Clinical Report

Monday, November 4th 2019

Doctors in charge :
1. FAM
2. SAR
3. SUL
4. BEN
5. OZY
6. FAR
7. AJP

Emergency Room : IAM

Action Supervisor : IAM
Operating Supervisor : ATA
Chief on Duty : INU

Consultants on Duty
07.00 – 14.00 : dr. ADK, SpOG(K)
14.00 – 21.00 : dr. WAN, SpOG(K)
21.00 – 07.00 : dr. MIA, SpOG(K)

I. DELIVERY ROOM
A. PHYSIOLOGIC DELIVERY (0)
B. PATHOLOGIC DELIVERY (1)
Maternal Ward 1. Mrs D, 28 yo, G2P1A0 GA 34 weeks 2 days (dr FAH)
4/11/19 MR 01910725
06.55
GENERAL ADP with permission dr FAH and MAN had assisted
spontaneous delivery, preterm P2A0

G2P1A0, 28 yo At 06.55 baby was born spontaneously, male, BW 2918 gram,

LMP 8/03/19 BH 50 cm, CC/HD 32/31,5 cm, AS 7/9
EDD 15/12/19
GA 34 weeks 2 days At 07.00 placenta was delivered spontaneously, size 22x21x2
cm, weight 500 gram, paracentral insertion, calcification (-),
BP 138/80 mmHg UCL 50 cm
HR 92 bpm
RR 20 bpm
T 36,5 C

BW 83 kg
BH 154 cm
↑ BB 11 kg
BMI 30.37 kg/m2

FHR 145 bpm

His: 3-4x/10’/35”/K

DS 34+4 weeks
1
IP 2,33

Maternal Ward Chronologic: Lab 4/11/19

4/11/19 S: Patient came by herself with chief complain of amniotic
01.00 fluid leakage since 22.30 3/11/19 and having contraction since WBC 14.19
GENERAL 20.00 3/11/19. bloody show (-), fetal movement was active. RBC 3.75
After amniotic fluid leakage, patient came to RS hidayatullah, HB 11.1
not cervix dilatation yet, given recommendation for go to RSS Hmt 33.4
G2P1A0, 28 yo directly because need NICU. Patient consider pregnant 34 MCV 89.1
LMP 8/03/19 weeks 4 days MCH 29.6
EDD 15/12/19 MCHC 33.2
GA 34 weeks 2 days History of Obstetric AT 293
1. 6 yo, BW 3100 gr, spontan, PKU HBsAg NR
BP 135/76 mmHg Glucose 118
HR 115 bpm 2. This pregnancy
RR 20 bpm
T 36,3 C History of surgery : (-)
History of marriage 1x ~ 6 years
BW 83 kg History of ANC SpOG in the Madukora and Hidayatullah ( dr
BH 154 cm Fahmi SpOG )
↑ BB 11 kg History of contraception (-)
BMI 30.37 kg/m2 History of HT (-), DM (-), cardiac diseases (-), Asthma (-),
Alergy (-),
FHR 158 bpm
His: 3x/10’/35”/L O: GC, well, conscious
Head: CA -/-, jaundice -/-
Abdomen: longitudinal singleton baby, cephalic presentation,
FHR (+) 160 bpm, Fetal movement (+), fundal height 30 cm.

BE: V/U normal, smooth vaginal wall, cervix soft at posterior,

eff 100%, head S-2, dilatation 1 cm, amniotic fluid (+),
nitrazin test (+)

A: G1P1A0 GA 34 weeks 2 days first stage latent phase in

labour

P:
- Propose to evaluation 4 hours
- Observation contraction and FHR
- Observation sign of labour
Report dr Fahmi SpOG -> not connected yet
Report dr Nuring SpOG (K) -> acc dx tx, re-report DPJP
ward

2
USG

Singleton baby,
longitudinal lie,
cephalic presentation,
movement +, FHR +,
amniotic fluid is
sufficient, placenta at
corpus anterior
BPD 8,8 cm
HC 31,8 cm
AC 33,8 cm
FL 5,97
EFW 2746 gram

CST

FHR baseline 158

bpm
Variability > 5
Acceleration (+)
Deceleration (-)
Fetal movement (+)
Contraction
3x/10’/120 Mvu

Category 1
Maternal Ward S : contraction (+) more frequently, movement active (+) BE: VU normal,
4/11/19 vaginal wall smooth,
05.00 O: GC Good conscious cervix in middle, soft,
GENERAL eff 100%, Ø 1 cm,
A: G2P1A0 GA 34 weeks 2 days, first stage latent phase in head in S-2, amniotic
labour fluid (+) blood mucus
G2P1A0, 28 yo (+), amniotic
LMP 8/03/19 membrane (+)
EDD 15/12/19
GA 34 weeks 2 days BS = 7

BP 137/96 mmHg
HR 106 bpm
RR 20 bpm
T 36,3 C

BW 83 kg
BH 154 cm
↑ BB 11 kg
BMI 30.37 kg/m2

FHR 148 bpm

His: 2-3x/10’/25”/S

Maternal Ward S: mother wanted to bear down, BE: VU was normal,

3
4/11/19 smooth vaginal wall,
06.45 O: GC good, conscious cervix unpalpable,
GENERAL dilatation complete,
A: 2nd stage of labor head at S-0, blood
G2P1A0, 28 yo mucus (+), amniotic
LMP 8/03/19 P: fluid (+)
EDD 15/12/19 Purpose
GA 34 weeks 2 days -Lead the delivery
-Preparation for neonate resuscitation
BP 138/80 mmHg Report dr Fahmi SpOG advice acc dx tx
HR 92 bpm
RR 20 bpm
T 36,5 C

BW 83 kg
BH 154 cm
↑ BB 11 kg
BMI 30.37 kg/m2

FHR 145 bpm

His: 3-4x/10’/35”/K

Delivery Resume
Duration Amount of bleeding
1st stage 5 hours 45 minutes 1st stage 30 cc
2nd stage 10 minutes 2nd stage 20 cc
3rd stage 5 minutes 3rd stage 50 cc
Total 6 hours 0 minutes 4th stage 50 cc
Total 150 cc
Documentation

4
 II. OPERATING ROOM
A. MAJOR OBSTETRIC (0)
OR GBST 1. Ms. Y, 31 yo. G1P0A0, GA 37 weeks
4/11/19 MR 01910596
20 48 WIB
PBI FAM supervised by dr WAN assisted by ENA and RKU had
DPJP dr WAN performed emergency C-section and insertion of IUD o.i.,
B20 on therapy, first stage latent phase on labour,P1A0
G1P0A0, 31 yo
LMP 18/02/19 ( At 20.48, baby was delivered abdominally, female, BW 2834
forget) gr, BH 47 cm, HC/CC 34/33 cm, A/S 8/9
EDD 25/11/2019
GA 37 weeks At 20.53 the placenta was delivered, complete, weight 350 gr,
size 15x14x1,5 cm, cord length 30cm, paracentralis insertion,
BP 110/82 mmHg calcification (-).
HR 78 bpm
RR 20 bpm
T 36.1 C

BW 59,7 kg
BH 152 cm
↑ BB 14,7 kg
BMI 19.48 kg/m2

ER Chronology Lab ( 4/11/19 )

4/11/19 Patient referred from PKM Girimulyo II with diagnosed WBC 11.83
12.00 WIB G1P0A0 GA 37 weeks first stage phase latent in labour with RBC 4.44
PBI mother B20 on theraphy. with complaint pregnant 9 months, HB 13.6
DPJP dr WAN contraction (+) since 05.00, mucous and blood (+), amniotic Ht 39.2
fluid leakage (-), fetal movement was active. It the first MCV 88.3
G1P0A0, 31 yo pregnancy. MCH 30.6
LMP 18/02/19 ( Patient was known B20 since 2/9/2019 in the PKM girimulyo, MCHC 34.7
5
forget) patient check up in the RSS 1/11/2019, and laboratorium Tromb 181
EDD 25/11/2019 examination was done, but not result yet. Patient got the ARV. PPT 14.6/14.8
GA 37 weeks Hystore of menstruation : menarche 13 yo, duration 3-5 days, APTT 32.0/32.0
26-3- days FAAL HATI
BP 110/70 mmHg History of marriage 1x ~ 3 years Albumin 3.15
HR 78 bpm History of Obstetric: I. This pregnancy SGOT/AST 18
RR 20 bpm History of ANC, at PKM 5x, SpOG 2 times SGPT/ALT 20
T 36.1 C History of contraception (-) BUN 7.7
History of surgery (-) Cr 0.48
BW 59,7 kg History of HT (-), DM (-), heart disease (-), asthma (-), allergy HBsAg NR
BH 152 cm (-). Na 135
↑ BB 14,7 kg K 4.04
BMI 19.48 kg/m2 O: Cl 102
GC: good, conscious Glucose 82
Eye: anemic (-/-), icteric (-/-) INR 1.07
Heart: S1.2 reg, murmur (-)
Pulmo: vesikuler (+/+), ronkhi (-/-), wheezing (-/-)
Abdomen: longitudinal singleton baby, cephalic presentation,
FHR (+) 148 bpm, Fetal movement (+), fundal height 31 cm,
contraction 3x/10’/20”/S
BE: V/U normal, vaginal wall smooth, cervix soft, eff 80%, Ø
1cm, head S-2, amniotic membrane (+), amniotic fluid (-),
mucous and blood (+)

A:
G1P0A0 GA 37 weeks first stage latent phase in labour with
mother B20 on theraphy ( viral load and CD4 had not been
checked)

P:
Proposed :
SC emergency + IUD insertion
Report to dr WAN, advice:
Acc Dx Tx

USG:
Singleton baby,
longitudinal lie,
cephalic presentation,
FHR (+), movement
(+), AF suffiecient
(DSP 3,8), placenta at
corpus anterior

BPD 9.17~34w1d
HC 30,9~34w3d
AC 32,5~36w2d
FL 7.17~36w5d
EF 2917 gram

6
CTG
FHR baseline 140
bpm
Variability > 5
Acceleration (+)
Deceleration (-)
Movement (+)
His 2x/10’/75 mvu
Category I

Documentation

7
ACC Consult Acc Consult Patient Perina Start Start Finish
DPJP Anaes Anest Perina arrived arrived anaes Operation operation
12.00 12.10 18.30 19.15 19.55 20.15 20.00 20.20 22.45
Condition this morning
BP: 100/73 mmHg FI: 600 ml Hb Post Op:
HR: 100 bpm FO: 750 ml No data
RR: 18 x/m BC: -150 ml
T: 36.6 C UO: 1,66

B. MAJOR GYNECOLOGY (4)

OR 4.04 1. Ny. J, P2A0, 55 yo Lab 30/10/19
4/11/19 MR 1906567 WBC 10.97
08.00 WIB RBC 4.61
JKN PBI Prof H assisted by WAR and RNO had performed HB 13.5
DPJP Prof H panhysterectomy omentectomy appendectomy, HMT 41.3
adhesiolysis, anastomose sigmoid resection o.i. MCV 89.4
P2A0, 55 yo Cysstoma Ovaari borderline, sigmoid perforation, MCH 29.3
Menopause 10 thn adhesion grade IV, P2A0 MCHC 32.7
Last child 33 yo AT 237
Dx pre op: Cysstoma Ovaarii suspect malignancy, PPT 16.1/14.5
BP 116/72 mmHg history of laparatomy cystectomy 2 years ago, P2A0 APTT 35.3/29.6
HR 84 bpm Alb 3.63
R 20 x/m Dx post Op: Post panhysterectomy omentectomy SGOT/AST 17
T 36.50 C appendectomy, adhesiolysis, anastomose sigmoid SGPT/ALT 15
resection o.i. Cysstoma Ovaari borderline, sigmoid BUN 13.0
CA 125 68.64 perforation, adhesion grade IV, P2A0 Cre 0.62
IOTA ADNEX RISK HBsAg NonReactif
MALIGNANSI 90.6 Durante op: Na 135
%, RISK BENIGN  Routine surgical procedure Ka 4.01
9.4%  In the narcose stadium, incision midline had been Cl 101
RMI 617.76 performed until 3 fingers above umbilicus INR 1.20
8
  Incision was deepened layer by layer until parietal
BW 43 kg peritoneum. Lab 31/10/19
BH 148 cm  Peritoneum was opened, identification and exploration WBC 8.02
BMI 19.64 kg/m2 had been performed, ascites -> fz -> malignant cell (+) RBC 4.14
 Seen cyst mass size 30x20x20cm from left adnexa, Hemoglobin 12.3
superior part of cyst mass adhesion with colon Hematokrit 36.6
EKG sigmoid, left part adhesion with peritoneum, inferior MCV 88.4
SR, HR 93 kpm part adhesion with uterus. MCH 29.7
 Performed adhesiolysis sharp and blunt -> injured of MCHC 33.6
X Thorax iatrogenic bowel on the colon sigmoid -> consult to AT 278
Pulmo and cor seen digestive surgeon PPT 17.1/15.0
normal  Performed debulking tumor mass -> Fz -> borderline APTT 41.3/30.6
 Decided to performed panhysterectomy, omentectomy, Albumin 3.19
appendectomy SGOT/AST 18
 Lig rotundum right and left  c/c/s SGPT/ALT 17
 Lig. Infundibulo pelvicum  c/c/s BUN 14.1
 Vesicouterina plica and rectouterine was set aside to Creatinin 0.64
caudal side HBsAg Non
 A.V. uterine right and left  c/c/s Reaktif
 Lig. Sacrouterina right and left  c/c/s Na 137
 Lig. Cardinale right and left  c/c/s K 3.82
 Cervix identification Cl 102
 Uterus was cut on the top of cervix Glucose 89
 Vaginal stump was sutured countinous interlocking 1 INR 1.28
layer
 Bleeding control (-)
 Visceral reperitonealisation
 Performed omentectomy and appendectomy
 Parietale reperitonealisation
 Abdominal wall was sutured layer by layer
 Skin sutured intracutaneously
 Operation finished

Total bleeding: 3000 ml

Durante op digestive surgeon :

 Take a consult durante operation from TS Obsgyn
 Seen cavum abdomen
 Performed exploration from ligamentum freitz until
rectosigmoid
 Found perforation of sigmoid ± 40% lumen
 Decided to performed sigmoid anastomose recection
 The remaining cyst capsule were found -> performed
cysct/tumor (capsule)
 Performed exploration again -> bleeding (-), perforation (-)
 Operation was continued by TS obsgyn
 Put drain by TS obsgyn ( left pelvical )

9
USG
Seen VU terisi, uterus
atrophy, free fluid (+)
in the cavum douglas,
cyst mass (+),
multiokuler (+), septa
(+), papil (-), solid
part (+).

Condition this morning

BP: 83/54 mmHg FI: 1000 cc Hb post op:
HR: 112 bpm FO: 114760 cc 8.0 gr/dl
RR: 22 x/m FB: -147 cc
T: 36.1 C UO: 0.9
OR PH 2.Ny. PA, P0A0, 27 yo. Lab 28/10/19
4/11/19 MR 01906287 WBC 7.63
13.00 WIB RBC 4.27
JKN PBI dr. WDD assisted by NIR and SUL had performed HB 12.2
DPJP WDD hysteroscopy, laparoscopy, adhesiolysis, patent test HMT 35.7
tuba, cystectomy bilateral, fulguration o.i. chocolate MCV 83.6
P0A0, 27 yo cyst bilateral, endometriosis, tuba paten bilateral, MCH 28.6
LMP 25/9/2019 adhesion gr IV, P0A0. MCHC 34.2
Married 1,5 yo AT 432
Dx pre op: Chocolate cyst bilateral, PID dd pseudocyst Blood type O
BP 115/66 mmHg peritoneal cyst Rhesus POSITIF
HR 70 bpm PPT 14.7/14.7
R 18 x/m Dx post Op: post hysteroscopy, laparoscopy, APTT 40.9/30.5
T 360 C adhesiolysis, patent test tuba, cystectomy bilateral, Alb 4.19
fulguration o.i. chocolate cyst bilateral, endometriosis, SGOT/AST 23
BW 52 kg tuba paten bilateral, adhesion gr IV, P0A0. SGPT/ALT 35
BH 150 cm BUN 8.1
BMI 23.11 kg/m2 Cre 0.61
Durante Op: HBsAg Non
Ca 125 156.20  Hysteroscopy was performed: Reaktive
AFP 0.65 o Ostium uteri externa was normal Natrium 135
LDH 179 o Canalis cervicalis was normal Kalium4.03
RMI 156.2 o Ostium uteri interna was normal Klorida 97
o Cavum uteri was normal Glucose 88
Sperm analysis o Ostium right and left tuba normal INR 1.08
01/2/2019  Performed laparoscopy:
normozoosperma o Hepar was normal
o Uterus size and shape was normal, found
EKG endometriosis nodule on the serousa uterus,
SR, HR 73 kpm performed fulguration
o Bowel and left tuba adhesion with lateral
X Thorax : pelvic wall, performed adhesiolysis
Pulmo and cor seen o Seen right and left tuba was normal
10
normal o Seen cyst mass in the left sinistra size 2cm,
performed cystectomy, ruptured, chocolate
porridge came out
o Seen cyst mass in the right ovarium size 3 cm,
performed cystectomy, ruptured, chocolate
porridge came out
o Patent tuba test, tuba patent bilateral
o Bleeding control (-)
o Operation was done

Total bleeding: 50 ml

USG
uterus size and shape
normal
right ovary:
chocolate cyst
size 1.6x1.57 cm
size 1.6x 1.8 cm
suspect peritoneal cyst
left ovary chocolate
cyst size 2x1.54 cm

Condition this morning

BP: 124/75 mmHg FI: 1240 cc Hb post op:
HR: 88 bpm FO: 1390 cc No data
RR: 20 x/m FB: -150 cc
T: 36.3 C UO: 1.4
OR 4.04 3.Mrs. NA, P0A0, 23 th, lab 2/11/2019
4/11/19 MR 01906291 WBC 9.02
11
11.00 WIB RBC 4.05
JKN Non PBI DIN assisted by IAM and RKU had performed HB 10.6
DPJP DIN Salphingoophorectomy sinistra, omentectomy, adhesiolysis, HMT 31.9
peritoneum mass biopsy oi Ca ovarii St II MCV 78.8
P0A0, 23 yo MCH 26.2
LMP 10/10/19 Dx pre op: TPO suspek Malignancy, P0A0 MCHC 33.2
Menopause 15 years AT 598
Dx post Op: Post Salphingoophorectomy sinistra, BUN 33.30
BP 130/80 mmHg omentectomy, adhesiolysis, peritoneum mass biopsy oi Ca Cre 4.38
HR 83 bpm ovarii St II Nat 138
R 20 x/m K 4.41
T 36.60 C Cl 99

BW 53 kg Durante op:
BH 158 cm  In the narcose stadium, performed preparation
BMI 21.2 kg/m2 operation area
 Incision midline had beed performed until 4 cm above
Ca 125 172.2 umbilicus
LDH 3258  Incision was deepened layer by layer until parietal
CEA 0.76 peritoneum.
AFP 1.65  Peritoneum was opened, identification and exploration
had been performed
RMI : 172.2  Seen left ovarium change become solid mass, size
20x20x15 cm
EKG  Seen uterus size 4x5x5 cm, adhesion on the left
SR, HR 75 kpm ovarium mass
 Seen tuba and right ovarium normal
X Thorax : Pulmo and  Perforemed peritoneal washing -> Fz : malignancy (-)
cor seen normal.  Palpable nodules of tumor mass in the peritoneum
 Decided to performed salphingoophorectomy sinistra .
USG Abdomen Upper Seen tumor mass left ovarium adhesion with bowel,
+ Lower uterus peritoneum -> adhesiolysis
- Parenchymal renal  Left lig. Infundibulopelvicum c/c/s
disease bilateral  Tumor mass of the left ovarium raised -> Fz :
- Seen nefrostomy in malignancy
the SPC bilateral  Decided to performed omentectomy and peritoneum
- Solid mass supect mass biopsy
uterus  Bleeding control (-)
- hepar, vesica felea,  Cavum abdomen was washed with aquabidest
lien, pancreas, vesica  Spongostan 3 were inserted
urinaria are normal.  Drain had been set intraabdominally
Not seen metastase  Abdominal wall was sutured all layer
- Not seen  Skin sutured intracutaneously
lymfadenopaty
paraaorta Durante op ( urology )
 The patient is tilted to the right with local anaesthesia
 Performed aseptic and antiseptic
 Narrowed operation area with doek sterile
 Local anaesthesi with lidocaine 2%
 Identification kidney gaiding USG -> performed ->
urine (-). Gaiding USG to the SPC, NGT 8 fr trocart
was inserted to the kidney. Fixcation NGT with side
2.0
12
  Operation was finished

Total bleeding: 500 ml

USG
Seen Vu filled . seen
uterus size
6.35x3.77x21.13. seen
solid mass cant be
measured by probe,
ascites (-)

13
 Condition this morning
BP: 114/68 mmHg FI: 1210 cc Hb post op:
HR: 93 bpm FO: 1270 cc 9,8 mg/dl
RR: 20 x/m FB: +60 cc
T: 36.5 C UO: 2.1
OK Emergency 4. Nn. I, P1A1, 22 yo Lab 4/11/19 00.44
04/11/2019 MR 01857982 WBC 12.57
JKN NPBI RBC 5.79
DPJP FAH Dr FAH with assistant ATA, WAR and SAR had performed Hemoglobin 15.1
relaparatomy TAH-Bisalphingectomy oi necrotic uterus and Hematokrit 44.9
P1A1, 22 yo salphing bilateral, post relaparatomy releasing tourniquet of MCV 77.5
LMP 2/11/19 uterus, hysterectomy was continued hysteroraphy oi ectopic MCH 26.1
last child, 1 yo scar of pregnancy dd choriocarcinoma H5, history of MCHC 33.6
laparotomy fixing tourniquet of uterus, post currattage AVM TC 710
TD107/80 mmHg oi insipiens abortion dd choriocarcinoma, H7, hypovolemic Blood type B+
N 98 bpm shock grade III resolved, heavy anemia resolved, obstructive PPT 21.6/14.5
R 20 bpm ileus, P1A1 APTT 31.7/31.8
T 37 C Albumin 4.28
Dx Pre Op:. SGOT/AST 21
BB 45 Kg SGPT/ALT 13
TB 155 cm Dx Post Op: Post relaparatomy TAH-Bisalphingectomy oi BUN 53.70
IMT 20.4 kg/m2 necrotic uterus and salphing bilateral, post relaparatomy Creatinin 1.33
releasing tourniquet of uterus, hysterectomy was continued Glucose 188
Abdomen 3 position hysteroraphy oi ectopic scar of pregnancy dd choriocarcinoma HBsAg Non
31/10/19 H5, history of laparotomy fixing tourniquet of uterus, post Reaktif
currattage AVM oi insipiens abortion dd choriocarcinoma, Natrium 130
- Obstructive ileus with high
site obstruction (SBO)
H7, hypovolemic shock grade III resolved, heavy anemia Kalium4.22
- Not seen of ascites and resolved, obstructive ileus, P1A1 Clorida86
pneumoperitoneum on the INR 1.67
abdomen photo 3 current Durante op ( digestive surgeon )
position
 Patient supine position, GA anesthesia Lab 4/11/19 9.34
Hystopathology  Performed septic and antiseptic WBC 1.31
14
28/10/19  Narrowed the operation field with duk sterile RBC 3.32
Uterine scar excision tissue:  Incision midline, Incision was deepened layer by layer HB 8.7
A pregnancy product
until parietal peritoneum. Hematokrit 26.1
 … peritoneum, identification MCV 78.6
 Seen cavum …. ( feses) on the cavum abdomen MCH 26.2
 Identification sisterna of boewl MCHC 33.3
 Seen bowel perforation 170 cm from lig treitz and 210 TC 401
cm from lig freitz
 seen ileum ,,,
 bleeding control
 decide to performed …
 operation was continued by obsgyn
 cavum abdomen was washed
 insert ..
 sutured layer by layer
 …
 Operation was finished
 Tissue was sent to PA

Durante op:
 Countinoued digestive surgeon operation
 Performed exploration and identification
 Seen uterus colored purple, necrosis
 Seen right and left tuba fallopi colored purple, necrosis
 Seen Right and left ovarium colored red with normal
size -> conservative
 Decide to performed, total abdominal hysterectomy
and bisalphingectomy
 Lig rotundum right and left c/c/s
 Lig ovarium propium right and left c/c/s
 a/v uterine right and left c/c/s, lig cardinal right and
left c/c/s
 Lig sacrouterine right and left c/c/s
 Plica vesicouterine was opened and set aside to caudal
side
 Uterus was cut
 Vaginal stump was sutured countineus interlocking 1
layer, bleeding control (-)
 Reperitonealisation visceral
 Bleeding control (-)
 Operation was continued by digestive surgeon.

Total bleeding: 150 ml

USG
VU filled, uterus size
7.68x5.1x4.9 cm. not
seen mass in the
adnexa

15
16
 Condition this morning
BP: 62/20 mmHg FI: 2322 cc Hb post op:
HR: 153 bpm FO: 230 cc 17,5 mg/dl
RR: 27 x/m FB: +2092 cc
T: 37 C UO: 0.52

C. MINOR GYNAECOLOGY (0)

D. STERILIZATION (0)
NONE
III. OPERATION PLAN
A. MAJOR OBSTETRIC (1)
AMT 1 1. Mrs. AN, 30 y.o. G2P1A0, GA 38 weeks (ADK) Lab 25/10/19
5/11/19 MR 01901050 WBC 10.38
06.00 RBC 4.03
JKN NPBI Hb 12.2
Dx : G2P1A0, GA 38 weeks 6 days, not yet in labor, with
Hmt 37.5
G2P1A0, 30 y.o MCV 93.0
multiple myoma uteri, history of SC 2 times
LMP 5/2/19 MCH 30.3
EDD 13/11/19 MCHC 32.6
GA 38 weeks 6 days RDW 13.1
Tx Re SC elective TC 361
BP 117/71 mmHg PPT 15.5/14.2
HR 90 bpm APTT 28.5/29.0
RR 20 tpm Alb 3.61
Time / Place : 06.00 / O.R. 4.04
T 36.5 0C SGOT 12
Team : ADK/WAR/ATA/RNO SGPT 6
BH 155 cm BUN 6.90
BW 63.8 kg Cre 0.61
↑BW 7.8 kg Blood Glucose 132
BMI 27.3 kg/m2 Na 133
K 3.76
Cl 108
17
 INR 1.14

USG

Singleton baby,
longitudinal lie,
cephalic presentation,
movement +, FHR +,
amniotic fluid is
sufficient ( 3,75 cm),
placenta at corpus
anterior, seen
hyperechoic mass in
the left lateral fundus,
myoma uteri 10x11cm
BPD 9,37 cm ~
38w1d
HC 33,65 cm~38 w 4d
AC 34,56cm~ 38w3d
FL 7,44 cm~ 386d
EFW 3461 gram
NST Cant found in the status
FHR baseline 145
bpm
Acceleration (+)
Deceleration (-)
Variability >5
Movement (+)
Reactive
B. MAJOR GYNECOLOGIC (4)
Bugenvil 2 1.Mrs. A, 29 y.o. P0A0 Lab 28/10/19
5/11/19 MR : 01553860 WBC 9.94
13.00 RBC 5.78
JKN NPBI Hb 13.2
DPJP WDD Hmt 42.5
Dx : Multiple myoma uteri
MCV 73.5
P0A0, 29 y.o MCH 22.8
LMP 29/10/19 MCHC 31.1
Marriage 3.5 years Tx : Hislap TC 289
PPT 16.1/14.7
BP 112/71 mmHg APTT 44.4/30.5
HR 98 bpm Albumin 5.02
RR 20 tpm Time / Place : 13.00/ O.R. 1.03 SGOT 17
T 36.3 0C Team : WDD/NIR/SUL SGPT 9
BUN 6.20
BH 150 cm Creatinin 0.77
BW 44 kg Blood Glucose 89
BMI 19.55 kg/m2 Na 141
K 4.17
Thorax PA : Cl 106
no abnormality in INR 1.20
lungs. shape and size
18
of heart is normal. No
sceletal metatastic
visualized
USG
VU filled, seen uterus
enlarge size 9.25x5,25
cm, seen 2 myoma
intramural, size
4,69x2,8 cm and
2,8x3,37 cm

Bugenvil 2 2. Mrs. D, 46 y.o. P0A0 Lab 1/11/19

5/11/19 MR 01903542 WBC 5.19
08.00 RBC 4.87
JKN NPBI Hb 11.3
DPJP BW Dx : ca ovarii with tumor residual, post TAH BSO 3 month ago
Hmt 36.6
TC 301
P0A0, 46 y.o PPT 16.0/15.0
HPHT 27/8/19 APTT 38.5/31.3
19
Menarche 12 yo Tx : relaparatomy optimalization debulking Albumin 4.29
SGOT/AST 36
BP 110/80 mmHg SGPT/ALT 46
HR 78 bpm BUN 10.10
Time/place : 08.00 / O.R. 4.04
RR 20 tpm Cre 0.68
T 37.3 0C Team : BW/DED/ATA/WAR N 144
K 3.97
BH 150 cm Chloe 107
BW 42.5 kg CEA 2.09
BMI 18.8 kg/m2 INR 1.18
Ca 125 21.68
PA 28/8/19
 Uterine tissue :
 cervix and corpus-cervix
→ endometrioid
carcinoma grade III,
limfovascular invasion
(+)
 right ovarium : focus of
endometrioid carcinoma
corpus : leiomyoma with
adenomyosis
USG Cant found in patient and status

CDN 3 2. Mrs. Su, 38 y.o. P2A0 Lab 4/11/19

5/11/19 MR. 01910055 WBC 13.11
08.00 RBC 3.56
UMUM Hb 10.1
DPJP MIA Hmt 30.2
Dx : vulnus laceratum at vulva sinistra with haematome, pelvic
MCV 84.8
fracture
P2A0, 38 y.o MCH 28.4
LMP 21/10/19 MCHC 33.4
Last child 10 y.o TC 250
Tx : Joint Operation with Orthopaedic surgeons ( Pro ORIF)
BP 100/57 mmHg
HR 113 bpm
RR 24 tpm
T 36.5 0C Time / Place : 08.00 / O.R. 5.05

Team : MIA/UCA/DNO
BH 155 cm
BW 95 kg
BMI 39.54 kg/m2

USG could not be found in MR or in patient

C. MINOR GYNAECOLOGY (0)
CW 3 1.Mrs. Se, 50 y.o. P0A0 (NIS) 04/11/19
5/11/19 MR. 01745173 WBC 6.50
12.00 RBC 4.37
JKN NPBI Hb 9.4
Hmt 30.9
Dx : AUB E dd M
P0A0, 50 y.o MCV 70.7
LMP 29/10/19 MCH 21.5
Marriage 3.5 years MCHC 30.4
20
 Tx : curettage for diagnostic and treatment by AVM TC 463
BP 112/71 mmHg PPT 14.9/14.8
HR 98 bpm APTT 33.8/32
RR 20 tpm Alb 4.01
Time / Place : 12.00 / O.R. 4.04
T 36.3 0C SGOT 17
Team : NIS/UCA/RNO SGPT 9
BH 150 cm BUN 5.80
BW 44 kg Crea 0.69
BMI 19.55 Blood Glucose 103
Na 141
K 4.44
Cl 106
USG TV
Seen vu filled enough,
uterus size and shape
normal, EL thickened
1,88cm, regular, seen
right ovarium size
3,26x2,1 cm, left
ovarium size
3,4x2,8cm

IV. HOSPITALIZED PATIENTS (3)

IGD 1.Mrs. AA, 26 yo Lab 4/11/19 jam 18.15
4/11/19 No.MR 01910943 AL 13.69
PBI AE 4.32
DPJP MIA Dx Edema pulmo resolved, PEB superimposed, bracht Hb 10.5
postition, G1P0A0 GA 29 weeks 3 days, not in labour Hct 32.1
G1P0A0, 26 yo MCV 74.3
LMP 10/4/2019 Tx : MCH 24.3
EDP 17/1/2020 - Conservative Management MCHC 32.7
GA 29 weeks 5 days - Metildopa 500mg/8j/oral AT 262
- Nifedipin 10mg/8j/oral Gol darah O+

21
BP 110/78 mmHg - Furosemid 40mg/24 jam/oral PPT 14.8/14.8
P 84 kpm - Kalk 500mg/8jam/oral APTT 33.6/32.0
R 20 kpm - Aspilet 80mg/24jam/oral INR 1.08
T 36.1 C - Evaluatiom rontgen thorax ulang Alb 2.99
- Report dr. Irwan SpOG(K) SGOT/AST 59
BH 156 cm - Acc dx tx SGPT/ALT 64
BW 45 kg - refer ward DPJP MFM BUN 12.90
Creat 0.46
GDS 91

Urin:
Blood/Darah 2+
Nitrit 2+
Lekosit esterase
3+
Eritrosit 590
Leukosit 575
Silinder 32.9
Bacteria 8664.4
Protein 1+
Bilirubin Negatif
Urobilinogen 1+

LDH 349
Natrium 139
Kalium3.88
Klorida 103

AGD:
FIO2 20.90
Temp. 36.5
pH 7.43
pCO2 14.4
pO2 106.0
SO2% 97.9
HCO3 9.7
TCO2 10.1
USG: janin tunggal,
memanjang, presbo,
gerak (+), DJJ (+), AK
cukup (SDP 3.8 cm),
plasenta di anterior
BPD 7.64 cm ~ 30+4
HC 26.38 cm ~ 28+5
AC 27.9 cm ~ 32+0
FL 5.24 cm ~ 27+6
EFW 1734 gram

22
CST:
FHR baseline 170
kpm
Variability >5
Acceleration (+)
Deseleration (-)
Movement (+)
HIS 3x/10’/80 mVu

IGD 2.Mrs. Y, 31 yo Lab 4/11/2019

4/11/19 No.MR 01910596 AL 11.83
PBI Hb 13.6
DPJP WAN G1P0A0 GA 37 weeks first stage latent phase in labour with AT 181
mother B20 on theraphy ( viral load and CD4 had not been AE 4.4
G1P0A0, 31 yo checked) Golda O+
LMP 18/2/2019 (lupa) PPT 14.6/14.8
EDP 25/11/2019 Tx : APTT 32.0/32.0
GA 37 minggu Usul: INR 1.07
- SC emergensi +IUD Alb 3.15
BP 110/70 - Report dr WAN SpOG(K), advis SGOT 18
HR 78 - Acc dx tx SGPT 20
R 20 BUN 7.7
T 36.1 Cr 0.48
HBsAg NR
BH 152 cm Anti HIV hasil
BW 59,7 kg terpisah
↑BW 14.7 kg Na 135
K 4.04
Cl 102
GDS 82
USG
Janin tunggal,
memanjang, preskep,
gerak (+), djj (+), AK
cukup (SDP 3.8 cm),
plasenta di corpus
anterior
BPD 9.17 cm ~ 34 w
1d
HC 30.9 cm ~ 34 w 3
d
AC 32.5 cm ~ 36 w 2
d
FL 7.17 cm ~ 36 w 5
d
EFW 2917 gram

23
FHR baseline 140
kpm
Variabilitas>5
Akselerasi (+)
Deselerasi (-)
Gerak janin (+)
HIS 2x/10’/75mVu
Kesan kategori I

IGD 3 .Mrs. G, 57 yo Lab 4/11

4/11/19 No.MR 01903367 Lekosit37.70
PBI Eritrosit 2.70
DPJP DIN Dx: Hemoglobin 5.4
-Ca cervix III-B dengan anemia Hematokrit 17.3
P4A0, 57 yo -Cancer pain MCV 64.1
Menopause 3 yo MCH 20.0
Last child 29 yo MCHC 31.2
Tx: Usul: Trombosit 727
BP 110/70 -Mondok perbaikan KU
HR 78 -Pro transfuse jika Hb < 10
R 20 -Lacak lab di bangsal
T 36.1 -Inj. Ketorolac 30mg k/p
-Pro pemeriksaan staff di bangsal
BH 152 cm Lapor dr. Addin SpOG(K), advis: acc dx tx.
BW 59,7 kg
↑BW 14.7 kg

PA biopsy cervix
(23/4/2019):
endocervical (clear
cell) adenocarcinoma.
IHC (22/10/19):
jaringan biopsy
servix: profil
imunohistokimia
seseuai untuk
adenocarcinoma
dengan primer dari
ovarium
V. WARDS SITUATION
Bougenvill 1 Bougenvill 2
ONKO: 6 GIN :3
OBS : 0
UROGIN : 0
ONKO : 5
IMP BANGSAL LAIN
MFM: ONKO: 1

24
 OBS: 1
MFM: -
VI. PATIENTS IN OTHER WARDS
VII. RECAPITULATION PHC
JETIS TEGALREJO
Physiologic delivery - Physiologic
Patologic delivery - delivery -
IUD - Patologic delivery
-
IUD -
VIII. DELIVERY ROOM (0)
IX. POST PARTUM HAEMORRHAGE
TEGALREJO 0
JETIS 0
RS BANJAR NEGARA 0
RS WONOSOBO 0
RS WATES 0
RS PATI 0
RS CILACAP 0
RS KLATEN 0
RS MUNTILAN 0
RS BANTUL 0
RS WONOSARI 0
RS SLEMAN 0
RS BANYUMAS 0
RS WONOSARI 0
RS PURWOREJO 0
RS SLEMAN 0

Corrector Case Manager

SAR FAM

Chief on Duty

INU

25