CHIEF REPORT

Friday, April 10 2015

OBSTETRICS AND GYNAECOLOGY REPORT

Elective Operation Chief

Dr. Alvilusia
Dr. Hariya Romiya

Obstetric Inpatient Chief

Dr. Lydia Octavia

Dr. Erliyanna Tolu Saputri
Dr. Oktrivianus Sanjaya

Gynecology Inpatient Chief

Dr. Jamatul Firdaus

Dr. Wahyudi
Dr. Emiruddin Sunny

Obstetric Outpatient Chief

Dr. Rodiani
Dr. Hendra Sugama Saputra

Gynecology Outpatient Chief

Dr. Agung Haryadi

Dr. Meita Esthi Harumi

Emergency Room Chief

Dr. Wirahadi Satria

Dr. Fista Divi Amesia

I. ELECTIVE OPERATION REPORT

Monday, April 6th, 2015 until Wednesday, April8th, 2015
Operation Room Chief

Dr. HariyaRomiza
Dr.Alvilusia
Total

N
o

Date

: 3patients
: 3patients
:6patients
Preoperative
Diagnosis

Intraoperative

Management

Mrs.
AIN /35/
UA/NS

G2P1A038
weeks
gestational
age not
inlabor
with prior
CS 1x (due
totwin
pregnancy)
SLF
transverse
lie

Pfannenstiel incision
Uterine size~ 38 weeks
gestation
Female life baby was born,
BW 3300 g ,BL 49 cm,
AS 8/9 FTAGA
Placenta was delivered
completely, PW 510 g,
UCL 48 cm , diameter
19x20 cm
Mother and baby was in
good condition

LSCS
(648.6)

P2A0post
LSCS due to
transverse lie

Mrs.EN
D/37/P5
A1/RA/A
F

Rectocele
grade II
(N81.6)

Suprapubic incision 2cm

Uterus was in normal limit
Identified both of tube
Perforned Pomeroy tubal
ligation
Longitudinal incision at
posterior vaginal to
perineal lateral 2cm
from midline
Vaginal perineomucocutan
seperated from
rectovagina fascia
Disection vaginal
perineomucocutan and
suture vaginal mucous
Suture vaginal
perineomucocutan
Uterus size normal
Both ovaries and tubes
were within normal limit
Performed total
hysterectomy
Performed methylene blue
test to bladder no
leakage
Performed anterior
colporaphy
Vaginal stump hanged to
uterosacral ligament

Pomeroy tubal
ligation
(26.51) +
posteriorcolpo
raphy(70.5)

Post
posteriorcolp
oraphyoi.
rectocele
grade II
(N81.6) +
post
pomeroytuba
l ligation
(26.51)

LAVH +
anterior
colporaphy
(70.5)

Post LAVH
+ anterior
colporaphyoi
. Uterine
prolaps
grade II +
cystocele
grade II
(N81.3 +
N81.4)

Identity

Postoperative
Diagnosis

dr.HariyaRomiza

1.

2.

06-042015

06-042105

VID

3.

08-042015

Mrs.JUA
/79/P6A0/
RA/IS
VID

Uterine
prolaps
grade II +
cystocele
grade II
(N81.3 +
N81.4)

ELECTIVE OPERATION PLANNING

Saturday, April11st, 2015 Tuesday, April15th, 2015
AssistantAssistantPreOp
I
II

No

Date

Identity

Diagnosis

Planning

Operator

1.

13-0415

Mrs.Sat/45/P0A0/
UA

OMI

RIS

LAT

14-0415

Mrs.Nur/35/
PoAo/RA

Hysterecto
my
Adenomyo
sis
resection

KYERL

2.

IS

OMI

MRZ

LAT

3.

14-0415

Mrs.Non/64/P3A0/
RA

AUB ec susp
L1
Uterine
Adenomyosi
s
Cervical
cancer
stage II B
post NAC 3rd
series

IS

OMI

RIS

KML

Radical
hysterecto
my

NAME
NO
1
2
3

N
o

ASSESMENT

VALUE MAX

Report technique
Paper acknowledgment
Honesty
Mean

Date

Dr. Alvilusia
1. 07-042015

Identity

Mrs.
HER/32/
P5A1/UA
/ AALYD

07-042015

Ms.
LIZ/RA/
19/
RS-RIS
PIC

Notes

30
35
35
100
Preoperative
Diagnosis

AUBec L1
(N93.9)

PIC

2.

dr.Hariya Romiza

Cyst ovary
neoplasm
malignancy
was
suspected
(N83.29)

Intraoperative

Exploration uterine
with bumpy surface
size ~ 16 weeks
Right and left ovarian
were in normal limit
Perform total
abdominal
hysterectomy
Uterine incised
C/intramural myoma
size 6cm, 2cm, ,
2 cm, 1,5 cm, 2 cm

Mediana incision
There was ascites liquid
500 cc at abdominal
cavityperform
citology
Uterus was in normal

Management

Postoperative
Diagnosis

Total
Abdominal
Hysterectomy
(68.4)

Post Total
Abdominal
Hysterectom
y due to
multiple
uterine
myoma
(D25.1)

Conservative
Surgical
staging
(162.9)

Stage IC
Ovarian
Cancer was
suspecteed
(C56.9)

3.

06-042015

Mrs.
ISM/40/
P4A0/RA
/
AT
PIC

limit
Left ovarian and tube
were in normal limit
There was cystic mass
greyish white size
10x20x5 cm derived
from right ovarian
rupture (+)
perform frozen section
C/ malignant
mucinous tumor
Right pelvic
lymphadenectomy,
partial omentectomy,
appendectomy
Endometria Performed sondage,
l
uterus AF 9 cm
hyperplasia Uterus size 14 weeks
(N85.00)
Both ovaries and tubes
were within normal
limit
Performed total
hysterectomy
Performed methylene
blue test to bladder
no leakage

LAVH
(68.51)

Post LAVH
due to
endometrial
hyperplasia
(N85.00)

ELECTIVE OPERATION PLANNING

Saturday,April11st, 2015 Tuesday,April15th, 2015
N
o

Date

Identity

Diagnosis

Planning

1.

11-0415

Mrs.Adu/53/P5A
1/UA

AUB ec L1

Hysterect
omy

AF

JUS

VIL

LAT

2.

11-0415

Mrs.Das/47/P0A
0/RA

Surgical
staging

AT

VIL

RIS

KML

3.

13-0415

Mrs.Yan/56/P2A
0/UA

Laparoto
my FS

AT

VIL

MRZ

KML

NO

ASSESMENT

Ovarian cancer
inadequate
staging
Cyst ovarian
neoplasm with
solid part
malignancy
was suspected
VALUE MAX

Operator

NAME

Assistant Assistant PreOp

I
II

Notes

dr.Alvilusia
1
2
3

Report technique
Paper acknowledgment
Honesty
Mean

30
35
35
100

II. OBSTETRICS INPATIENTS REPORTS

Sunday, April 5th 2015 until Wednesday, April 8th , 2015

Physiological Patients

: 2

Pathological Patients
Total

: 7 cases
: 9 cases

Chief Obstetrics Inpatient

dr. Oktrivianus Sanjaya

: 3 cases

dr. Erliyanna Tolu Saputri

dr. Lydia Octavia

: - cases
: 4 cases

PROM
Antepartum haemorrhage
Preterm
Breech presentation
Prolonged 2nd stage
Placentae incarcerated
TOTAL

No

Initial

Age

cases

: 1 cases
: 1 case
: 1 case
: 1 case
: 1 case
: 2 cases
: 7 cases

Diagnosis

Treatment

Physician

Brandt Andrew Manouvre

1.

WAN

25

Incarcerated placentae

2.

WAR

22

Preterm

3.

ROD

41

COR

Spontaneous delivery
(80.0)

Breech presentation

RZM
RZM

Spontaneous bracht
4

4.

LUS

19

Ante Partum Hemorrhage

( O46.9)

Expectative

TMS

5.

DIA

25

Prolonged 2nd stage

Vaccuum extraction

RZM

Brandt Andrew Manouvre

6.

NEL

32

Incarcerated placentae

7.

MAR

21

PROM

COR

Spontaneous delivery
(80.0)

TMS

MATERNAL MORTALITY

No.
-

Initial
-

Age
-

Diagnosis

Treatment
-

Physician
-

dr. Oktrivianus Sanjaya

1.
06-04-15
Brandt Andrews Manouvre
04:25 PM
Mrs.WAN/25/UA/SWA/COR
D/ P1A0 post spontaneous delivery 3 hours (outside) with early PPH cb incarcerated
placentae
08-04-15
D/ P1A0 post Brandt Andrew Manouvre due to Incarcerated placentae (day 2)
06:00 AM
M/ Cefadroxil 500 mg/ 12 hour PO
Mefenamic acid 500 mg / 8 hour PO
Roborantia
Mother was discharged
2.

06-04-15
07:35 PM

Preterm spontaneous delivery

Mrs.WAR/22/RA/SWA/RZM
D/ G2P1A0 35 weeks of gestational age inlabour 2 stage SLF cephalic presentation
D/ P2A0 post preterm spontaneous delivery day 2
Female life baby was born with BW : 2300 g BL : 44 cm
M/ Cefadroxil 500 mg/ 12 hour PO
Mefenamic acid 500 mg / 8 hour PO
nd

08-04-15
06:00 AM
Balard score:
34-36 weeks

Roborantia
Mother and baby were discharged
3.

08-04-15
04.30 WIB
09-04-15
06:00 AM

NO

1
2
3

US
09-04-15
07:00 AM

05-04-15
04:00 PM
07-04-15

Mrs.ROD/41/RA/NIL/RZM

D/ G2P0A1 37 weeks of gestasional age inlabor 1st stage active phase SLF breech
presentation
D/ 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
ASSESMENT
Dr. Oktrivianus Sanjaya

Report technique
Paper acknowledgment
Honesty
Mean

dr. Lydia Octavia

1
05-04-15
8:51 AM

2.

Spontaneous bracht

VALUE MAX
Notes
30
35
35
100

Expectative 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
US confirmation (NS):
C/ 34 weeks gestational age SLF cephalic presentation with total placentae previa +
BPP 10
D/ 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
Vacum 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
D/ P1A0 post vacum extraction due to prolonged 2nd stage (outside) day 2
6

06:00 PM

3.

06-04-2015
04:08 AM
08-04-15
06:00 AM

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
Brandt Andrew Manouvre
Mrs.NEL/32/RA/ASR/COR
D/ P3A0 post spontaneous delivery 3 hours (outside) with early PPH cb incarcerated
placentae
D/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.

08-04-15
03:30 AM
09-04-15
06:00 AM

Spontaneous delivery

D/ G2P1A0 37 weeks of gestasional age inlabor 1st stage active phase with history of
ROM 13 hours SLF cephalic presentation
D/ 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

NO

1
2
3

Mrs. MAR/21/UA/NIL/TMS

Report technique
Paper acknowledgment
Honesty
Mean

ASSESMENT
Dr. Lydia Octavia

VALUE MAX
Notes
30
35
35
100

III. GYNAECOLOGYCAL INPATIENT REPORT

Thursday, April 2nd, 2015 until Wednesday, April 8th, 2015
Gynaecological Inpatient Chief
dr. Emiruddin Sunny
dr. Wahyudi
dr . Jamatul Firdaus
Total patients

Dr. Emiruddin Sunny

06-04-15
1.
11:38 AM

2.

:
:
:
:

3
2
3
8

patients
patients
patients
patients

Chemotherapy
Mrs. MIR/42/P0A0/RA/MUL
D/ 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
05-04-15
Plan for laparotomy FS
Mrs.NUR/36/P4A0/UA/MUL
01:38 AM
D/ Cystic ovarian neoplasm malignancy was suspected + mild anemia
US
M/ Blood transfusion
P/ Laparatomy FS

3.

07-04-15

Plan for laparotomy FS

07: 38 PM
US

Mrs.CIK/55/P1A0/UA/MUL
D/ Solid ovarian neoplasm malignancy was suspected + mild anemia
M/ Blood transfusion
P/ Laparatomy FS
NAME

NO
1
2
3

ASSESMENT

VALUE MAX

Report technique
Paper acknowledgment
Honesty
Mean

Dr. Wahyudi
1.
05-04-15
17.40 PM
Hb : 12.6 g/dL

dr.Emirudi Sunny

Notes

30
35
35
100

Medicinalis
Mrs.EMI/37 /UA/NRM
D/ G4P3A0 9 weeks gestational age with threatened abortion
T/ :

- Amoxicillin 3x500 mg
- Luminal 3x30 mg
- P/ US Confirmation
US
US confirmation (NS) :
C/ 10 weeks gestational age SLF intrauterine
2.
04.04.15
Chemotherapy (V58.1) + Plan for radical hysterectomy
Mrs.NON/64/P8A0/RA/FOR
03.45 PM
D/ Stage II B cervical cancer post Neoadjuvant Chemoyherapy PaclitaxelCarboplatin 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
NAME
NO

ASSESMENT

VALUE MAX

dr.Wahyudi

Notes

1
2
3

Report technique
Paper acknowledgment
Honesty
Mean

30
35
35
100

Dr. Jamatul Firdaus

1.
04.04.15

Chemotherapy (V58.1) + Plan for radical hysterectomy

Mrs.NON/64/P8A0/RA/FOR
03.45 PM
D/ 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.

06.04.15
02.00 PM

Chemotherapy
Mrs. CAS/36/P2A0/RA/FOR
D/ 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.
07.04.15
Chemotherapy
Mrs. NIS/55/P2A0/RA/FOR
02.00 PM
D/ Cervical cancer stage IIB
P / NAC Paclitaxel - Carboplatin 1st course
Pathology : Moderatelly differentiated non keratinizing squammous cell carcinoma on cervical biopsy

Gynaecologi Chief on Duty

Monday, April 6th 2015 at 02 .00 PM Tuesday, April 7th 2015 at 07.00 AM
Consultant on duty : dr. Awan Nurtcahyo, SpOG(K)

NO

ASSESMENT

VALUE MAX

NAME

Notes

Dr. Jamatul Firdaus

1
2
3

Report technique
Paper acknowledgment
Honesty
Mean

30
35
35
100

10

IV. OBSTETRICS OUTPATIENT REPORT

Thursday, April 2nd, 2015 until Wednesday April 8th, 2015
Obstetric outpatient chief :
dr. Rodiani
dr. Hendra Sugama Saputra
TOTAL
DATE
4

VISITE
Lactation &
puerperal
1

5
3
1
14

3
6
3
13

Obstetric
April 2nd
April 3rd
April 4th
April 5th
April 6th
April 7th
April 8th
TOTAL

: 7 patients
: 7 patients
: 14 patients

Family
Obstetric
Planning
6
4
Holiday
3
1
Holiday
1
5
8
3
3
1
21
14

PATIENT
Lactation &
puerperal
1

Family
Planning
6

3
6
3
13

1
8
3
21

1. dr. Rodiani
OBSTETRIC CASE
No

Initial

Age

Add

Diagnosis

DIA

33

UA

G2P1A0 33 weeks
gestational age not inlabor
SLF cephalic presentation

US

32 weeks gestational age

SLF cephalic presentation

LACTATION AND PUERPURAL

No Initial Age Add
.

ICD
Code
Z.34

Treatment/Plan
Folic acid 1x400g
Recontrolled within
2 week

Physician
FCH ROD

Diagnosis

ICD Code

Treatment/Plan

Physician

TET

32

UA

P1A1 post LSCS due to

impending eklampsia and
breech presentation

082.1

Roborantia

ROD

WID

23

UA

P1A1 post LSCS due to

impending eklampsia

082.1

Roborantia

ROD

FAMILY PLANNING
No. Initial
Age

Status

Diagnosis

Contraception

Physician
11

HER

36

(New/Old)/Date
April 1st 2015

RIA

26

April 1st 2015

RIA

28

April 1st 2015

ELY

28

April 1st 2015

P7A1 post incomplete

abortion day 1
O03.4
P3A0 post spontaneous
bracht day 1
652.2
P2A0 post spontaneous
preterm delivery day 1
O60
P1A0 post LSCS due to
fetal distress day 1
656.8

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

IUD
Z97.5

BOY-ROD

Obstetrical Chief on Duty

Tuesday, April 7 , 2015 at 02.00 AM Wednesday, April 8th, 2015 at 07.00 AM
Consultant on duty : Dr. H. Rizal Sanif, Sp.OG(K)
07.04.15
Conservative management
Mrs. RIS/24/UA/NIL
02:30 PM
D/ G2P1A0 32 weeks of gestasional age with threatened preterm labor SLF cephalic
presentation
M/ Conservative management
Observed vital sign, FHR, contraction
IVFD RL gtt xx/minute
Hb 11.0 gr/dl
Laboratory examination
WBC 11.9 103/mm3
Ceftriaxone inj 1 g/12 hour IV (ST)
IT : 2
Deksamethason inj 6 mg/12 hour IV (2 days)
Nifedipine 10 mg/6 hour po
Vaginal swab
08.04.15
P/ US confirmation
US (AK) :
C/ 32 weeks gestational age SLF cephalic presentation+ cervical length 4,4 cm
th

1.

2.

08.04.15
03.00 AM
GI : 6
Hb : 10.8 g/dl
PIC

LSCS due to Severe Preeclampsia + Condiloma Acuminata

Mrs.RIN/20/UA/RS-GUH
D/ G1P0A0 37 weeks of gestasional age with severe preeclampsia and condiloma
acuminata not in labor 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
12

3.

10.30 AM
10.33 AM

P/ Abdominal delivery after stabilization

Consult to consultant on duty agree for abdominal delivery
Male life baby was born, BW 2600 g, BL 47 cm, A/S 8/9 FT AGA
Placenta was delivered completely, PW 400 g, UCL 46 cm 16x17 cm
The mother and baby were in good condition

08.04.15

Spontaneous bracht

02:15 AM

04:25 AM
04.30 AM
04.35 AM

4.

08.04.15
03.30 AM
Hb : 11.5 g/dL

05.10 AM

Mrs.ROD/41/RA/NIL
D/ G2P0A1 37 weeks of gestasional age inlabor 1 stage active phase SLF breech
presentation
M/ Observed vital sign, FHR, contaction
IVFD RL gtt xx/minute
Laboratory examination
P/ Vaginal delivery
D/ G2P0A1 37 weeks of gestasional age inlabor 2nd stage SLF breech presentation
M/ Conduct the labor
Male life baby was born, BW 2700 g, BL 48 cm, A/S 8/9 FT AGA
Placenta was delivered completely, PW 400 g, UCL 50 cm 17x18 cm
The mother and baby were in good condition
st

Spontaneous delivery

Mrs. MAR/21/UA/NIL
D/ G2P1A0 37 weeks of gestasional age inlabor 1st stage active phase with history of
ROM 13 hours SLF cephalic presentation + olygohydramnious
M/ 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
D/ 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 AM

Female life baby was born, BW 2800 g, BL 45 cm, A/S 8/9 FT AGA

05.20 AM

Placenta was delivered completely, PW 500 g, UCL 50 cm 17x18 cm

The mother and baby were in good condition

5.

08.04.15

Spontaneous delivery
13

01.30 PM

02.40 AM

02.50 PM
02.55 PM

6.

08.04.15
06.30 AM

08.04.15
08.04.15

7.

08.04.15
04:00 AM

Mrs. SIT/32/UA/NIL
D/ 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
D/ G3P1A1 38 weeks of gestasional age inlabor 2nd stage with history of ROM 3 days
SLF cephalic presentation
M/ Conduct the labor
Male life baby was born, BW 3000 g, BL 48 cm, A/S 8/9 FT AGA
Placenta was delivered completely, PW 500 g, UCL 45 cm 18x19 cm
The mother and baby were in good condition
Expectative management

Mrs. DEV/36/UA/NIL
D/ 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
US (AK) :
C/ 35 gestational age SLF cephalic precentation
ENT department :
A/ Epistaxis e.c severe preeclampsia
M/ anterior sufratule tamponade 4/3
Analgetic and antibiotic
Joint Care with Rhinology ENT Subdivision
LSCS due to Prior LSCS 1 x and PROM
Mrs.SEL/28/UA/RS-ROD
D/ G2P1A0 40 weeks of gestasional age with prior LSCS 1 x (o.i unripe cervix)
14

+ 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 iv
P/ Abdominal Delivery
Consult to consultant on duty agree for abdominal delivery
Male life baby was born, BW 2900 g, BL 46 cm, A/S 8/9 FT AGA
Placenta was delivered completely, PW 500 g, UCL 50 cm 17x18 cm
The mother and baby were in good condition

05.40 AM
05.45 AM

ASSESMENT

NO
1
2
3

VALUE MAX

dr. Rodiani
Report technique
Paper acknowledgment
Honesty
Mean

30
35
35
100

2 dr. Hendra Sugama Saputra

OBSTETRIC CASE
No Initi Ag Ad
Diagnosis
.
al
e
d
1
SRI
37 UA G2P1A0 39 weeks
gestational age not inlabor
SLF cephalic presentation
US

MAR

20

ICD
Code
Z.34

Treatment/Plan

Physician

1x400g
Recontrolled within 1 week

FCH
SUG

39 weeks gestational age

SLF cephalic presentation

LACTATION AND PUERPERAL

No.
Initial
Age
Add

Notes

UA

Diagnosis

ICD
Code

Treatment/Plan

Physician

P1A0 post SSTP a.i

transverse lie

082.1

Roborantia

SUG

15

FAMILY PLANNING
No.

Initial

Age

NEL

32

Status
(New/Old)/Date
April 6th 2015

WAN

26

April 6th 2015

WAR

23

April 6th 2015

WIN

16

April 6th 2015

YUL

28

April 1st 2015

NO
1
2
3

ASSESMENT
dr. Hendra Sugama
Report technique
Paper acknowledgment
Honesty
Mean

Physician

Diagnosis

Contraception

Post Brandt
Andrew
Manoeuvre day 1
75.4
P1A0 post
spontaneous
delivery (outside)
3 hours + post
Brandt Andrew
Manoeuvre day 1
75.4
P2A0 post
spontaneous
delivery day 1
O80.0
P1A0 post
spontaneous
delivery day 1
O80.0
P1A0 post LSCS
o.i uterine inertia
day 6
661.2

IUD
Z97.5

SUG

IUD
Z97.5

SUG

IUD
Z97.5

SUG

IUD
Z97.5

SUG

IUD
Z97.5

SUG

VALUE MAX

Notes

30
35
35
100

V. GYNECOLOGY OUTPATIENT REPORT

Thursday, April 2th, 2015 until Wednesday,April 8st, 2015
Gynaecological Outpatient Chief
dr. Agung Haryadi
: 5 patients
dr. Meita Esthi Harumi
: 6 patients
Total
: 11 patients
DATE
Apr 2nd
Apr 3rd
Apr 4st
Apr 6st

PATIENT

VISITE

Gynecology

Oncology

Endocrinology

Urogynecology

Gynecology

Oncology

Endocrinology

Urogynecology

5
2
1

23
24
16
22

4
7
9
10

16

Apr 7st
Apr 8st
Total

1.

06.04.15

1
2
-

1
1
11

Dr. Agung Haryadi

Ms. SUR/45/RA
Stage IB
endometrial
cancer (C53.9)

28
22
135

8
6
44

1
1

Chemotherapy
PaclitaxelCarboplatin
1st
course (V58.1)

NIS

Chemoradiation
PaclitaxelCarboplatin
2nd
course (V58.1)
Pathology : Well moderatelly differentiated squamous cell carcinoma cervix with solid
limfoplasmasitic and limfovaskuler invasion
3.
07.04.15
Mrs.
Stage IIIB
Chemoradiation
ZUR/45/P2A1/UA
cervical cancer Paclitaxel(C53.9)
Carboplatin
4th
course (V58.1)

FIT

Pathology : Malignant mesodermal mixed tumor at uterus

2.

07.04.15

Mrs.
DAH/50/P5A1/UA

Stage IIIB
cervical cancer
(C53.9)

Pathology : Moderate differentiated non keratinizing squamous cell carcinoma cervix,

limfovascular invasion
4.
07.04.15
Ms.RAH/24/UA
Right ovary
Operative
endometriosis
laparoscopy
US
cyst
(54.21)
(N80.1)
Leiomyosarcoma
5.
08.04.15
Mrs.
Surgical staging
(C53.9)
AST/47/P3A0/RA
(68.49)
US

FIT

PUT

NIS

Pathology : Leiomyosarcoma

1.

08.04.15

Gynaecologi Chief on Duty

Wednesday, April 8th 2015 at 02 .00 PM Thursday, April 9th 2015 at 07.00 AM
Consultant on duty : dr. H. Irawan Sastradinata, SpOG(K)
General 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 sign
IVFD RL : D5 1 : 1 xx drops/m
Laboratory examinations
Thorax X-Ray
P/ - US Confirmation
Consult to internal Department

17

1.

07.4.15

Dr. Meita Esthi Harumi

Mrs.
Stage IIB cervical
NIS/49/P8A0/RA
cancer
(C53.9)

NAC
PaclitaxelCarboplatin
1st
course
(V58.1)

Pathology : Moderatelly differentiated non keratinizing squamous cell carcinoma cervix

2.
07.04.15
Mrs.
Stage IIIC ovarian Chemotherapy
JUR/32/P1A0/RA
cancer
Docetaxel(C56)
Carboplatin
1st
course (V58.1)

FIT

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 fluid
Teratoma cystic matur with multiple cyst at bilateral ovarian folicel
There was no tumor mass at peritoneum, omentum and mesocolon
3.
07.04.15
Mrs.
Residive ovarian
Chemotherapy
NIS
MAY/58/P4A0/UA
cancer (C53.9)
GemcitabineOxaliplatin
4th
course (V58.1)
Pathology : High grade serous carcinoma ovarian (cystadenocarcinam serosum papilliferum
multiloculare)
4. 07.04.15 Mrs. LIN/41/P4A0/UA GTN stage I FIGO Chemotherapy
NIS
score 7 (C54)
MethothrexateEtoposide
1st
Curve
course (V58.1)
Hcg :
52788

Pathology : hydatid mole, mild proliferation thropoblast

5.

08.04.15

6.

US
08.04.15
US

1.

07.4.15

Ms.ERN/29/UA

Right ovary
endometriosis cyst
(N80.1)
Mrs.
Left ovary
MAY/29/P0A0/RA
endometriosis cyst
+ Primary infertile
10 years
(N80.1)
Dr. Meita Esthi Harumi
Mrs.
Stage IIB cervical
NIS/49/P8A0/RA
cancer
(C53.9)

Operative
laparoscopy
(54.21)
HDLO
(54.21) (68.12)

NAC PaclitaxelCarboplatin 1st

course
(V58.1)

PUT
PUT

FIT

18

Pathology : Moderatelly differentiated non keratinizing squamous cell carcinoma cervix

2.
07.04.15
Mrs.
Stage IIIC ovarian Chemotherapy
JUR/32/P1A0/RA
cancer
Docetaxel(C56)
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 fluid
Teratoma cystic matur with multiple cyst at bilateral ovarian folicele
There was no tumor mass at peritoneum, omentum and mesocolon
3.
07.04.15
Mrs.
Residive ovarian
Chemotherapy
NIS
MAY/58/P4A0/UA
cancer (C53.9)
GemcitabineOxaliplatin 4th
course (V58.1)
Pathology : High grade serous carcinoma ovarian (cystadenocarcinoma serosum papilliferum
multiloculare)
4. 07.04.15 Mrs. LIN/41/P4A0/UA GTN stage I FIGO Chemotherapy
NIS
score 7 (C54)
MethothrexateEtoposide
1st
Curve
course (V58.1)
Hcg :
52788

Pathology : hydatid mole, mild proliferation thropoblast

5.

08.04.15

6.

US
08.04.15
US

Ms.ERN/29/UA
Mrs.
MAY/29/P0A0/RA

Right ovary
endometriosis cyst
(N80.1)
Left ovary
endometriosis cyst
+ Primary infertile
10 years
(N80.1)

Operative
laparoscopy
(54.21)
HDLO
(54.21) (68.12)

PUT
PUT

Obstetric Chief on Duty

Wednesday, April 8th 2015 at 02 .00 PM Thursday, April 9th 2015 at 07.00 AM
Consultant on duty : dr. H. Irawan Sastradinata, SpOG(K)

(-)
VI. EMERGENCY ROOM REPORT
Monday, April 6th, 2015 until Wednesday, April 8th, 2015
OBSTETRICS
19

Physiological patient
Pathological patient

: - case
: - case

GYNAECOLOGY/ONCOLOGY
Gynecology patient
: 1 case
Oncology patient
: - case
Emergency Room Chiefs
Dr. Fista Divi Amesia
Dr. Wira Hadi Satria
Total

: - case
: 1 case
: 1 case

OBSTETRIC
NSR/
No

ID

Age

Diagnosis

MAF
Treatment
Physicia
n
-

GYNAECOLOGY/ONCOLOGY
No

ID

Age

Diagnosis

1.

Mrs.
LIN

32

D/ Post coital bleeding

(N.93.0)

NSR/M
AFTreatment
Physicia
n
Suture laceration
WRA
( 665.4)

Dr. Wira Hadi Satria

1
07-04-2015
Suture laceration
10.45 AM

Mrs. LIN/ 38/UA/MAF

D/ Post coital bleeding c.b laceration vaginal posterior lateral

Laceration at back
of vaginal wall at 3
aclock 3 cm
Hb : 12 g/dL

NO
1
2
3

M/ Suture laceration
Amoxycilin 500mg/ 8 hours
Mefenamic Acid 500 mg/ 8 hours
The patient was discharge

ASSESMENT
dr. Wira Hadi Satria
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX

Notes

30
35
35
100
20

Dr. Fista Divi Amesia

Gynecology Chief on duty: Dr. Fista Divi Amesia
Tuesday, April 7th, 2015 at 02.00 PM - Wednesday, April 8th, 2015 at 07.00 AM
Consultant on duty: Dr. H. Rizal Sanif, SpOG (K)

1.

07.04.15
04:00 PM
Hb 7.6 g/dl

2.

07.04.15

Medicinalis
Mrs. SUS/62/P1A0/UA/RIS
D/ AUB cb M1 was suspected with moderate anemia
US Confirmation :
Uterine RF sized 6,08 x 2,68 mm
Both ovaries dificult to identified, atrophy was suspected
C/ 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
Curettage due to incomplete abortion
Mrs. MAH/27/P2A0/UA/NIL

09:10 PM

01.00 AM
3.

07.04.15
09:30 PM
Hb : 9,0 g/dl

D/ Incomplete abortion
M/ Observed vital sign, bleeding
IVFD RL gtt XX/minute
Laboratory examination
Ceftriaxone inj 1 g/12 hour IV (ST)
P/ Curettage
blood and tissue 10 cc
Plan Laparotomy + FS
Mrs. CIK/54/P1A0/RA/RIS
D/ solid ovarian neoplasm with cystic part malignancy was suspected +
dehidration low intake + mild anemia
US Confirmation:
Uterine hard to identified
There was solid mass with cystic part, multiloculare , papil (-) sized 50 x 50 cm
that posible from ovaries
Intramass blood flow (+)
C/ solid ovarian neoplasm with cystic part malignancy was suspected
21

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
NO
1
2
3

ASSESMENT
dr. Fista Divi Amesia
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX

Notes

30
35
35
100

Mengetahui ,
Konsulen

Dr. H. Rizal Sanif, SpOG (K)

22