III.

GYNECOLOGYCAL INPATIENT REPORT

Thursday, June23th, 2016 until Thursday,June 30th, 2016
Gynecological Inpatient Chief
Dr. Rakmat Akbar
Dr. Meidina Rahma
Dr. Jhon Heriansyah
Dr. Darlin Forbes
Total patients

:25 patients

TOTAL PATIENT IN WARD

No ICD -9
1.

DIAGNOSIS

TOTAL

Ovarian cancer

13

C56

2.

Cervical cancer

C53.0

Treatment

ICD-10

Chemotherapy
General condition
improvement
Plan for laparotomy FS

V58.1

Chemotherapy
Post radical hysterectomy

V58.1

TOTAL
10
2
1
4
1

Radical Hysterectomy

3.

Stump carcinoma

General condition
improvement

4.

Sarcoma Bartyoides
cervicalis

General condition
improvement

Stage I GTN FIGO

score 6

Chemotherapy

Endometriosis cyst

LO

Hydatidiform mole

Mole evacuation

69.5

Incomplite abortion

curretage

69.0

C53.8
5.

C58.0
6.

V58.1

N80.1
7.

O01.9
8.

O03.4

NO
1.

Patients ID
Mrs.KAR/55/RA/P3A0

Diagnosis
Right multiloculare cystic
ovarian neoplasm

Management
Plan for laparotomy FS

Physician
FOR

2.
3.
4.
5.
6.

Mrs.EMI/40/RA/P2A0
Mrs.NUR/56/RA/P3A0
Mrs.SRI/45/UA/ P3A0
Mrs.TIY/47/RA/ P2A0
Mrs.JAM/28/RA/ P4A0

7.
8.

Mrs.NUR/49/RA/P2A0
Mrs.MAY/60/RA/P7A0

Stage III BOvarian Cancer

Stage IV B cervical cancer
Stage I C Ovarian Cancer
Stage IIIC OvarianCancer
Stage III BCervical Cancer
post radical hysterectomy +
stage II hypertension + mild
anemia + urinary retension
Stage IIICOvarianCancer
Recurrent Ovarian Cancer

9.
10.

Mrs.HOM/62/UA/P1A0
Mrs.SAP/51/UA/P2A0

Stage IVAOvarianCancer
Stump Carcinoma

11.

Miss.MEI/34/RA

12.

Mrs.TIR/53/UA/P0A1

Progresive disease ovarian

cancer
Stage I GTN FIGO score 6

13.
14.
15.

Mrs.SIT/52/UA/P1A1
Mrs.HER/36/UA/P2A0
Miss.HEN/16/RA

16.
17.
18.
19.
20.
21.
22.
23.
24.

Mrs.IYU/50/RA/P2A1
Mrs.HES/56/UA/P3A1
Mrs. SUS/30/UA/P1A2
Mrs.KAR/31/UA/ P0A1
Mrs.YUH/51/UA/
Mrs.NUR/63/RA/P3A0
Mrs.NUR/62/RA/ P3A0
Mrs.YAT/34/UA/P2A0
Mrs. MUL/53/RA/P1A1

25.

Mrs. NUR/40/RA/P2A0

1.

25.06.16

Recurrent Ovarian Cancer

Stage II B Cervical Cancer
Sarcoma Bartyoides
cervicalis
Stage III B Cervical Cancer
Endometriosis cyst
Hydatidiform mole
Incomplite abortion
Recurrent Ovarian Cancer
Stage IIIC ovarian Cancer
Recurrent cervical cancer
Stage IIIA2Ovarian Cancer
Stage IIB cervical cancer
post NAC 3 courses
Stage IIIC ovarian cancer

Chemotherapy
Chemotherapy
Chemotherapy
Chemotherapy
Post radical hysterectomy

JHN
JHN
FOR
FOR
RAD

Chemotherapy
General condition
improvement
Chemotherapy
General condition
improvement
General condition
improvement
Chemotherapy

RAD
JHN
RAD
RAD
FOR
RAD

Chemotherapy
Chemotherapy
General condition
improvement
Chemotherapy
LO
Mole evacuation
Curettage
Chemotherapy
Chemotherapy
Chemotherapy
Chemotherapy
Radical hysterectomy

RAD
NSR
NSR
NSR
FOR
FOR
MAN
JHN
JHN
FOR
JHN
FOR

Chemotherapy

DIN

Plan for laparotomy FS

Mrs.KAR/55/RA/P3A0/FOR

03:31PM
US:

D/ Right multiloculare cystic ovarian neoplasm

M/ Plan for laparotomy FS

Ca125 : 7,8

2.

25.06.16

Chemotherapy

Mrs.EMI/40/RA/P2A0/JHN
D/ Stage III B Ovarian Cancer
M/ Chemotherapy Paclitaxel Carboplatin 6th course
Pathology No. PA 698/A/2016
I. Non specific cronic Cervicitis with ovula nobothy cyst
07:35 PM

- Uterine withi normal limit

- Right multiple folicel and simplex cyst ovarii
- Falopian tube within normal limit
II. wide granulation tissue, non malignancy cell at omental
III. Reactive hyperplasia in 7 right pelvic lymph nodes
IV. Reactive hyperplasia in 10left pelvic lymph nodes
V. Clear cell carcinoma on left ovarian
VI. clear cell carcinoma metastase derived from rectum mass
3.

25.06.16

Chemotherapy
Mrs.NUR/56/UA/ P3A0/JHN

04.28 PM

D/ Stage IV B Cervical Cancer

M/ Chemotherapy Paclitaxel Cysplatin5th course
Pathology No. PA 950/A/2016
Well diferentiated adenocarcinoma, endocervical type on cervix biopsy
DD/ adenocarcinoma cervix, endometrioid type
4.

25.06.16

Chemotherapy
Mrs.SRI/45/UA/ P3A0/FOR

05:24 PM

D/ Stage I C Ovarian Cancer

M/ Chemotherapy Paclitaxel Carboplatin 6th course
Pathology No. PA 769/M/2016
I.
Ovarian clear cell carcinoma
II.
No sign of malignancy on omental
III.
Hystiositosis sinusial at 3 pelvic limfe nodes
IV.
No sign malignancy on ovarian
V.
Carcinoma metastase in abdominal washing
5.

22.06.16

Chemotherapy
Mrs.TIY/47/RA/ P2A0/FOR

04:28 PM

D/ Stage IIICOvarianCancer
M/ Chemotherapy Paclitaxel Cysplatin1st course
Pathology No. PA 5329/A/2013
I. Leimyoma uterine
II. Serosum multiloculare papiliferum Cystadenoma ovarii
III. Endometriosis cyst
Pathology No. PA 660/C/2016
Adenocarcinoma metastasis cytologi ascites fluid
6.

21.06.16
11:37AM

7.

18.06.16

Post radical hysterectomy

Mrs.JAM/28/RA/ P4A0/RAD
D/ Stage III BCervical Cancer post radical hysterectomy + stage II
hypertension + mild anemia + urinary retension
M/ medicinalis
P/ external radiation
Chemotherapy
Mrs.NUR/49/RA/P2A0/RAD

02.17 PM

D/ Stage IIIC Ovarian Cancer

M/ Chemotherapy paclitaxel Carboplatin1st course

Pathology No. PA 2653/A/2016
A. FS
High grade serous carcinoma metastase on anterior peritoneum
B. FS
- Atrophy endometrium
- Leimyoma with uterine adenomyosis
- High grade serous carcinoma metastase on uterine tunica serouse, both falpofian
tube tunica serouse
- High grade serous carcinoma on right ovarii with clear differentiated cell carcinoma
- High grade serous carcinoma on left ovarii
- High grade serous carcinoma metastase on omental
- High grade serous carcinoma metastase on peritoneal
- Cytology peritoneal washing with cell carcinoma
8.

27.06.16

General condition improvement

Mrs.MAY/60/RA/P7A0/JHN

03.25 PM

D/ Residive Ovarian Cancer

M/ PRC transfusion
Pathology No. PA 1437/C/2015
Adenocarcinoma on ascites
9.

28.06.16

Chemotherapy

Mrs.HOM/62/UA/P1A0/RAD
D/ Stage III C Ovarian Cancer
M/ Chemotherapy Docxilitaxel Carboplatin4th course
Pathology No. PA 307/A/2016
I.
High grade serous carcinoma on ovarian that expanded to cervix wall, myometrium wall
and both tube falopian wall
II.
High grade serous carcinoma metastase on omental
III.
High grade serous carcinoma metastase on rectosigmoid tunica serous
IV.
High grade serous carcinoma invasion on vascular submucosa appendix
02.58 PM

10.

24.06.16

General condition improvement

Mrs.SAP/51/UA/P2A0/RAD

04.10 PM

D/ Stump Carcinoma
M/ PRC transfusion
P/ Abdominal CT-Scan
Pathology No. PA 2655/A/2016
Adenocarcinoma on vaginal stump
11.

28.06.16

General condition improvement

Miss.MEI/34/RA/FOR

11.53 PM

D/ Progresive disease ovarian cancer

M/ PRC transfusion
P/ VAC chemotherapy
Pathology No. PA 227/A/2016
A. FS
Ovarian stromal sarcoma, fibrosarcoma on right ovarian

B. FS
12.

No malignancy sign on omental

Hystiositosis sinusial on 1 paraaorta limfe node
Hystiositosis sinusial on 11right pelvic limfe nodes
No sign of malignancy on peritoneum
Sarcoma metastase on ascites cytology

27.06.16

Chemotherapy
Mrs.TIR/53/UA/P0A1RAD

02.54 PM

D/ Stage I GTN FIGO score 6

M/ Chemotherapy Methotrexate Rescovulin1st course
Pathology No. PA 233/08/160602
Hydatidiform mole with severe proliferation
13.

28.06.16

Chemotherapy

Mrs.SIT/52/UA/P1A1/RAD
D/Reccurent Ovarian Cancer
M/ Chemotherapy Gemcitabine oxaloplatin 4st course
Pathology PA 4819/A/2014
High grade serous carcinoma (cystadenocarcinoma serosum papiliferum right ovary)
High grade serous carcinoma (cystadenocarcinoma serosum papiliferum left ovary)
Metastase carcinoma on omentum and 23 of lymph node
Positive malignancell on cytology
06.57 PM

14.

24.06.16

Chemotherapy
Mrs.HER/36/UA/P2A0/DIN

05.26 PM

D/ Stage II B Cervical Cancer

M/ Chemotherapy paclitaxel Carboplatin2nd course
Pathology PA 256/H/UM/2016
Non keratinizing squamous cell carcinoma on cervical biopsy.
15.

25.06.16

General condition improvement

Miss.HEN/16/RA/DIN

00.01 AM

D/ Sarcoma Bartyoides cervicalis

M/ PRC transfusion
P/ Radical hysterectomy
Pathology PA 853/A/2015
Sarcoma bortryoides
16.

24.06.16

Chemotherapy
Mrs.IYU/50/RA/P2A1/DIN

03.04 PM

D/ Stage III B Cervical Cancer

M/ Chemotherapy paclitaxel Cysplatin4th course
Pathology No. PA 319/P/2016
Papilary squamous cell carcinoma cervix
17.

25.06.16

Laparoscopy operative

Mrs.HES/30/UA/P0A0/FOR

18.

06:34 PM

D/ endometriosis cyst
M/ post operative endometriosis ASRM grade IV

25.06.16

Mole evacuation
Mrs.SUS/36/RA/P3A0/FOR

05:02 PM
HcG : 288617
19.

27.06.16

D/ Hydatidiform mole
M/ Mole evacuation
Curettage
Mrs.KAR/31/UA/P0A1/DIN

05:37 PM
20.

27.06.16

D/ Incomplete abortion
M/ Curettage
Chemotherapy
Mrs.YUH/51/UA/JHN

D/ Recurrent Ovarian Cancer

M/ Chemotherapy Gemcitabine oxaloplatin4st course
Pathology No. PA 474/A/2012
I.
Non specific cronic cervicitis + ovula nobothy cyst
II.
Leimyoma
III.
Poorly undifferantiated adenocarcinoma on ovarium 1 + endometriosis
IV.
Poorly undifferantiated adenocarcinoma on ovarium 2
V.
Carcinoma metastase on peritoneal
VI.
Carcinoma metastase on omental
21.

27.06.16

Chemotherapy
Mrs.NUR/63/RA/P3A0/JHN

D/ Stage IIIC ovarian Cancer

M/ Chemotherapy Docxilitaxel Carboplatin3rd course
Pathology No. PA 1519/A/2016
A. Carcinoma on left ovarian
B. Non spesific cronic cervicitis, endometrium cyscic atrophy, carcinoma metastase on
peritoneal and cytology ascites, reactive hyperplasia on 13 para aorta limfe nodes
C. No malignancy sign on omental
22.

24.06.16

Chemotherapy
Mrs.NUR/62/RA/P3A0/FOR

03:16 PM

D/ Recurrent Cervical Cancer

M/ Chemotherapy Cysplatin Mesna Ifosfamid course
Pathology PA 1988/A/2011
Cervical adenosqamous carcinoma invasive to vaginal cuff and metastatic to paraaortic lymph node
and left iliaca lymph node
23.

24.06.16

Chemotherapy
Mrs.YAT/34/UA/P2A0/JHN

D/ Stage IIIA2 Ovarian Cancer

M/ Chemotherapy paclitaxel Carboplatin3rd course
Pathology No. PA 1672/A/2016
I.
Adenocarcinoma that suspected high grade serous carcinoma on bilateral ovarium

II.
24.

that metastase to falopian tube wall. 1.uterine tunica serous, 2 paraaorta limfe nodes
and peritoneal whasing
Reactive hyperplasia at 4 left pelvic limfe node

24.06.16

Radical hysterectomy
Mrs.MUL/34/UA/P2A0/FOR

D/ Stage IIIA2 Ovarian Cancer

M/ Chemotherapy paclitaxel Carboplatin3rd course
Pathology No. PA 1672/A/2016
Adenocarcinoma that suspected high grade serous carcinoma on bilateral ovarium that metastase to
falopian tube wall. 1.uterine tunica serous, 2 paraaorta limfe nodes and peritoneal cytology
Reactive hyperplasia at 4 left pelvic lymph node
25.

28.06.16

Chemotherapy

Mrs.NUR/49/RA/P2A0/DIN
D/ Stage III C ovarian cancer
M/ Chemotherapy paclitaxel carboplatine 1st course
Pathology PA2653/A/2016
High grade serous carcinoma on right ovary with clear cell carcinoma differentiation
High grade serous carcinoma on left ovary
Metastatic carcinoma high grade serous on omentum
Metastatic high grade serous on uterine serosum and right and left fallopian tube
Metastatic high grade serous on cytology

NO
1
2
3

NO
1
2
3

NO
1
2
3

ASSESMENT
Dr. Darlin Forbes
Report technique
Paper acknowledgment
Honesty
Mean
ASSESMENT
Dr. Rakmat Akbar
Report technique
Paper acknowledgment
Honesty
Mean
ASSESMENT
Dr. Meidina Rahma
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX

Notes

30
35
35
100

VALUE MAX

Notes

30
35
35
100
VALUE MAX
30
35
35
100

Notes

NO
1
2
3

ASSESMENT
Dr. Jhon Heriansyah
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX
30
35
35
100

Notes