Thursday, April 17 th , 2014 until Wednesday April 23 th , 2014
Gynaecological Inpatient Chief: dr. Adrin M. Harahap : 4 patients dr. Albert L. Tobing : 4 patients dr. Wahyu Pranata : 4 patients dr. Edo Brendo Stevano : 5 patients dr. Syifa Alkaf : 4 patients dr. Bertha Octarina : 5 patients Total patients : 26 patients
dr. Adrin M. Harahap GYNAECOLOGY WARD DAS-SMA-LIN/SUG 1. 17.04.14 Chemoradiation Mrs.PUT/48/P 9 A 0 /RA/LAS 10.18 AM M/ Stage IIIB cervical cancer C53.9
09.30 PM Pregnancy test: (+) Intraoperative consult from Surgery departement: There was 1500 cc blood, liver laceration and rupture of right tube pars ampullaris
D/ Rupture of right tube pars ampullaris
M/ Right salfingectomy Vital sign and bleeding observation Antibiotic inj Transfusion until Hb 8 g/dl Joint care with Surgery Department
24.04.14 Follow up
Hb : 8,4 g/dL Drain : 200 cc Urine : 5 cc/kgBB/hour Sens : CM HR : 98x/mnt BP : 120/80 mmHg T : 36,5 0 C ONCOLOGY WARD LAS-EST 08.04.14 Pathology result : high grade serous papillary carcinoma
3. 23.04.14 Chemotherapy Mrs.SUA/48/P 0 A 0 /RA/EST 09.53 AM D/ Stage IIIC ovarian cancer C56
M/ Chemotherapy Paclitaxel-Carboplatin 3 rd course Pathology result : moderate diffrentiated endometrioid carcinoma at right ovarian
ENDOCRINOLOGY, FERTILITY AND REPRODUCTION
UROGYNECOLOGY WARD
GYNAECOLOGY WARD DAS-SMA-LIN/SUG
1. 21.04.14 Chemoradiation Mrs. ROH/56/P 7 A 0 /RA/EST 11.19 AM D/ Stage IIIB cervical cancer C53.9
31.08.13 Pathology result : Cervical biopsy : poorly differentiated adenosquamous cell carcinoma at serviks 2. 22.04.14 Adjuvant chemotherapy Mrs. MAS/40/P 1 A 0 /RA/LAS 09.51 AM D/ Stage IC ovarian cancer C56
M/ Adjuvant chemotherapy BEP 4 th course
Pathology result : adult granulosa cell tumour at right ovarian - - - - - - dr. Albert L Tobing 1. 21.04.14 Laparoscopy cystectomy Mrs.SIT/21/P 0 A 0 /RA/SUG
08.24 AM D/ Endometriosis cyst
M/ laparoscopy Plan for cystectomy
24.04.14 Intraoperative: - There was cystic white-greyish mass 4 x 3 cm derived from right ovary - There were adhesion of the right adnexa with omentum and colon, and left adnexa with posterior uterine wall - The was Severe adhesion of the posterior uterine wall with Douglas cavity
D/ Left ovarian functional cyst + Internal genital adeshion + Endometriosis ASRM grade I ONCOLOGY WARD LAS-EST
ENDOCRINOLOGY, FERTILITY AND REPRODUCTION
UROGYNECOLOGY WARD
dr. Wahyu Pranata GYNAECOLOGY WARD DAS-SMA-LIN/SUG
ONCOLOGY WARD LAS-EST 1. 21.04.14 Adjuvant Chemotherapy Mrs. MAI/43/P 1 A 0 /RA/EST 11.45 AM D/ Stage IC ovarian cancer C56 M/ Chemotherapy Docetaxel-Carboplatin 2 nd course Pathology result : endometrioid carcinoma at left ovarian
2. 22.04.14 Chemotherapy Mrs. SRI/42/P 1 A 0 /UA/EST 10.00 AM D/ Stage IIIB cervical with inadequate therapy C53.9 M/ Chemotherapy paclitaxel-carboplatin 2 nd course Pathology result : Keratinizing squamous cell carcinoma FNAB : inguinal regio show carcinoma
01.05 PM D/ Cystocele grade II + Rectocele grade II + caruncle of paraurethra
P/ Plan for transvaginal hysterectomy
22.04.14 Intraoperative: - identifying the border of vesica, vagina and servix C/ cystocele grade II and rectocele grade II - Identifying mass at parauretrhra C/ caruncle of paraurethra
Foto D/ cystocele grade II + Rectocele grade II + caruncle of paraurethra 1. 21.04.14 Total abdominal hysterectomy Mrs. ROH/40/P 3 A 1 /RA/SUG
03.34 PM D/ Uterine myoma
US P/ Total abdominal hysterectomy
24.04.14 Intraoperative: - uterine was 20 weeks
Foto D/ Uterine myoma - - - UROGYNECOLOGY WARD dr. Edo Brendo Stevano GYNAECOLOGY WARD DAS-SMA-LIN/SUG
1. 17.04.14 Neo adjuvant chemotherapy Mrs.KAR/46/P 2 A 0 /RA/EST 10.23 AM D/ Stage IIB cervical cancer C53.9
M/ NAC Paclitaxel Carboplatin 2 nd course Pathology result : moderate differentiated non keratinizing squamosa cell carcinoma
P/ Radical hysterectomy
2. 22.04.14 Adjuvant chemotherapy Mrs.PIN/27/P 0 A 0 /RA/EST
D/ Stage IIIC ovarian cancer inadequate treatment C56
M/ Adjuvant chemotherapy Gemcitabin-Oxaliplatin 4 th course day VIII
12.11.06 05.02.14 Pathology Result : Papillary ovarian adenocarcinoma Mixed type cystadenocarcinoma
3. 22.04.14 Chemoradiation Mrs. RUS/49/P 4 A 0 /UA/LAS 1. 19.04.14 Total vaginal hysterectomy + anterior et posterior colporraphy Mrs. MAH/62/P 7 A 0 /RA/WRA
08.00 AM D/ Cystocele grade II + Rectocele grade III + uterine prolaps grade II
M/ Total vaginal hysterectomy + anterior et posterior colporraphy 1. 23.04.14
Curettage oi. incomplete abortion Mrs.ELI/27/P 2 A 0 /UA/DAS
01.38 AM D/ Incomplete abortion (O03.4)
M/ Curettage (68.1)
Blood and tissue 40 cc
2. 23.04.14 Plan for laparotomy Mrs.RIS/26/P 2 A 0 /RA/SUG
09.35 AM CEA : 0,85 ng/mL Ca 125 :29,21 RI : 0,19 PI : 0,378 RMI 3 : 29,21 D/ Cyst ovarian neoplasm with solid part malignancy was suspected
US P/ laparotomy + FS ONCOLOGY WARD LAS-EST 10.08 AM D/ Stage IIIB cervical cancer C53.9
dr. Syifa Alkaf GYNAECOLOGY WARD DAS-SMA-LIN/SUG 1. 19.04.14 Laparotomy Mrs. MAR/29/P 1 A 0 /RA/SUG 08.22 AM US D/ Cyst ovarian neoplasm malignancy was suspected 21.04.14 Laparotomy Intraoperative : there was greyish white mass sized 20x15x5 cm derived from retroperitoneal cavity Mass biopsion from digestive subdivision D/ Retroperitoneal mass P/ Refer to surgery Department
ENDOCRINOLOGY, FERTILITY AND REPRODUCTION UROGYNECOLOGY WARD
Passed Away - - - - - - 1. 15.04.2014 General condition improvement Mrs. RIK/34/P 1 A 0 /RA/EST-DEN 04.00 PM D/ Cervical cancer stage III B was suspected + severe anemia + CKD stage V DD/ AKI stage III + dyspnue Hb: 3,3 g% Ureum 87 Creatinin 13,85 M/ IVFD RL gtt x/m O2 5 l/m Blood transfusion Transamin inj. 3x1 amp iv Ceftriaxone injection 2x1 g IV P/ Biopsi Clinical staging Abdominal CT scan BNO-IVP Abdominal US 15.04.2014 Consult to Internal Department: C/ - CKD stage V cb. Uropathy obstructive cb. Cervical cancer stage III B was suspected. DD/ AKI stage III cb. Uropathy obstructive cb. Cervical cancer stage III B was suspected. CKD stage V cb. Uropathy obstructive cb. Cervical cancer stage III B was suspected. - Hypertention stage II - Chronic anemia Advice: Clonidin 3x0,15 mg tab Folic acid 3x400 mg tab Plan for hemodialysis Join care with Renal and Hypertensive Subdivision Department Laboratory examination 18.04.2014 D/ Cervical cancer stage III B was suspected + severe anemia + CKD stage V + moderate anemia + dyspnue Hb: 7,7 g% M/ IVFD RL gtt x/m
Control List Date Vital Sign April,21, 2014 Sens BP Pulse
RR T 07.00 AM Somnolen 80/50 130 28 36,5 Urine : 0 cc 07.15 AM Somnolen 80/50 115 28 36,5 07.30 AM Somnolen 80/50 115 28 36,5 Consult to Oncology ward supervisor, dr. Irawan S, SpOG(K): Advice: Informed consent Ureum 112 Creatinin 17,64 O2 5 lpm Blood transfusion Transamin inj. 3x1 amp iv Ceftriaxone inj. 2x1 gr iv P/ Hemodialysis 19.04.2014 D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage V + mild anemia + dyspnue + post hemodialysis + hyperkalemia Hb: 9,2 g% Ureum 84 Creatinin 14,04 Na : 142 K : 6,9 M/ Ca Gluconas inj 1 amp iv P/ consult to urology surgery division
20.04.2014 D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage V + mild anemia + dyspnue + hyperkalemia Ureum 103 Creatinin 16,63 Consult to Urology department -> not yet assesed P/ Nefrostomy 21.04.2014 03.00 AM D/ Cervical cancer stage III B was suspected + mild anemia + CKD stage V + dyspnue + decrease of consciousness Sens: somnolens RR: 46x/m M/ Close observation IVFD RL gtt x/m O2 10 l/m Intubated at oncology ward Consult to ICU -> ICU was full 07.20 AM
Consult to Oncology ward supervisor, dr. Irawan S, SpOG(K): Advice: Informed consent Consult to ICU Referral reply from ICU: ICU was full 02.00 PM Consult to consultant on duty, Prof. dr. Syakroni Daud R, SpOG(K): Advice: Informed consent 03.20 PM Patient became apneu DNR 03.30 PM Patient was passed away in front of doctor and midwife 07.45 AM Somnolen 80/50 115 28 36,5 08.00 AM Somnolen 80/50 114 28 36,5 08.15 AM Somnolen 80/50 116 28 36,5 09.00 AM Somnolen 80/50 112 28 36,5 09.30 AM Somnolen 80/50 114 28 36,5 10.00 AM Somnolen 80/50 115 28 36,5 10.30 AM Somnolen 80/50 116 28 36,5 11.00 AM Somnolen 80/50 110 28 36,5 11.30 AM Somnolen 80/40 113 24 36,5 00.00 PM Somnolen 80/40 74 24 36,5 00.30 PM Somnolen 80/40 75 24 36,5 01.00 PM Somnolen 80/40 75 24 36,5 01.30 PM Somnolen 80/40 70 24 36,5 02.00 PM Somnolen 80/40 70 24 36,5 02.15 PM Sopor coma 50/palpable 64 16 36,5 02.30 PM Sopor coma 50/palpable 62 16 36,5 02.45 PM Sopor coma 50/palpable 70 10 36,5 03.00 PM Sopor coma 50/palpable Not palpable 10 36,5 Dobutamin drips 1 amp in 100 ml NS gtt x/mnt 03.15 PM Sopor coma 50/palpable Not palpable 10 36,5
03.20 PM coma Not measured Not palpable apneu 36,5 CPR, Bagging 03.30 PM Patient was passed away in front of doctor and midwife