TOTAL PATIENT IN WARD

Ward
Patients
New Patient
Old Patient
st
1 Enim
3
2
nd
2 Enim
6
Mawar
2
9
Lematang
1
1
Musi Elok
2
1
Ogan
3
3
Yasmin C
1
1
Kenanga A
17
18

Total
5
6
11
2
3
6
2
35

TOTAL PATIENT BY SUBDIVISON

Patients
Gynecology
Oncology
Endocrinology
Urogynecology

New Patient
6
2
1
8

Gynecological Inpatient Chief

Dr. Rakmat Akbar
Dr. Jhon Heriansyah
Total patients

NO
1.

Patients ID
Mrs. SAR/39/P0A1/UA

2.

Mrs. YUL/41/P3A0/RA

3.

Mrs. NAI/26/P0A0/UA

4.

Mrs. MEL/16/RA

5.

Mrs.RIS/42/P2A0/RA

6.

Mrs. ELI/47/UA/P4A0

7.

Mrs. DAU/56/UA/P5A0

8.

Total
Old Patient
9
10

6
11
1
18

: 8 patients
: 9 patients
: 17 patients

Diagnosis
Ovarian Cancer inadequate
staging
Stage III B Cervical cancer

Management
Chemotherapy

Physician
NSR

Chemotherapy

NSR

Stage III GTD score FIGO

3
Stage I C Ovarian Cancer

Chemotherapy

NSR

Chemotherapy

NSR

Cervical cancer Stage III B

was suspected
Stage II B Cervical cancer

NSR

Mrs. ZUR/55/RA/P2A0

Uterine prolapse grade III +

Cystocle grade II
Stages III C Ovarian Cancer

General condition
improvment
Plan for radical
hysterectomy
Plan for TVH + kolporafi
anterior + SSF
Chemotherapy

9.

Mrs. HOM/63/UA/P1A1

Stages IVA Ovarian Cancer

Chemotherapy

RAD

10.

Mrs. SUD/70/UA/P10A3

Stage III B Cervical cancer

Chemotherapy

JHN

RAD
RAD
RAD

11.

Mrs. YUL/44/UA/P0A0

Uterine myoma

12.

Mrs. RUS/76/RA/P2A0

13

Mrs. SUF/27/G1P0A0/UA

14
15
16

Mrs. AGU/27/G3P2A1/
UA
Ms. MAR/32/UA
Mrs. PON/60/ P4A0/RA

Cystic ovarian neoplasm

malignancy was suspected
G1P0A0 9 weeks gestational
age with threatened
abortion intrauterine
Ectopic pregnancy was
suspected
Multiple uterine myoma
AUB e.c L1

17

Mrs. REN/32/ P0A2/UA

Intramural uterine myoma

Plan for Myomectomy

RAD

Chemotherapy

JHN

Medicinalis

COR

Laparoscopy right
salphyngostomy
Medicinalis
Medicinalis + plan for
hysterectomy
Plan for HDLO

RZM
ASN
ASN
ASN

Dr. Rakhmat Akbar Dinur

1
06.06.16
Chemotherapy
Mrs. SAR/31/ P0A1/UA/NSR
D/ Ovarian Cancer Inadequate Staging
(C56.9)
rd
M/ Chemotherapy Oxalaplatin Gemcitabin 3 course
(Z51.11)
Pathology No. PA 879/AS/2015
Cystic malignancy from epitheleal
07.06.16
Chemotherapy
Mrs. YUL/41/ P3A0/UA/NSR
07.30 PM
D/ Stage III B Cervical cancer
(C53.9)
nd
M/ Chemotherapy Paclitaxel Carboplatin 2 course
(Z51.11)
Pathology No. PA 1807/A/2016
Moderate differentiated non keratinizing squamous cell carcinoma cervix with limfovaskular
invation
06.0616
Plan for radical hysterectomy
Mrs. ELI/47/UA/P4A0 /RAD
07:08 PM
D/ Cervical cancer Stage III B was suspected + post NAC 3rd course
(paclitaxel-cisplatin)
(C53.9)
M/ Plan for radical hysterectomy
(68.6)
Pathology No. PA.2408/PA/CH/16
Nonkeratinizing squamous cell carcinoma cervic,moderately differentiated
04:00 PM

07.08.16

Plan for TVH + kolporafi anterior + SSF

02:55 PM

Mrs. DAU/56/UA/P5A0/RAD
D/ Uterine prolapse grade III + Cystocle grade II
(N81.3,N81.11)
M/ Plan for TVH + kolporafi anterior + SSF
(68.8)

08.06.16

Chemotherapy

Mrs. ZUR/55/RA/P2A0/RAD
D/ Stages III C Ovarian Cancer
(C56.9)
M/ Chemotherapy paclitaxel-carboplatin VI course
(Z51.11)
Pathology No. P1501990 B
Ovarial : clear cell carcinoma
02:04 PM

Omental : clear cell carcinoma metastatic

6

08.06.16

Chemotherapy

Mrs. HOM/63/UA/P1A1/RAD
02:05 PM
D/ Stages IVA Ovarian Cancer + post ileostomy
(C56.9)
M/ Chemotherapy docetaxel-carboplatin III course
(Z51.11)
Pathology No. 307/A/2016
I. High grade serouse carcinoma ovarial that expanded to the cerviks wall, myometrium and right
and left fallopian tube
II. High grade serouse carcinoma omental metastase
III. high grade serouse carcinoma tunica serouse rectosigmoid metastase
IV. high grade carcinoma invasion to submucosa appendic vascular
7

03.06.16

Plan for Myomectomy

05:50 PM

D/ Intramural uterine myoma

M/ Plan for Myomectomy

02.06.16

Laparascopy salphingostomy dekstra

02.00 PM
06-06-16

NO
1
2
3

VALUE MAX

Mrs. AGU/27/G3P2A1/ UA/RZM

(O00.9)
(66.01)

Notes

30
35
35
100

Chemotherapy

Mrs. NAI/23/ P0A1/UA/NSR

D/ Stage III GTN score FIGO
(C58)
rd
M/ Chemotherapy Methotrexate-Rescovulin 3 course
(Z51.11)
Pathology No. PA 0311/PA/CH/2016
Hydtidiform mole trofoblast cell complete proliferation
06.06.16
Chemotherapy
Msr. SAN/54/P4A0UA/NSR
11:00 AM
D/ Cervical Cancer Recurent
(C53.9)
M/ Chemotherapy Oxalaplatin Gemcitabin 1st course
(Z51.11)
Pathology No. PA 2217/A/2016
Non keratinizing squamous cell carcinoma cervic,moderately differentiated
02.06.16
General condition improvment
Mrs.RIS/42/P2A0
03:00 PM

D/ Ectopic pregnancy was suspected

M/ Laparascopy salphingostomy dekstra

ASSESMENT
Dr. Rakhmat Akbar Dinur
Report technique
Paper acknowledgment
Honesty
Mean

Dr. Jhon Heriansyah

1
07.06.16

Mrs. YUL/44/UA/P0A0/ASN
(D25.1)

D/Cervical cancer stage III B was suspected + moderate anemia

M/General condition improvment
Plan for clinical staging
Pathology No. PA SS.1604004249
keratinizing squamous cell carcinoma cervic,moderately differentiated
4

/RA/NSR
(C53.9)

26.05.16

Chemotherapy

07:46 PM

Mrs. SUD/70/UA/P10A3/JHN
D/ Stage III B Cervical cancer
(C53.9)
st
M/ Chemotherapy paclitaxel-carboplatin 1 course
(Z51.11)

Pathology No.
keratinizing squamous cell carcinoma cervic,moderately differentiated
5

06.06.16

General condition improvement

11:20 PM

Mrs. RUS/76/RA/P2A0/JHN
D/ Cystic ovarian neoplasm malignancy was suspected
(N83.29)
M/ plan for laparotomy FS
(54.11)

03.06.16

Medicinalis

03.00 PM

04.06.16
10.37 AM

04.05.16
02.30 PM

Mrs. SUF/27/G1P0A0/UA/COR
D/ G1P0A0 9 weeks gestational age with threatened abortion intrauterine
(O20.0)
M/ medicinalis
Plan for Myomectomy
D/ Multiple uterine myoma + moderate anemia
M/ PRC transfusion
P/ Myometomy

Ms. MAR/32/UA/ASN
(D25.1,285.29)

Plan for hysterectomy

Mrs. PAR/60/ P4A0/RA/ASN
D/ PMB e.c intramural uterine myoma + moderate anemia (N92.4,285.29)
M/ PRC transfusion
P/ total abdominal hysterectomy

05.06.16

Plan for HDLO

05.30 PM

Mrs. REN/32/ P0A2/UA/ASN

D/ Intramural uterine myoma + secondary infertile 5 years
(D25.1)
M/ Plan for HDLO

Obstetrical Chief on Duty: Dr. Jhon Heriansyah

Tuesday, June 7th, 2016 at 03.00 PM- Thursday, June 8th, 2016 at 07.00 AM

Consultant on Duty: Dr. A. Abadi, SpOG(K)

1 07-06-16
. 02:15 PM
Hb: 11.2 g/dL
WBC: 9.100
PLT 264.00
LEA(-)

Internal Departement

03:00 PM

19:10 WIB

19:30 PM

Spontaneous delivery

Mrs.
DAH/31/UA/RZM
D/ G2P1A0 40 weeks gestasional age inlabor first stage
latent phase with PROM 1 day + extrapulmonary
tuberculosis with incomplete therapy, SLF cephalic
presentation
US ER (GIN)
- Single life fetus cephalic presentation
- Biometry:
BPD: 95.2 mm
AC: 344 mm
HC : 352 mm
FL: 72.5 mm
EFW: 3490 g
- Placenta in anterior corpus of uterine
- Amniotic fluid index
3.2 3.8 = 12 cm
1.8 4.2
C/ 40 weeks gestational age, single life fetus cephalic presentation
M/ Observed vital sign, FHR, contraction
IVFD RL xx drops/mnt
Laboratory examination
Ampicillin injection 1 g/6 hours IV (skin test)
Acceleration with oxytocin drip
Consult to internal department
P/ Vaginal delivery
A/ there is no sign of pulmonary TB
D/ G2P1A0 40 weeks gestasional age inlabor first stage
active phase with history of ROM 1 day +
extrapulmonary tuberculosis with incomplete therapy,
SLF cephalic presentation
Th/ Observed vital sign, FHR, contraction
IVFD RL xx drops/mnt
Ampicillin injection 1 g/6 hours IV (skin test)
Acceleration with oxytocin drip
P/ Vaginal delivery
D/ G2P1A0 40 weeks gestasional age inlabor second stage
with history of ROM 1 day + extrapulmonary tuberculosis
with incomplete therapy, SLF cephalic presentation
P/ conduct the labor
Male life baby was born spontaneously, BW 3500 g, BL
51 cm, AS 8/9 FTAGA

19:45 PM

2. 07-06-16
05:00 PM
GI: 6
Hb: 10.6 g/dL
WBC: 14.000 mm3
PLT: 352.000 mm3
LDH: 444

Placenta was delivered completely PW: 610 g, PTP 52

cm, 20x21 cm
Mother and the baby was in good condition

Spontaneous delivery

Mrs. ROH/36UA/RZM
D/ G3P2A0 38 weeks gestational inlabor first stage active phase with
severe preeclampsia, SLF cephalic presentation
M/ Stabilisation 3 hours
Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Urinary catheter insertion
MgSO4 inj protocol
Nifedipine 10 mg/ 8 hours PO
Evaluation with gestosis task
Consult to internal and ophthalmology department
Tubal ligation counseling, refuse
Contraception counseling

09:00 PM
GI: 4
09:15 PM
09:20 PM

3. 07-06-16
03:17 PM

IG: 8
Hb: 13.6 g/dL
WBC: 7.300 mm3
PLT: 324.000 mm3
LDH: 886

P/ Vaginal delivery
D/ G3P2A0 38 weeks gestational inlabor second stage with severe
preeclampsia, SLF cephalic presentation
P/ conduct the labor
Male life baby was born spontaneously, BW 3100 g, BL 47 cm, AS 8/9
FTAGA
Placenta was delivered completely with PW 520 g, UCL 49 cm, 19 x
20 cm
Mother and baby were in good condition
Expectative management

Mrs. YUN/26/RA/ABR
D/ G1P0A0 29 weeks gestational age not inlabor with severe
preeclampsia + partial HELLP syndrome, SLF cephalic presentation
US ER (GIN)
- Single life fetus cephalic presentation
- Biometry:
BPD: 76.3 mm
AC: 242 mm

HC : 268 mm
FL: 52.1 mm
EFW: 1314 g
- Placenta in posterior corpus of uterine
Amniotic fluid was enough
C/ 29 weeks gestational age, SLF cephalic presentation
M/ Observed vital sign, FHR, inlabor signs
IVFD RL xx drops / mnt
Laboratory examination
Urinary catheter insertion
MgSO4 inj protocol
Nifedipine 10 mg/ 8 hours PO
Consult to internal and ophthalmology department
Deksametasone injection 10 mg/12 hours
P/ Expectative management
4. 07-06-16
07: 00 PM

07:40 PM
07:45 PM

07-06-16
07:15 PM
IG: 7
Hb: 10.6 g/dL
WBC: 7.300 mm3
PLT: 276.000 mm3
LDH: 590

Partial extraction

Mrs. SRI/29/RA/ABR
D/ G3P1A1 39 weeks gestasional age inlabor second stage, single life
fetus breech presentation
M/ obs. Vital sign, contraction, FHR
Laboratory examination
IVFD RL xx drops/m
P/ conduct the labor
Male life baby was born with partial extraction, BW: 3500 g, BL: 50
cm, AS 8/9 FTAGA
Placenta delivered completely, PW 500g, UCL 48 cm diameter 17x18
jam
Mother and the baby were in good condition
Partial extraction

Mrs. SAH/47/RA/RZM
D/ G4P3A0 37 weeks gestasional age inlabor first stage active phase,
single life fetus breech presentation
M/ Stabilisation 3 hours
Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Urinary catheter insertion
MgSO4 inj protocol
Nifedipine 10 mg/ 8 hours PO
Evaluation with gestosis task

Acceleration with oxytocin drip

Consult to internal and ophthalmology department
Tubal ligation counseling, agree
P/ vaginal delivery
08-06-16
01:10 AM
IG 4
01:30 AM
01:40 AM

6.

7.

D/ G4P3A0 37 weeks gestasional age inlabor second stage, single life

fetus breech presentation
P/ conduct the labor
Male life baby was born with partial extraction, 2900g, BL 46 cm, AS
8/9 FTAGA
Placenta was delivered completely, PW: 510g, UCL 49 cm, diameter
18x19 cm
Mother and baby were in good condition

07-06-16
02:51 PM

Conservative

08-06-16
02:15 PM
BS: 2

SSTP ai PROM 12 hours + Prior CS 1 (cb post term)

Mrs. LIN/30/UA/ABR
G3P2A0 38 weeks gestational age not inlabor with PROM 12 hours +

Mrs. NUR/43//RA/ABR
D/ G3P2A0 27 gestasional age weeks not inlabor with PPROM 3 hours
+ prior CS 2x time, SLF intrauterine + oligohydramnios
US ER
- Single life fetus intrauterine
- Biometry:
BPD: 67.9 mm
AC: 231 mm
HC : 265 mm
FL: 47.2 mm
EFW: 1010 g
- Placenta in anterior corpus of uterine
- Amniotic fluid index
0
1.1 = 2.4 cm
1.1 0.2
C/ 27 weeks gestational age, single life fetus intrauterine +
oligohydramnios
M/ Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Nifedipine 10 mg/ 8 hours PO
Ampicillin injection 1g/ 6 hours
Consult to fetomaternal division

history of CS 1x, SLF cephalic presentation

US ER
- Single life fetus cephalic presentation
- Biometry:
BPD: 93.3 mm
AC: 340 mm
HC : 330 mm
FL: 71.9 mm
EFW: 3290 g
- Placenta in anterior corpus of uterine
- Amniotic fluid index
1.5 1.3 = 6.4 cm
1.6 2.0
C/ 38 weeks gestational age, single life fetus cephalic presentation
M/ Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Plan for abdominal delivery
Ampicilin inj 1g/ 6 hours IV
10:20 AM
10:25 AM

8.

07-06-16
01:01 PM

10:00 PM
IG: 6

P/ abdominal delivery
Male life baby was born, BW 2950 g, BL 48 cm, AS 8/9
Placenta was delivered completely PW 470 g, UCL 49 cm, 18x19 cm
Mother and the baby were good condition
Vacuum extraction

Mrs. NUR/31/UA/AF-JHN
D/ G2P1A0 38 weeks gestational age not inlabor with mild
preeclampsia SLF cephalic presentation
M/ Obs TVI, contraction, FHR
Induction the labor with oxytocin drip
D/ G2P1A0 38 weeks gestational age inlabor first stage latent phase
with severe preeclampsia, SLF cephalic presentation
M/ Stabilisation 3 hours
Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Urinary catheter insertion
MgSO4 inj protocol
Nifedipine 10 mg/ 8 hours PO
Evaluation with gestosis task
Acceleration with oxytocin drip

11:30 AM

8/6/16
02:30 AM
IG 4
03: 00 AM
03:05 AM
03:10 AM
NO
1
2
3

/ G2P1A0 38 weeks gestational age inlabor first stage active phase with
severe preeclampsia, SLF cephalic presentation
P/ vaginal delivery
Observed vital sign, contraction, FHR
IVFD RL xx drops / mnt
Laboratory examination
Urinary catheter insertion
MgSO4 inj protocol
Nifedipine 10 mg/ 8 hours PO
Evaluation with gestosis task
Acceleration with oxytocin drip

P/ vaginal delivery
D/ G2P1A0 38 weeks gestational age inlabor second stage with severe
preeclampsia, SLF cephalic presentation

P/ conduct the labor

D/ G2P1A0 38 weeks gestational age inlabor second stage with severe
preeclampsia, SLF cephalic presentation
P/ vacuum extraction
Male life baby was born with vacuum extraction, 3200 g, 47 cm, AS
7/9 FTAGA
Placenta delivered completely

ASSESMENT
Dr. Jhon Heriansyah
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX
30
35
35
100

Notes