2 10 l/m Intubated at oncology ward
Consult to ICU -> ICU was full
07.20 AM

Consult to Oncology ward supervisor, dr. Irawan S, SpOG(K):
Advice: Informed consent
Consult to ICU
Referral reply from ICU: ICU was full
02.00 PM Consult to consultant on duty, Prof. dr. Syakroni Daud R, SpOG(K):
Advice: Informed consent
03.20 PM Patient became apneu
DNR
03.30 PM Patient was passed away in front of doctor and midwife
07.45 AM Somnolen 80/50 115 28 36,5
08.00 AM Somnolen 80/50 114 28 36,5
08.15 AM Somnolen 80/50 116 28 36,5
09.00 AM Somnolen 80/50 112 28 36,5
09.30 AM Somnolen 80/50 114 28 36,5
10.00 AM Somnolen 80/50 115 28 36,5
10.30 AM Somnolen 80/50 116 28 36,5
11.00 AM Somnolen 80/50 110 28 36,5
11.30 AM Somnolen 80/40 113 24 36,5
00.00 PM Somnolen 80/40 74 24 36,5
00.30 PM Somnolen 80/40 75 24 36,5
01.00 PM Somnolen 80/40 75 24 36,5
01.30 PM Somnolen 80/40 70 24 36,5
02.00 PM Somnolen 80/40 70 24 36,5
02.15 PM Sopor
coma
50/palpable 64 16 36,5
02.30 PM Sopor
coma
50/palpable 62 16 36,5
02.45 PM Sopor
coma
50/palpable 70 10 36,5
03.00 PM Sopor
coma
50/palpable Not
palpable
10 36,5 Dobutamin drips 1 amp
in 100 ml NS gtt x/mnt
03.15 PM Sopor
coma
50/palpable Not
palpable
10 36,5

03.20 PM coma Not
measured
Not
palpable
apneu 36,5 CPR, Bagging
03.30 PM Patient was passed
away in front of doctor
and midwife