PRE OPERATIVE PLANNING

MONDAY, December 31st 2018

Resident on duty :
Dr. Excellena

Supervisor :
 Preoperative Patients Recapitulation
Patients have been
Patients have been scheduled Waiting list patients
operated

DIVISI COT I COT II Jan 2nd Total COT I COT II Jan 2nd Total COT I COT II Jan 2nd Total

ONCOLOGY 538 31 567 451 33 484 90 1

GYNECOLOGY 231 218 447 214 207 421 13 12

UROGYNECOLOG
144 5 149 139 5 144 3 0
Y

OBSTETRICS 84 31 115 82 31 113 2 0

TOTAL
997 285 1282 886 276 1162 108 13

No Identity
1 Mrs. SUL/ 40 YO/ P0A0
2 Mrs. SAK/ 43 YO/ P1A0L1
Central Operating Theatre I
MONDAY, December 31st 2018
Diagnosis ICD 10 Planning ICD -9 OP
Abnormal bleeding of the
uterus e.c L1 + primary Myomectomy KY
infertility 10 years
Uterus adenomyosis +
bilateral endometriosis cyst
DD/ ovarium cyst neoplasm + Laparotomy HT AA
right tubal endometriosis +
internal genitalia adhesion
COT I

Anamnase
CC : Prolonged menstrual
cycle
Since 1 month before
admission, patient has been
complained about prolonged
menstrual cycle, 20 days
each, with the amount of 4x
change of paed/ day. Patient
denied any history of
dyspareunia, vaginal
discharge and post coital
bleeding. Patient had normal
urinary routine and bowel
habits. Patient didn’t
experience weight but she
lost her appetite.
. Vaginal Toucher: Portio elastic, closed OUE, CUT~normal, non tense right and left AP,
(2) Mrs. SUL/ 40 YO/ P0A0
Physical Examination and supportive exam Diagnosis and
Planning
Menstrual : Menarche 14 YO, regular cycle, 26 days, 3 days each. First day of last Diagnosis:
period 27/11/18, 25/10/18, 20/09/18 Abnormal bleeding
Marrital : Married 1x, 10 YO of the uterus e.c L1
Obstetric : P0A0 + primary infetility
10 years
Prior operation : -
Physical examination : Planning :
BP : 120/80 mmHg, HR :88x/m, RR: 20x/m, T: 36,5ºC Myomectomy
General status : Normal
Doctor in charge :
Gynecologic status : KY
Abdomen : Flat, supple, symmetrical, fundal of uterine 3 fingers above symphisis,
tenderness (-), free fluid sign (-)
Vaginal Speculum exam: Portio non livide, Closed OUE, Fluor (-), Fluxus (-) non active
bleeding, E/ L/ P (-)
cervical motion tenderness (-), no protrusion of Cavum Douglass
Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the
recty, MIL (-)
 (2) Mrs. SUL/ 40 YO/ P0A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus AF, enlarge shape and size
˗Endometrial line (+), 0.2 cm in thickness
˗Circumscribed hypoechoic mass on the anterior corpus with feeding arteries, 6.9 x 6.3 cm
in size, suspected for intramural myoma of uteri
˗Both ovarium in normal condition
˗Liver and both kidney in normal condition

Conclusion: Intramural myoma of uteri

Laboratory examination :
Hb 7.9 WBC 7600 PLT 519.000 SGOT 16 SGPT 9 Alb 4.2 GDS 96 Cr 0.68 Ur 15 Na
145 K 4.0
 Procedure No Case Outcome
laparotomy 1. Mrs. SUL/ 40 YO/ P0A0/KY 08.30 AM Operation started
myomectomy Patient on supine position, on general aneshthesia.
Mediana incision were performed
ICD 10 Preop diagnosis:
When peritoneum layer were opened, exploration:
N93.9 Abnormal bleeding of the
Uterine size enlargement ~ 20 weeks
uterus e.c L1 + primary
Performed myomectomy
infetility 10 years
10.00 AM operation end
ICD 9-CM Post op diagnosis:
68.29 Intranural Uterine Myoma
(post laparotomy
DR. Dr. H. Kms. Yusuf myomectomy)
Effendi, SpOG(K)
 (3) Mrs. SAK/ 43 YO/ P1A0L1
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC : Menstrual pain Menstrual : Menarche 14 YO, regular cycle, 5-6 days each. First day of last period: Diagnosis:
20/10/18 Uterus
Patient has been complaining Marrital : Married 1x, 16 years adenomyosis +
about menstrual pain and Obstetric : P1A0L1 bilateral
then went to ObGyn endoemtriosis cyst
specialist and had been told Prior operation : Cystectomy DD/ ovarium cyst
that she had ovarium tumor. Physical examination : neoplasm + right
In 2017, patient had BP : 120/80 mmHg, HR :88x/m, RR: 20x/m, T: 36,5ºC tubal
cystectomy procedure with General status : Normal endometriosis +
PA: simple cyst and ovarium internal genitalita
endometriosis cyst. Patient Gynecologic status : adhesion
denied any history of Abdomen : Flat, supple, symmetrical, fundal of uterine not palpable, tenderness (-),
dyspareunia. Patient didn’t free fluid sign (-) Planning :
experience weight lost and Laparotomy HT
loss of appetite. Vaginal Speculum exam: Portio non livide, Closed OUE, Fluor (-), Fluxus (-) non active
bleeding, E/ L/ P (-) Doctor in charge :
AA
Vaginal Toucher: Portio elastic, closed OUE, CUT~normal, tense right AP; 4x3 cm mass
in the right pelvic area, non tense left AP, cervical motion tenderness (-), no
protrusion of Cavum Douglass

Rectal Touche: Palpated lower pool of the tumor, circumscribed and solid in
consistency
 (3) Mrs. SAK/ 43 YO/ P1A0L1
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus AF, enlarge shape and size
˗Uncircumscribed mass with vascularisation, 4x3x2.6 cm in size suspected for uterus
adenomyosis
˗Endometrial line (+), 0.6 cm in size
˗Right adnexa, inhomegen complex mass, 9.4 x 9.0 cm in size suspected for inflammation
mass DD? Ovarium cyst neoplasm
˗Left adnexa,homogen cystic mass, 6.3 x 3.1 cm in size suspected for ovarium cyst
neoplasm
˗Internal genitalia adhesion
˗Liver and both kidney in normal condition

Conclusion: Uterus adenomyosis, inflammation mass DD/ right ovarium cyst neoplasm ,
left ovarium cyst neoplasm, internal genitalia adhesion

Laboratory examination :
Hb 13.2 WBC 7400 PLT 409.000 Alb 4.3 GDS 100 Cr 0.6 Ur 20 Na 149 K 3.6
Procedure No Case Intraoperative
Hysterectomy Mrs. SAK/ 43 YO/ P1A0L1 10.55 AM operation started
ICD 10 Patient on supine position, on general
C53.9 aneshthesia.
ICD 9-CM Preop diagnosis: Mediana incision were performed
68.49 Uterus adenomyosis + When peritoneum layer were opened,
bilateral endoemtriosis exploration:
cyst DD/ ovarium cyst Uterine size enlargement ~ 16 weeks
neoplasm + right tubal pregnancy
Dr. H. A. Abadi, endometriosis + internal Performed hysterectomy
SpOG(K) genitalita adhesion Performed SOD
Tissue was sent to PA examination
Post op diagnosis:
Bleeding intraoperative 800 cc, urine 100 cc
Endometriosis ASRM clear.
Grade IV
12.55 AM: Operation was finished.
Thank You