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PRE OPERATIVE PLANNING

MONDAY, JULY 8th 2019

Resident on duty :
dr. Sartika Nopradilova

Supervisor :
Dr. H. A. Abadi, OBGYN (C)
COT I Recapitulation Planning
No Date Urogynecology Oncology Gynecology Obstetric Cases

1 July 1st 2019 - 1 1 1 3

2 July 2nd 2019 - 2 - 1 3

3 July 3rd 2019 1 2 1 - 4

4 July 4th 2019 - 2 1 1 4

5 July 5th 2019 2 - - - 2

TOTAL 3 7 3 3 156
COT II Recapitulation Planning
No Date Urogynecology Oncology Gynecology Obstetric Cases

1 July 1st 2019 - - 1 - 1

2 July 2nd 2019 - - 3 - 3

3 July 3rd 2019 - - 2 - 2

4 July 4th 2019 - - 2 - 2

5 July 5th 2019 - - 1 - 1

TOTAL - - 9 - 9
Preoperative Patients Recapitulation

COT 1 COT 2

Patient
Patient Have been New New
have Have been New New Waiting list Waiting list
have been operated schedule operated
DIVISI been operated schedule operated Until July 2nd July 2nd
scheduled until July 2nd until July until July
schedule until july 2nd July 2nd July 2nd
July 2nd 2nd 2nd
d july 2nd

ONCOLOGY 221 164 3 2 58 37 37 0 0 0

FER 30 15 0 0 15 84 80 2 2 4
GYNECOLOG
54 52 0 0 2 107 94 0 0 13
Y
UROGYNECO
51 48 0 1 2 5 5 0 0 0
LOGY
OBSTETRICS 51 51 1 0 1 -

MOW 0 0 11 11 0 0 0

TOTAL
407 330 4 3 78 244 227 2 2 17
Central Operating Theatre I
MONDAY, JULY 8th 2019

No Identity Diagnosis ICD Planning ICD -9 OP


10

1 Mrs. EVI/ 25 YO/ P2A0 Cystic Ovarium neoplasm D27.9 Laparotomy FS 54.1 FB-AT

Hysterectomy
2 Mrs. SUT/ 47 YO/ P2A0 Intramural uterine myoma D25 68.9 IS
laparotomy
Central Operating Theatre II
MONDAY, JULY 8th 2019

No Identity Diagnosis ICD 10 Planning ICD -9 OP


Dysmenorrhea c.b
endometriosis cyst + N80.1 Laparoscopic
1 Mrs. DIA/ 36 YO/ P1A0 65.14 IS
adenomyosis uteri + internal N80.0 operatif
genitalia adhesion

Laparoscopic
2 Mrs. IDA/ 51 YO/ P6A0 HGSIL R87.612 68.9 AT
hysterectomy
COT I
(1) Mrs. EVI/ 25 YO/ P2A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Abdominal enlargement Menstrual : Menarche 13 YO, regular cycle Diagnosis:
Marrital: Married 1x, 4 years Cystic Ovarium
Since 12 days before Obstetric : P2A0 neoplasm
admission, patient has been
complaining about abdominal Prior operation : - Planning:
enlargement after giving birth. Laparotomy FS
Patient had normal urinary Physical examination :
routine and bowel habits. BP : 120/80 mmHg, HR: 88x/m, RR: 20x/m, T: 36,5ºC Doctor in charge :
Patient denied any vaginal General status : Normal FB-AT
discharge, dyspareunia and
post cotal bleeding but agreed Gynecologic status :
for having history of irregular Abdomen : Raised, supple, symmetrical, fundal of uterine not palpable, mass (+);
menstrual cycle. Patient didn’t upper border – umbilicus; right border – right LMC; left border – left LMC; lower
experience weight lost or any border – symphisis; tenderness (-), free fluid sign (-)
loss of appetite. Patient visited
ObGyn specialist, got
diagnosed with cyst (Post
partum for 11 days + suspected
ovarium cyst neoplasm)
RMI 3 = 130
RMI 4 = 260
(1) Mrs. EVI/ 25 YO/ P2A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus AF, normal shape and size
˗Endometrial line (+), 0.9 cm
˗Adnexa, hypoechoic mass, 17.4 x 11.1 cm, suspected for ovarium cyst neoplasm
˗Both ovarium in normal condition
˗Liver and both kidney in normal condition

Conclusion: Non papiliformmucinosum unilocular ovarium cyst neoplasm

Laboratory examination :
Hb 10.1 WBC 5840 PLT 264.000 SGOT 66 SGPT 12 Cr 0.60 Ur 17 Na 143 K 4.3 Ca
125 130
(1) Mrs. EVI/ 25 YO/ P2A0
(1) Mrs. EVI/ 25 YO/ P2A0
(1) Mrs. EVI/ 25 YO/ P2A0
(1) Mrs. EVI/ 25 YO/ P2A0
(1) Mrs. EVI/ 25 YO/ P2A0
(2) Mrs. SUT/ 47 YO/ P2A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Abdominal lump Menstrual : Menarche 13 YO, regular cycle Diagnosis:
Marrital : Married 1x, 19 years Intramural uterine
Patient has been Obstetric : P2A0 myoma
complaining about 2
weeks of painless Prior operation: - Planning :
abdominal lump, hard on Physical examination : Laparotomy
palpation. Patient denied BP : 120/80 mmHg, HR: 88 x/m, RR: 20 x/m, T: 36.5 ºC hysterectomy
any dyspareunia, vaginal General status : Normal
discharge and post coital Doctor in charge :
bleeding. Patient had Gynecologic status : IS
nprmal urinary routine Abdomen: Raised, supple, symmetrical, fundal of uterine half umbilicus - symphisis,
and bowel habits. Patient immobile, tenderness (-), free fluid sign (-)
didn’t experience weight
lost or any loss of Vaginal Speculum exam: Portio non livide, closed OUE, fluor (+), fluxus (-), non active
appetite. bleeding, E/L/P (-)

Vaginal Toucher: Elastic portio, closed OUE, CUT~16 weeks, non tense right and left AP,
no protrusion of cavum douglassi

Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the recti,
MIL (-)
(2) Mrs. SUT/ 47 YO/ P2A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :
˗Uterus RF, enlarge shape and size, 15.73 x 7.92 cm
˗Posterior corpus: circumscribed hyperechoic mass, 7.12 x 7.16 cm in size, suspected for
intermural uterine myoma
˗Both ovarium in normal condition
˗Endometrial line (+), 0.80 cm
˗Liver and both kidney in normal condition

Conclusion: Intramural uterine myoma

Laboratory examination :
Hb 12.9 WBC 7000 PLT 438.000 PT 13.2 INR 1.02 APTT27.0 Fibrinogen 478.0 D-
dimer 0.28 SGOT 16 SGPT 17Alb4.3 GDS 111 Cr 0.74 Ur 19 Na 140 K 3.6 AFP 4.82
CEA 1.70 CA 125 47.0
(2) Mrs. SUT/ 47 YO/ P2A0
(2) Mrs. SUT/ 47 YO/ P2A0
COT II
(1) Mrs. DIA/ 36 YO/ P1A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Abdominal lump Menstrual: Menarche 12 YO, regular cycle Diagnosis:
Marrital : Married 1x, 9 years Dysmenorrhea c.b
Since 10 years before, Obstetric : P1A0 endometriosis cyst
patient has been + adenomyosis
complaining about Prior operation: 2011 – Mohammad Hoesin Hospital for laparoscopy e.c uteri + internal
abdominal lump. Patient endometriosis cyst; 2013 – laparoscopic operation with PA result intramural uterine genitalia adhesion
denied any history of myoma, bialteral endometriosis cyst; 2016 – Mohammad Hoesin Hospital LSCS and
dyspareunia, post coital myoma-cyst operation Planning:
bleeding, and vaginal Physical examination : Laparoscopic
discharge but agreed for BP : 120/80 mmHg, HR: 88x/m, RR: 20x/m, T: 36.5ºC operatif
having menstrual pain. General status : Normal
Patient had normal urinary Doctor in charge :
routine and bowel habits. Gynecologic status : IS
Patient denied any weight Abdomen : Flat, supple, symmetrical, fundal of uterine not palpable, free fluid sign (-),
lost or any loss of appetite. tenderness (-), mass (-)

Vaginal Speculum exam: Portio non-livide, closed OUE, fluor (-), fluxus (-) non active
bleeding, E/L/P (-)

Vaginal Toucher: Elastic portio, closed OUE, CUT~normal, non tense right and left AP,
no protrusion of cavum douglassi
(1) Mrs. DIA/ 36 YO/ P1A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation:
˗Uterus AF, normal shape and size
˗Posterior corpus: uncircumscribed hyperechoic mass, 1.7 x 3.2 cm in size suspected for
adenomyosis
˗Right adnexa: cystic mass, 27.1 x 5.1 cm suspected for endometriosis
˗Left adnexa: mass (+) 5.17 x 2.11 cm, suspected for endometriosis cyst
˗Internal genitalia adhesion
˗Liver and both kidney in normal condition

Conclusion: Adenomyosis uteri, bilateral endometriosis cyst, internal genitalia adhesion

Laboratory examination:
Hb 11.2 WBC 7900 PLT 314.000 SGOT 13 SGPT 14 GDS 99 Cr 0.76 Ur 19 Na 143 K
4.0 AFP 1.36 CA 125 51.3
(1) Mrs. DIA/ 36 YO/ P1A0
(1) Mrs. DIA/ 36 YO/ P1A0
(2) Mrs. IDA/ 51 YO/ P6A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
CC: Vaginal spotting Menstrual: Menopause 4 years Diagnosis:
Marrital : Married 1x HGSIL
Patient has been complaining Obstetric : P6A0
about vaginal spotting for 3 Planning:
months. Patient denied any Prior operation: Biopsy Laparoscopic
history of dyspareunia and hysterectomy
post coital bleeding but Physical examination :
agreed for having vaginal BP : 120/80 mmHg, HR: 88x/m, RR: 18x/m, T: 36.5ºC Doctor in charge :
discharge. Patient had General status : Normal AT
normal urinary routine and
bowel habits. Patient denied Gynecologic status :
any weight lost or any loss of Abdomen : Flat, supple, symmetrical, fundal of uterine not palpable, free fluid sign (-
appetite. Patient went to ), tenderness (-)
ObGyn specialist and got
diagnosed with HGSIL. Vaginal Speculum exam: Portio non-livide, closed OUE, fluor (-), fluxus (-) non active
bleeding, E/L/P (-)

Vaginal Toucher: Elastic portio, closed OUE, CUT~normal, non tense right and left AP,
no protrusion of cavum douglassi

Rectal Touche: Adequate sphincter of ani, normal mucosa, empty ampula of the recti,
MIL (-)
(2) Mrs. IDA/ 51 YO/ P6A0
Anamnase Physical Examination and supportive exam Diagnosis and
Planning
USG Confirmation :

Laboratory examination :
Hb 14.2 WBC 8300 PLT 324.000 PT 12.4 INR 0.93 APTT 30.2 Alb 4.7 BSS 90 Cr
0.80 Ur 21 Na 150 K 4.6
Thank You

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