PRE-OPERATIVE PLANNING RESUME

TUESDAY, 15TH SEPTEMBER 2020

COT I
Identity
Identity Name
Name Linda
Ida
NopiWati
Hardiyani
Marlina
Med
Med Rec/
Rec/Reg
Reg 830228
1163143
1178336
Age
Age 28.12.1976
09.07.1964
10.11.1997( (35
37
23yo)
yo)
Address
Address Sukarami,
Ogan Komering
Seberang Palembang
Ulu II,IlirPalembang
Operator
Operator Dr.
DR.H.Dr.
Irawan Sastradinata,
H. Kms.
Ferry Yusuf
Yusrizal,OB/GYN
Effendy,
OB/GYN ( C),
OB/GYN MARS,
(C), ( C)SH
M.Kes
Anamnesis
Anamnesis
Chieft complaint
Chief complain Abdominal mass
Full term pregnancy
Menstrual pain with prior CS 1x.
History
History
Patient
On 112thcame
Since forbefore
years re-consult
September 2020, forpatient
surgery
admission, patient
complained
complained
has abdominal
had menstrual
contraction
pain, specially
radiates on
to
1st – irregular
waist 2nd day of sincecycle,
10 hours
and disturbed
before admission.
activity, But withright
VAS now, Score
patient
4-5.didn’t
History
felt of
it
Patient admitted has abdominal mass since 2 years ago. History of abdominal pain (+)
anymore.
dyspereunia History
(-), history
of bloody
of dyscezia
show (-), (-),history
historyofofamniotic
vaginal bleeding
intermitten, history of vaginal bleeding (+) blood spotting, but rarely. History of
fluid leakage
(-). (-). History of
trauma (-), history of abdominal massage (-), history of leucorrhea
dysmenorrhea (-), history of loss of apatite (-), history of weight loss (-). Patient (+), white color,
admitted has
smell
Patient (+),
hasitchy
underwent
(+). History
normal micturition and defecation surgery
of consume
at Moh. traditional
Hoesin medicine
Hopsital (-)
in 2014, on indication
endometriosis
Past operation & cyst,
Pastbut PA result hasPatient
Illness gone.has Patient went to Hermina
been diagnosed with uterine Hospital,
myoma and
Patient admitted
diagnosed with endometriosis
has full term pregnancy
cyst. Patient with
since referred
fetalago,
2 years movement
to Moh. Hoesin
and advicestillfor
can
Hospital
be felt patient
surgery
Past operation & Past Illness Patient routinely done antenatal care with
refused
On 08th September 2020, patient underwent
Marrital midwife
Haven’t laboratory
marriage yet examination Hh result Hb 5,9
g/dL.
Marrital
ObstetricPatient than admitted and has gotP0A0 3 colf of
Married 1xPRCfor 5Transfusion.
years
Past operation
Obstetric
Menstrual & Past Illness History
1. 2016, at
Menarche of surgery
male, on
3700
13 years 2014,
old,gram, PAcsfor
regular, result
on has LMP
gone :
indication
7 days,
Marrital Married
03 rd 2x
hydrocephalus,
July 2020 AK Gani, healthy
Economic and nutrition status 1. 10 years
Moderate
2. Current pregnancy
Physical
Menstrual examination 2. 10 at
Menarhce years
13 years old, regular, for 5-7 days,
General
Obstetric condition Good P0A0 RR th
LMP : 26 July 2019 20 x/m
Sens
Menstrual
Economic and nutrition CM status Menarche
Moderate Pulseat 13 years old, regular, 80 x/mfor 7 days,
BP
Physical examination 120/80 mmHg Temperature
th
LMP : 15 August 2020 36,2oC
Weight
Economic and nutrition 60 kgstatus Height 155 cm
General condition Good RR 20 x/m
Obstetrical examination ( 21.02.2020)
Physical
Sens examinationCM Pulse 80 x/m
Abdomen
General
BP condition
Flat abdomen, Good
120/80 mmHg
supple, tenderness (-), uterine fundalRR height in umbilical, 20
Temperature x/m
36,2
mass
o
C
hard to assess,
Sens
Weight
free fluid sign (-) CM
57 kg Pulse
Height 80 x/m
155 cm
BP
Gynecology examination 120/80 mmHg Temperature 36,2oC
Weight
Abdomenexamination50
Speculum andkgvaginal toucher : Height not performed 156 cm
Rectal
Gynecologytoucher
Uterine fundal examination
height in 4 fingers below xyphoid process ( 24 cm), longitudinal lie,
Good tonesspine,
right fetal
Abdomen of sphincter
cephalic,ani,Usmooth mucous, intraluminal
5/5 contraction mass (-), lower
(-), FHR 148x/minute, EFWpart2480
of mass
gram was
palpable in anterior rectum
Flat abdomen, supple, symmetrical, tenderness (-), uterine fundal height in 2 fingers
US Examination
Genitalia
below umbilical,(mass 21.02.2020)
(-), free fluid sign (-)
Dr. Abarham Martadiansyah, OB/GYN ( C)
Vaginal toucher
Soft- portio,
Genitalia posterior,
Anteflexed effacement
uterine, 0%,shape
with larger dilatation
and isze0 cm, amniotic cm,
23,08x11,17 and endometrial
denominator can’t
line (+)
be assess
Speculum yet
examination
3,86 cm
Unlivide portio,
US -Examination
Portio andclosed OUE,influor
( 11.09.2020
endocervix ) (-),limit
normal fluxus (-), E/L/P (-)
Vaginal toucher
Dr. -H. Abarham
There Martadiansyah,
is multiple hypoechoic OB/GYN
mass, well( C),defined
MARSborder, with feeding artery (+), in
Firmed posterior
portio, closed
corpus OUE, CUT
of uterine size~9,41x7,58x8,61
12 weeks, both cm;AP was supple,
in anterior corpusdouglas pouch
of uterine size
- Single
1,18x1,19
didn’t bulging lifecmfetus
and cephalic
1,77x1,22 presentation
cm ~ multiple intramural uterine myoma
US -Examination
Both
Fetalovaries
biometric hard to evaluate
(08.09.2020)
C/
Dr.intramural
-H. Abarham
Amniotic uterine
fluid myoma
sufficient, AFI
Martadiansyah, 15,15 cm( C)
OB/GYN
- Placenta
- Anteflexed in posterior
uterine, corpussize
with enlarged of uterine
16z10x10,26 cm
- Non - homogenous
LUS thickness 0,13 cm Regular basalis stratum, endometrial line (+) 11,20
myometrium
mm- Cervical length 3,07 cm
-C/
In 36 weeksand
anterior gestational
posteriorage, Single
corpus, lifewas
there fetus cephalic presentation
hyperechoic mass with well defined
LUS Thickness 0,13 cm
border size 8,94x14,38 cm ~ uterine adenomyosis diffuse type
- Both ovaries hard to evaluate
-
C/
Uterine adenomyosis diffuse type
Both ovaries hard to evaluate
Identity Name Kurnia Valentine
Med Rec/ Reg 1181735
Age 43 years old
Address Palembang
Operator Dr. H. Rizal Sanif, OB/GYN (C), MARS, PhD
Anamnesis
Chief complain Menstrual pain
History (31.08.2020)
Since 6 month before admission, patient complained menstrual pain, VAS 3,
disturbing her daily activity, 3 days before menstruation until 3 days after
menstruation, pain get better when patient consume some analgetic.

Patient came to OBGYN and diagnosed with endometriosis cyst and referred to FER
endocrinology clinic

History of abdominal mass (-), history of vaginal bleeding (-), history of dyspereunia
(+), history of leucorrhea (+). Patient admitted has normal micturition and defecation.
History of loss of appetite (-), history of weight loss (-).
Past operation & Past Illness (-)
Marrital Married 1x for 20 years
Obstetric P3A1 ( LSCS on 2002)
Menstrual Menarche at 13 years old, regular menstruation,
cycle of 28 days, for 6 days, LMP : 23rd August
2020
Economic and nutrition status Moderate
Physical examination
General condition Good RR 20 x/m
Sens CM Pulse 80 x/m
BP 120/80 mmHg Temperature 36,2oC
Weight 66 kg Height 158 cm
Gynecology examination
Abdomen
Flat abdomen, supple, symmetrical, uterine fundal height not palpable, cystic mass
palpable at left lower abdominal size 9x6 cm, left border: left anterior axilla line, right
border: right midclavicularis line, upper border: 3 fingers below umbilicus, free fluid
sign (-), tenderness (-)

Genitalia
Speculum examination
Unlivide portio, closed OUE, fluor (-), fluxus (-), E/L/P (-)
Vaginal toucher
Firmed portio, closed OUE, CUT ~ , left AP tenderness palpable cystic mass 9x6 cm,
right AP tense, douglas pouch not bulging
US Examination ( 31.08.2020)
Dr. H. Abarham Martadiansyah, OB/GYN ( C)
- Anteflexed uterine, shape globular and size enlarged 9.36 x 5.42 cm
- Non homogenous myometrium, regularly stratum basalis, endometrial line 6.50
mm, there in situ IUD
- There was hyperechoic mass with undefined borders with scattered
vaskularization at posterior corpus size 2.96 x 1.78 cm ~ posterior uterine
adenomyosis
- There was a cystic mass with echointerna inside from left ovary size 8.80 x
7.66 cm and right ovary size 4.10 x 3.78 cm ~ bilateral endometriosis cyst was
suspected
Identity Name Sherly Zurnia
Med Rec/ Reg 1181921
Age 42 yo
Address Palembang
Operator Dr. H. A. Abadi, OB/GYN ( C) COT
Dr. H. Patiyus Agustiansyah, OB/GYN ( C), MARS II
Anamnesis
Chief complain Menstrual pain
History
Patient came to endocrinology reproductive outpatient, complained about menstrual pain
since 2 months ago. History of abnormal bleeding from vagina (-), dyschezia (-), dyspareunia
(+), dysuria (-), irregular menstruation (-), leuchorrhea (+), post coital bleeding (-), abdominal
enlargement (-), weight loss (-), loss appetite (-), defecation and urination normal.

Patient was check up her complain to OBGYN in AK Ghani Hospital, and was diagnosed
with endometriosis cyst, then patient referred to RSMH.
Past operation & Past Illness (-)
Marrital Menarche at 12 y.o. regular menstrual, 28 days of
cycle, last 5-7 days, LMP: 02-08-2020
Obstetric P2A0
Menstrual Married 1x for 15 years
Economic and nutrition status Moderate
Physical examination
General condition Good RR 20 x/m
Sens CM Pulse 80 x/m
BP 120/80 mmHg Temperature 36,2oC
Weight 55 kg Height 165 cm
Gynecology examination
Abdomen
Flat abdomen , supple, sym metrical, uterine fundal not palpable, tenderness (-), free fluid sig
n (-), mass (-)

Genitalia
Speculum examination
Non-livide portio, closed OUE, fluor (-), fluxus (-), Erotion (+), Laceration (-), Polyp (-)
Vaginal toucher
Firmed portio, closed OUE, CUT ~ normal, both of AP supple, douglas pouch not bulging.

US Examination 01.09.20
Dr. Awan Nurtjahyo, OBGYN (C)
- Uterine corpus size 7 x 6,3 cm, asymmetrical anteroposterior uterine wall
- There is hyperechoic mass with undefined border on posterior corpus
- there is multiloculare mass with echointerna, size 7,31 x 5,68 from left ovary,
vascularization (-), sliding sign (-) ~ endometriosis cyst
- there is multiloculare mass with echointerna, size 6,13 x 6,76 from lright ovary,
vascularization (-), sliding sign (-) ~ endometriosis cyst
- kissing ovary (-)
- there is rectovaginal nodule, size 2,3 cm
- there is internal genitalia adhesion on proximal uterine corpus extends to distal uterine
corpus

C/
- Bilateral endometriosis cyst
- Uterine adenomyosis
- Internal genitalia adhesion (DIE was suspected)