FERTILITY ENDOCRINOLOGY

REPRODUCTIVE DIVISION
REPORT
Tuesday, April 4th 2017
Consultant in charge :
DR. Dr. H. K. Yusuf Effendi, SpOG(K)
Supervisor :
DR. Dr. H. K. Yusuf Effendi, SpOG(K)
Resident on duty :
Dr. Iman Ruansa
 I. OUT PATIENT REPORT
Tuesday, April 4th 2017
No Date Patient Diagnose ICD-10 Management ICD 9

1 04-04-17 Mrs.FIS/34yo/ Post myomectomy D25.2 - Counseling -

P0A0/RA Primary infertile 3 years N97.0 - Control if
menstruasion
2. 04-04-17 Mrs. Endometrial polyp N84.0 - Hysteroscopy D & C 68.12
DES/30yo/ Primary infertile 4 years N97.0
P0A0 /RA
3. 04-04-17 Ms. SAK/21yo/ Endometriosis cyst N80.1 - Plan for HDLO 65.23
UA

4 04-04-17 Mrs. Endometriosis ASRM N80.1 - Leuprolide inj 2nd 793.9

SEP/26yo/ grade III N80.0 course
P0A0 /UA Adenomyosis
Identity Mrs.FIS/34yo/ P0A0/RA
Chief complain Continued therapy
History Patient come to RSMH with history myomectomy at 29-01-2017 (RSMH). She had
regular menstrual cycle with 1-2 x changing pad/day. Dispareunia (-). Post coital
bleeding (-). She get ovulation induction with clomiphene citrate 50mg and control at
day 11 menstruasion.
Marital-obstetric 1x/ 3 years.
status Menarche at 14 y, 28 cycle, regular, 5 days. LMP: 24/03/2017
Gynecology BP : 110/70 mmhg RR: 20 x/mnt BW : 50 kg
examination HR : 80 x/mnt T : 36.5 C 0
Hieght : 156 cm
Abdominal palpation : flat, flexible, symmetrical, uterine fundal is not palpated,
mass (-), pain (-) , sign free fluid (-).
US (04-04-2017) - Uterine AF, within normal limit
- Endometrial line tri layer (proliferatiffphase)
- Right ovarii within normal limit, Folicle 1,58 cm
- Left ovarii within normal limit, there was 3 dominan folicle , size 1,85-
2,43 cm
- C/ No internal genital abnormality
Proliferatif phase
Diagnosis Post myomectomy
Primary infertile 3 years
Therapy - Counseling
- Control if menstruasion
Identity Mrs. DES/30yo/ P0A0 /RA
Chief complain Want to get a child

History Since 2 month ago patient complain vaginal bleeding. Menstruation 7-10 days She
had irregular menstrual cycle with 1-2 x changing pad/day. Dispareunia (-). Post
coital bleeding (-)
History HSG bilateral paten tubes

Marital-obstetric 1x/ 2 years.

status Menarche at 14 y, 28 cycle, irregular, 7-10 days. LMP: 10/03/2017, 13/02/2017,
01/01/2017,
Gynecology BP : 110/70 mmhg RR: 20 x/mnt BW : 54 kg
examination HR : 80 x/mnt T : 36.5 C 0
Hieght : 165 cm
Abdominal palpation : flat, flexible, symmetrical, uterine fundal is not palpated,
mass (-), pain (-) , sign free fluid (-).

US 24-03-2017 - Endometrial polyp 0,67x0,57cm

Diagnosis Endometrial polyp

Primary infertile 2 years
Therapy Hysteroscopy D & C (26/04/2017)
Identity Ms. SAK/21yo/ UA
Chief complain Abdominal pain
History Since + 1 months ago patient complain dismenorea with VAS 6. pain
become worsen day 1 and 2 menstruation. She had regular menstrual
cycle with 1-2 x changing pad/day.
Obstetric status Menarche at 14 y, 28 cycle, regular, 7 days.
LMP: 21/03/2017

Gynecology BP : 110/70 mmhg RR: 20 x/mnt BW : 47 kg

examination HR : 80 x/mnt T : 36.50C Hieght : 164 cm
Abdominal palpation : flat, flexible, symmetrical, uterine
fundal is not palpated ,mass (-), sign free fluid (-).

US (31-03-2017) Endometiosis cyst was suspected

Size 3,02 cm

Diagnosis Endometriosis cyst

Therapy - Plan for HDLO (06/04/2017)

Identity Mrs. SEP/26yo/ P0A0 /UA
Chief complain Continued therapy
History Since + 8 months ago os complained of intermittent
abdominal pain, VAS 4.. Patient control to RSMH, History
laparotomy oi bilateral endometriosis cyst (08-02-2017)

Marital-obstetric 1x, 10 month

status Menarche at 13 y, 28 cycle, regular, 7 days.
LMP: 15/01/2017; 15/12/2017; 7/11/2017

Gynecology BP : 120/70 mmhg RR: 20 x/mnt BW : 56 kg

examination HR : 80 x/mnt T : 36.50C Hieght : 154 cm
Abdominal palpation : flat, flexible, symmetrical, uterine
fundal is not palpated ,mass (-), sign free fluid (-).

PA 628/A/2017 I. Adenomyosis
II. Right endometriosis cyst
III. Left endometriosis cyst
IV. Not found malignancy cell at peritoneal washing
Diagnosis Endometriosis ASRM grade III (score 30, EFI score 6)
Adenomyosis
Therapy - Leuprolide inj 2nd course
- Calcium 500mg/24 hours
THANK YOU