Beruflich Dokumente
Kultur Dokumente
I. Duty
Report
1. Friday : Dr. Chaerannisa Akmelia
2. Saturday : Dr. Ita Chandrawasih
3. Sunday : Dr. Gery Irawan
II. Elective Operation Planning : Dr. Aria Indrabrata
III.
Outpatient Report
A. Oncology Outpatient Report : Dr. Fitrah Tindar Attariq
B. Urogynecology Operative Report : Dr. Veny Melinda
C. FER Outpatient Report : Dr. Kgs. Irawan Satria
D. FER Operative Report : Dr. M. Ardianto Airlangga
E. Fetomaternal I Report : Dr. Arif Krisnadhi Prasoj
F. Fetomaternal II Report : Dr. Ita Chandrawasih
G. Obstetric Outpatient Report : Dr. Dian Aviani
H. Gynecology I Outpatient Report : Dr. Gery Irawan
I. Gynecology II Outpatient Report : Dr. Santa Maria
J. Family Planning Clinic Report : Dr. Raissa Nurwany
IV. Emergency Room Report : Dr. Uci Elisa
V. Emergency Operative Room Report : Dr. Raden Gilang Nala Suwastra
VI. Delivery Room Report : Dr. Aprian Ilhami
VII. Social Obstetric : Dr. Eka Handayani Oktharina
VIII. Pathology Anatomi : Dr. Mustika Dharma
IX. Perinatology Report : Dr. Sary Indriany
X. Intensive Care Unit Report : Dr. Excellena
XI. Public Health Center Report : Dr. Nahrisyah Ulfa Safna
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
2018
I. DUTY REPORT
A. FRIDAY
• Physiologic obstetrical patient : 1 cases
• Pathologic obstetrical patient : 3 cases
• Gynecological patient : 3 case
• Passed Away : 0 case
Total patients : 7 cases
• Obstetric ward patients : 22 patients
• Gynecology and Oncology ward patients : 58 patients
• P1/ HCU/ ICU patient : 1 patients
Total patients : 91 patients
OBSTETRIC PATIENT
No. Identity Diagnosis ICD 10 Procedure
1 Mrs. LIN G3P2A0 32 weeks gestational age not inlabor O14.13 • Stabiliz
39/RA with severe preeclampsia + failed expectant O34.21 • Consult
management + prior CS 1x SLF cephalic and Op
presentation Departm
• LSCS
• Tubal li
2 Mrs. HER G1P0A0 37 weeks gestational age inlabor 1st O14.13 • Stabiliz
28/RA stage latent phase with superimposed E05.90 • Consult
preeclampsia + uncontrolled hyperthyroid and Op
SLF cephalic presentation Departm
• Tubal li
3 Mrs. FIT G2P1A0 34 weeks gestational age in labor 1st O15.2 • Stabiliz
28/UA stage latent phase with eclampsia • Consult
antepartum SLF cephalic presentation Ophtha
Neurolo
Departm
• Vaginal
GYNECOLOGY PATIENT
No. Identity Diagnosis ICD 10 Procedure
3 Mrs. MIM Cervical cancer was suspected stage IIIB + C53.9 • Blood tr
72/UA severe anemia D64.9 • Plan for
• Plan for
• Consult
Departm
• Plan for
confirma
B. SATURDAY
• Physiologic obstetrical patient : 1 case
• Pathologic obstetrical patient : 7 cases
• Gynecological patient : 2 cases
• Passed Away : - cases
Total patients : 10 cases
• Obstetric ward patients : 29 patients
• Gynecology and Oncology ward patients : 53 patients
• P1/ HCU/ ICU patient : 1 patients
Total patients : 83 patients
OBSTETRIC PATIENT
• Vaginal de
3 Mrs.RIS /33 yo/ G3P2A0 34 weeks of gestational age with O34.21 • Conserva
UA threatened preterm labor + prior CS 1x SLF
O60.00 • Lung mat
cephalic presentation
• Tocolytc a
• LSCS
• Forcipal e
P/LSCS
7 Mrs. LEN / 42 yo / G3P2A0 24 weeks of gestational age not in R17 Induction of labo
UA labor with obstructive icteric cb CBD stone +
O36.4 p/ Vaginal delive
cholelithiasis SDF intrauterine
GYNECOLOGY PATIENT
C. Sunday
II. ELECTIVE OPERATION PLANNING
H A H A
- - - - Pap smear
1
- - - 2 P/ radical hyst
- - - 1 cervical biops
Ovarian cancer C56.9 - - 2 3 Chemotherap
2 1 tumor marker
P/ secondary
4 1 tumor marker
H A H A
GTN - - 1 2 hemotherapy
5
2 tumor marker
TOTAL - 4 17
H A H A
- - - - Pap smear
1
- - - 2 P/ radical hyst
- - 1 cervical biops
2 tumor marker
P/ secondary
6. mole confirmation
- -
Laboratory ex
- cervical biopsy
- US abdomen
cervical cancer stage
2 Mrs. NUR/58/RA - BNO IVP
IIIB was suspected
- Ro Thorax
- lab exam
- plan for chemotherapy
Ovarian cancer stage
3 Mrs. REN/42/RA paclittaxel-carboplatin 6th
IC
series
Multiloculare solid
ovarian neoplasm
5 Ms. MUT/14/RA - plan for laparatomy FS
malignancy was
suspected
6 Mrs. ERN/43/RA Cervical cancer stage IIB - plan for radical hysterectomy
- hospitalization
Recapitulation
UROGYNECOLOGY OPERATIVE
Friday, August 31th, 2018
1. 3
TVH + anterior – posterior colporaphy + SSF
Total 3
UROGYNECOLOGY OPERATIVE REPORT
Friday, August 31th, 2018
N81.3
Mrs. SIT Uterine prolapse grade III + Cystocele TVH + anterior
1. N81.10
71/P5A2/UA grade III + Rectocele grade III colphorraphy +
N 81.6
N81.3
Mrs. SIT Uterine prolapse grade III + Cystocele TVH + anterior
2. N81.10
74/P5A0/UA grade III + Rectocele grade III colphorraphy +
N 81.6
N81.3
Mrs. WAR Uterine prolapse grade IV + Cystocele TVH + anterior
3. N81.10
56/P2A2/RA grade III + Rectocele grade III colphorraphy +
N 81.6
C. FER OUTPATIENT REPORT
Recapitulation
Friday, August 31st 2018
1 Endometriosis 2
Total 4
N T
20.08.18 1 5
21.08.18 3 5
22.08.18
23.08.18 2 5
24.08.18 1 3
TOTAL 7 18
Doctor
ICD-
NO Identity in Diagnosis
10
charge
• Dismenorrhea ec
AC-
1 Mrs.JAR/25/UA/P0A0 endometriosis N80.0
SAT
was suspected
• Endometriosis
ASRM grade IV
(score 76 EFI
Score 6) post
Mrs. AC- leuprorelide 3.75 N80.0
2
SUC/32/RA/P1A0 SAT mg 3 N97
course+patent
both tubes +
internal genitalia
adhesion +
secondary
infertile 7 years
• Multiloculare
Mrs. AC-
3 cystic ovarian D27.9
RAT/48/RA/P6A0 SAT
neoplasm
Endometrial
polyp was
Mrs. AC- suspected N84.0
4
MAR/38/UA/P0A0 SAT +primary N97
infertile 12 years
on IVF process
D. FER OPERATIVE REPORT
Day/ Preop
No. Identity Intra op finding
Date Diagnosis
E. FETOMATERNAL I REPORT
Recapitulation
st
Friday, August 31 2018
No. Category Jumlah Pasien
1 Obstetric 3
2 Oncology 2
3 Gynecology -
Total 5
FETOMATERNAL REPORT
(ULTRASOUND DIAGNOSTIC)
st
Friday, August 31 2018
No Identity Diagnosis US exam
Recapitulation
st
Friday, August 31 2018
No. Diagnosis Total P
1 Obstetric inpatient 1
2 Gynecology inpatient 5
Total 6
FETOMATERNAL REPORT
(ULTRASOUND DIAGNOSTIC)
th
Friday, August 24 2018
No Identity Diagnosis US exa
Pathology Patient 3
Total 4
Physiology Pathology
Total 1 12
Resume Fetomaternal Clinic
TOTAL 3 10
1. Mrs. HAR/ 31 y.o/ UA G2P1A0 32 weeks gestational age with prior CS 1x SLF transvers
3. Mrs. DWI/ 35 y.o/ UA G4P1A2 37 weeks gestational age with prior CS 1x ( oi oligohidra
circlage SLF cephalic presentation
4. Mrs. EKA/ 23 y.o/ UA G4P2A1 36 weeks gestational age with MDR TB on therapy SLF
presentation with IUGR was suspected
H. GYNECOLOGY I OUTPATIENT REPORT
No patient to be reported
I. GYNECOLOGY II OUTPATIENT REPORT
No patient to be reported
Lactation-puerperal
O34.21 Counselin
1 Mrs. KIF/36 yo / UA P2A1 post LSCS oi prior CS 1x day 10
V25.11 Educatio
O34.21 Counselin
2 Mrs. DES/36 yo / UA P1A0 post LSCS oi fetal distress day 10
V25.11 Educatio
GYNECOLOGY 0 patient
OBSTETRIC
RECAPITULATION
Friday, 31th August 2018
Pathology patient
GYNECOLOGY
TOTAL PATIENT
Obstetrics
G1P0A0 32
weeks of
gestational
age in labor
1ST stage
Mrs. DEW active phase O34
1 LSCS
/34/UA SLF breech O41
presentation +
umbilical
cord prolapse
+ fetal
distress
OBSTETRICS
Pil -
Condom -
Family Planning D -
Injection
C -
IUD -
GYNAECOLOGY -
N 2
OBSTETRIC
O 1
N -
High Risk Pregnancy
O -
1 Mrs. RIN/ 24yo/RA G2P1A0 28 weeks gestational age not Z34 ANC
inlabor SLF cephalic presentation
3 Mrs. MON/ 25yo/RA G2P1A0 38 weeks gestational age not Z34 ANC
inlabor SLF cephalic presentation
Oncology 1 2 3 2 -
Gynecology 2 2 2 4 -
Urogynecology - - - - -
Obstetric - - - - -
PERINATOLOGY REPORT
August 27th – Sep 2nd 2018
ROOMING-IN : 28 patients
NICU : 2 patient
NEONATE : 3 patient
TOTAL : 33 patients
1 Mrs. FIT/ 28 yo/ UA P2A0 post spontaneous preterm delivery with O15.0
antepartum eclampsia + partial HELLP syndrome O14.2
O60.1
27 August 2018
2 Mrs. 34 20 Ilir, Ilir Timur G3P1A1 33 weeks gestational Z34.0
MAL I age SLF cephalic presentation
28 August 2018 3 Mrs. SIT 31 Jl Ratu Sianum, 3 G4P2A1 36 weeks gestational Z34.0
Ilir age SLF cephalic presentation
4 Mrs. 39 20 Ilir G2P0A1 20 weeks gestational Z34.0
KAR age SLF Intrauterine
29 August 2018
28 August 2018 3 Mrs. SIT 31 Jl Ratu Sianum, 3 G4P2A1 36 weeks gestational Z34.0
Ilir age SLF cephalic presentation
4 Mrs. 39 20 Ilir G2P0A1 20 weeks gestational Z34.0
KAR age SLF Intrauterine
29 August 2018
31 August 2018
27 August 2018
28 August 2018
28 August 2018
3 Mrs. RAT 26 Ilir Timur II G2P1A0 19 weeks gestational age Z3A
SLF Intrauterine
1 Mrs. NIA 28 Ilir Timur II G2P1A0 15 weeks gestational age Z3A
SLF Intrauterine
29 August 2018
2 Mrs. SAF 27 20 Ilir G2P1A0 17 weeks gestational age Z3A
SLF Intrauterine
30 August 2018
2 Mrs. IRM 28 Ilir Timur I G1P0A0 25 weeks gestational Z3A.2
age SLF Intrauterine
1 Mrs. NIA 26 Ilir Timur 3 G1P0A0 35 weeks gestational Z3A.3
age SLF Cephalic Presentation
31 August 2018
FAMILY PLANNING
29
31 August 2018
2 Mrs. MIF 30 Ilir Timur I Depo-Provera Injection