GYNECOLOGY WARD REPORT

Thursday, August 10th 2017

Residents:
1. dr. Rina Sinta Danu
2. dr. Novi Rindi
3. dr. Ormias Pratama
4. dr. Alfiani Sari R. Cy

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Haji Adam Malik General Hospital
2017
Ward Patients : 4 patients
1. Mrs. T, 36 yo, P1A0
Diagnosis : post cystectomy d/t Endometriosis cysts + D2 + post laparotomy d/t
appendicitis

Supervisor : dr. Indra Z Hasibuan, M.Ked(OG), Sp.OG

Resident :

Planning : NGT removal, Mobilization

2. Mrs. N,47 yo, P11A2

Diagnosis : Susp. Ca cervix + decrease of conciousness d/t urosepsis DD: PSMBA d/t
stress ulcer + CKD stg V + Bilateral Hydronefrosis

Supervisor : dr. Indra Z Hasibuan, M.Ked(OG), Sp.OG

Resident :

Planning : Continuous therapy

3. Mrs. S, 34 yo, P2A0

Diagnosis : Post TAH + SOS d/t Intramural Uterin Fibroid + D-1

Supervisor : dr. T. M. Ichsan, Sp.OG

Resident : dr. Widya

Planning : Continuous therapy, Mobilization

Patient 1
Follow up Monday , August 14th 2017
Cons : Alert Anemic : (-)
BP : 120/70 mmHg Icteric : (-)
HR : 104 x/min Cyanosis : (-)
RR : 28 x/i Dyspnoe : (-)
Temp : 37,3 OC Edema : (-)
Localise state:
Abdomen : Sopel, Normo peristaltic
Vaginal Bleeding : (-)
W/O : covered by gauzed, dry
Micturition : (+) via catheter UOP 60 cc/hour, clear, yellow-ish
Defecation : (-) flatus (+)
Diagnose : post cystectomy d/t Endometriosis cysts + D1 + post laparotomy d/t appendicitis
Planning : mobilization, NGT removal
Therapy : IVFD RL 20 dpm
Inj. Ceftriaxone 1gr/12 hr/IV
Drip Metronidazole 500 mg/8 hr/IV
Inj. Ketorolac 30mg/8hr/IV
Inj. Ranitidine 50 mg/12 hr/IV
Inj. Transamin 500 mg/ 8 hr/IV
Mrs. T, 36 yo, P1A0, Married 1 times at 29 yo, Moslem, Javanese,
Senior High School, Housewife, married to Mr. D, 37 yo, Moslem,
Javanese, Senior High School, Enterpreneur.

CC : Lower abdominal pain

This has been experienced since 3 months ago and worsened
since 1 week. History of vaginal bleeding (-), history of palpable
mass (-). History of nausea (-), vomiting (+) 1 time. History of
fever (+) since 1 week, history of abdominal massage (+), History
of leukorhea (+), History of post coital bleeding (-), history of
trauma (-), History of losing weight (-), History of losing appetite
(-), Micturition and defecation no abnormality.
Previous illness :-
Previous medical :-
Contraception history : Injection contraception 3
years ago.

Menstruation history: Menarche 12 y.o, duration

about 3-4 days, underpad changing around 2-3
times/day, 28 days cycle, regularly, LMP:
5/8/2017, dismenorrhea: (-)
Present State
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 82 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,8 OC Edema : (-)

Localized St :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)

Neck : No abnormalities

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Abdominal : Laxed, normo peristaltic

Vaginal bleeding : (-)

Pregnancy test : (+)

Ginecology state :
Inspeculo : not performed

Vaginal toucher :
Uterus anteflexi, adnexa left and right no abnormality, Cavum
Douglas not protruded.

Conclusion : Gynecology without abnormality

USG TAS
 USG TAS
Bladder filled
UT bigger than normosize
Both adnexa in normal limit
Free fluid (-)

Conclusion : gynecology without abnormality

 LABORATORY FINDINGS on August 12rd 2017 :

Hb : 13,1 N: 12-14 gr/dl

Leukocyte : 18.650 N:4000-11000/mm3
Hematocrit : 39,7 N: 36,0-42,0/%
Platelet : 347.000 N:150000-400000/mm3
Ad random Glucose : 102 N : 70-105 mg/dL
Albumin : 3,80 N : 3,60-5,00 g/dL
Ureum : 20 N : > 50 mg/dl
Creatinin : 0.67 N : 0,6-1,2 mg/dl
Natrium : 142 N :135-155
Kalium : 3,20 N : 3.6-5.5
Cloride : 103 N : 96-106
 LABORATORY FINDINGS on August 13rd 2017 :

Hb : 14,0 N: 12-14 gr/dl

Leukocyte : 25.980 N:4000-11000/mm3
Hematocrit : 42,2 N: 36,0-42,0/%
Platelet : 362.000 N:150000-400000/mm3
Diagnosis:

Plan :
Patient 2
Follow up Monday , August 14th 2017
Cons : apatis Anemic : (-)
BP : 100/70 mmHg Icteric : (-)
HR : 92 x/min Cyanosis : (-)
RR : 16 x/i Dyspnoe : (-)
Temp : 37,8 OC Edema : (-)

Diagnose : Susp. Ca cervix + decrease of conciousness d/t urosepsis DD: PSMBA d/t stress ulcer +
CKD stg V + Bilateral Hydronefrosis
Planning : continous therapy
Therapy : therapy based on Internal Department
 LABORATORY FINDINGS on August 2th 2017 :

Hb : 5,1 N: 12-14 gr/dl

Leukocyte : 18.280 N:4000-11000/mm3
Hematocrit : 15,2 N: 36,0-42,0/%
Platelet : 431.000 N:150000-400000/mm3
Natrium : 144 N :135-155
Kalium : 9,10 N : 3.6-5.5
Cloride : 113 N : 96-106
HbsAg : non reactive N : non reactive
 LABORATORY FINDINGS on August 4th 2017 :

Hb : 9,1 N: 12-14 gr/dl

Leukocyte : 16.550 N:4000-11000/mm3
Hematocrit : 27,7 N: 36,0-42,0/%
Platelet : 426.000 N:150000-400000/mm3
Ureum : 138 N : > 50 mg/dl
Creatinin : 10,91 N : 0,6-1,2 mg/dl
Natrium : 147 N :135-155
Kalium : 6,50 N : 3.6-5.5
Cloride : 113 N : 96-106
 LABORATORY FINDINGS on August 6th 2017 :

Hb : 10,3 N: 12-14 gr/dl

Leukocyte : 15.910 N:4000-11000/mm3
Hematocrit : 30,6 N: 36,0-42,0/%
Platelet : 465.000 N:150000-400000/mm3
Ad random Glucose : 97 N : 70-105 mg/dL
Albumin : 3,80 N : 3,60-5,00 g/dL
Ureum : 114 N : > 50 mg/dl
Creatinin : 7,42 N : 0,6-1,2 mg/dl
 LABORATORY FINDINGS on August 7th 2017 :

Hb : 10,0 N: 12-14 gr/dl

Leukocyte : 15.720 N:4000-11000/mm3
Hematocrit : 30,3 N: 36,0-42,0/%
Platelet : 399.000 N:150000-400000/mm3
Ad random Glucose : 98 N : 70-105 mg/dL
Ureum : 51 N : > 50 mg/dl
Creatinin : 3,66 N : 0,6-1,2 mg/dl
Natrium : 146 N :135-155
Kalium : 3,90 N : 3.6-5.5
Cloride : 106 N : 96-106
 LABORATORY FINDINGS on August 9th 2017 :

Ad random Glucose : 94 N : 70-105 mg/dL

Ureum : 106,00 N : > 50 mg/dl
Creatinin : 7,09 N : 0,6-1,2 mg/dl
Natrium : 150 N :135-155
Kalium : 4,50 N : 3.6-5.5
Cloride : 112 N : 96-106
 LABORATORY FINDINGS on August 10th 2017 :

Hb : 10,5 N: 12-14 gr/dl

Leukocyte : 15.580 N:4000-11000/mm3
Hematocrit : 33,6 N: 36,0-42,0/%
Platelet : 386.000 N:150000-400000/mm3
Ad random Glucose : 97 N : 70-105 mg/dL
Albumin : 3,80 N : 3,60-5,00 g/dL
Ureum : 114 N : > 50 mg/dl
Creatinin : 7,42 N : 0,6-1,2 mg/dl
 LABORATORY FINDINGS on August 12th 2017 :

Ureum : 98,06 N : > 50 mg/dl

Creatinin : 6,43 N : 0,6-1,2 mg/dl
Mrs. S, 55 yo, P5A1, Married 1 times at 25 yo, Moslem, Javanese,
Primary School, Housewife, married to Mr. J, 58 yo, Moslem,
Javanese, Senior High School, Enterpreneur.

CC : Vagina bleeding
This has been experience since 1 week ago, frequency of
underpad changing 1X, reddish black colour, lumps, and
worsened since 1 day with underpad changing 3x. History
of abdominal pain (+), history of abdominal mass (-), History
of prolonged menstruation cycle (-). History of abnormal
bleeding out of menstrual cycle (-). History consumption of
herbal remedies (+). History of abdominal massage (-).
History of trauma (-). History of post coital bleeding (+).
History of pain when coitus (-). History of dysmenorhea (-).
History of vaginal discharge (-). Micturation and defecation
no abnormality. History of loss of appetite (-). History of loss
of body weight (+), 7 kg in 6 months.
Previous illness :-
Previous medical :-
Contraception history : Injection contraception

Menstruation history: Menarche 15 y.o, duration

about 5-7 days, underpad changing around 3-4
t i m e s / d a y, 2 8 d a y s c y c l e , r e g u l a r l y,
dismenorrhea: (-), menopause since 1 year ago
Present State
Cons : Alert Anemic : (+)
BP : 160/80 mmHg Icteric : (-)
HR : 98 x/min Cyanosis : (-)
RR : 24 x/i Dyspnoe : (-)
Temp : 36,8 OC Edema : (-)

Localized St :
Head : Conj Palpebra inferior pale (+)/(+), icteric (-)/(-)

Neck : No abnormalities

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Abdominal : Laxed, normo peristaltic

Vaginal bleeding : (+)

micturition / defecation : (+) / (+) normal

Ginecology state :
Inspeculo : Seen bloody exophytic mass , fulfilling 2/3 proximal
vagina

Vaginal toucher :
Seen bloody exophytic mass , fulfilling 2/3 proximal vagina
Vagina : Both of adnexa theres no palpable mass
left parametrium is palpable tenss, right parametrium laxed
USG TAS
USG TAS
 LABORATORY FINDINGS on July 30th 2017 :

Hb : 7,3 N: 12-14 gr/dl

Leukocyte : 13.640 N:4000-11000/mm3
Hematocrit : 22,3 N: 36,0-42,0/%
Platelet : 504.000 N:150000-400000/mm3
Ureum : 154 N : > 50 mg/dl
Creatinin : 10,95 N : 0,6-1,2 mg/dl
Natrium : 145 N :135-155
Kalium : 8,30 N : 3.6-5.5
Cloride : 115 N : 96-106
Diagnosis:
Susp. Ca cervix + Anemia + CKD stage I + Hypertension stage I

Plan :
-Hospitalization
Patient 3
Mrs. V, 41 yo, P1A2, Married 1 times at 17 yo, Youngest child 29 yo,
Moeslem, Karonese, Junior High School, Housewife, married to Mr.
Y (Alm), was referred from Gynecology Outpatient Clinic H. Adam
Malik General Hospital at July 25th 2017 with:

CC : Abdominal Enlargement
This has been experienced since 6 months ago. Times to
times getting bigger. History of abdominal pain (+) since 2 months.
History of menstrual expanding (-).History of vaginal bleeding
outside the menstrual cycle (-). History of leukorhea (-), history of
abdominal massage (-). Hisotry of decreased appetide (-). History
of losing weight (-). Micturition and defecation no abnormality.
Previous illness : Hypertension
Previous medical : Amlodipine
Contraception history : -

Menstruation history: Menarche 13 y.o, duration

about 4-5 days, underpad changing around 2-3
times/day, 28 days cycle, regularly
Present State
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 80 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,6 OC Edema : (-)

Localized St :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)

Neck : No abnormalities

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Abdominal : normo peristaltic, palpable solid mass at 3 finger below processuss
xipoideus, with lower pole at symphisis, immobile, smooth surface : mass
origin difficult to identified, tenderness (-)
Vaginal bleeding : (-)
Ginecology state :
Inspeculo : Portio is pushed to the sacral, looks mass out of
OUE of marbles, blood (-), F/A (-)

Vaginal toucher : UT difficult to identified

Palpable solid mass, immobile, smooth surface :
mass origin difficult to identified
Douglas cavity not protruded
Looks mass out of OUE of marbles Cervical
polyps
 LABORATORY FINDINGS on July 28 th 2017 :
Hb : 9,50 N: 12-14 gr/dl
Leukocyte : 6.790 N:4000-11000/mm3
Hematocrit : 29,90 N: 36,0-42,0/%
Platelet : 294,000 N:150000-400000/mm3
Post Prandial Glucose : 126 N : 76-140 mg/dL
Ureum : 18 N : > 50 mg/dl
Creatinin : 0,71 N : 0,6-1,2 mg/dl
Natrium : 127 N :135-155
Kalium : 3,30 N : 3.6-5.5
Cloride : 126 N : 96-106
PT : 13,4 C: 14.1 s
APTT : 30,4 C : 31,0
INR : 1,09 C : 1-1,3
SGOT : 17 N : 5 - 34 U/L
SGPT : 15 N :0 55 U/L
Albumin : 3.9 N : 3.5 5 g/dL
Ca 125 : >1000 N : < 35 U/mL
HbsAg : non reactive
Diagnosis:
Adnexa solid tumor DD : Intraabdominal tumor + Hypertension +
susp. Cervical polyp

Plan :
USG gynecology confirmation
Patient 4
Mrs. R, 62 yo, P6A0, Moeslem, Primary School, Farmer, married to
Mr. B, 65 yo, Primary School, Farmer

CC : Abdominal Enlargement
This has been experienced since 2 years ago. Times to times
getting bigger. History of abdominal pain (-). History of vaginal
bleeding (+), History of leukorhea (-), history of abdominal
massage (+), History consumption of herbal remedies (+), History
of losing weight (+), History of decreased appetide (-). This
patient came to Internal departement before, with no
abnormality.
Previous illness : Hypertension
Previous medical :-
Contraception history : implants

Menstruation history: Menarche 13 y.o, underpad

changing around 1-2 times/day, regularly,
dismenorrhea: (-), menopause since >5 year ago
Present State
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 80 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,6 OC Edema : (-)

Localized St :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)

Neck : No abnormalities

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Abdominal : distension (+), palpable solid mass, immobile, smooth surface, with
upper pole at processuss xipoideus, lower pole at symphisis, tenderness
(-), shifting dullness (-)
Vaginal bleeding : (+)
Ginecology state :
Inspeculo : Portio difficult to identified, pushed by mass to
anterior, looks blood in vaginal introitus, cleaned
not flow, F/A (-)

Vaginal toucher : portion is smooth to anterior, UT difficult to

identified, Palpable solid mass as big as aterm
pregnancy, immobile, smooth surface: mass origin
difficult to identified, both adnexa difficult to
identified, both parametrium are flexible, Douglas
cavity not protruded
 LABORATORY FINDINGS on July 21st 2017 :
Hb : 12,1 N: 12-14 gr/dl
Leukocyte : 10.330 N:4000-11000/mm3
Hematocrit : 26,10 N: 36,0-42,0/%
Platelet : 364,000 N:150000-400000/mm3
Post Prandial Glucose : 144 N : 76-140 mg/dL
Ureum : 29,54 N : > 50 mg/dl
Creatinin : 0,94 N : 0,6-1,2 mg/dl

CA-125 : 48,61 N : 0-35 U/ml

 LABORATORY FINDINGS on July 31st 2017 :

Natrium : 146 N :135-155

Kalium : 4,70 N : 3.6-5.5
Cloride : 107 N : 96-106
 LABORATORY FINDINGS on August 14th 2017 :
Hb : 11,5 N: 12-14 gr/dl
Leukocyte : 7.240 N:4000-11000/mm3
Hematocrit : 34,60 N: 36,0-42,0/%
Platelet : 241,000 N:150000-400000/mm3
Glucose ad random : 90 N : 76-140 mg/dL
Ureum : 19 N : > 50 mg/dl
Creatinin : 0,32 N : 0,6-1,2 mg/dl
Natrium : 144 N :135-155
Kalium : 3,20 N : 3.6-5.5
Cloride : 110 N : 96-106
USG TAS
USG TAS
Diagnosis:
Adnexa tumor permagna DD : Intraabdominal tumor

Plan :