III.

GYNECOLOGYCAL INPATIENT REPORT

Thursday, June 16th, 2016 until Wednesday, June 22th, 2016
TOTAL PATIENT IN WARD
Ward
Patients
New Patient
Old Patient
1stEnim
6
2
nd
2 Enim
12
Mawar
4
9
Lematang
2
1
Musi Elok
4
1
Ogan
6
3
Yasmin C
2
1
Kenanga A
-

Total

TOTAL PATIENT BY SUBDIVISON

Patients
Gynecology
Oncology
Endocrinology
Urogynecology

New Patient
6
2
1

Gynecological Inpatient Chief

Dr. Rakmat Akbar
Dr. Jhon Heriansyah
Dr. Darlin Forbes
Total patients

Total
Old Patient
9
-

: patients
: patients
: Patients
: patients

NO
1.
2.

Patients ID
Ms. TUT/56/UA/P2A0
Mrs. ATK/29/RA/P0A1

3.

Mrs. HEN/50/RA/P2A1

4.

Mrs. HAY/66/UA/P3A0

5.

Mrs. NUR/53/RA/P2A1

Diagnosis
Residive Ovarian Cancer
Stage I Malignant
Trofoblastic Tumor
Stage II B Cervical Cancer +
Post Radical Hysterectomy
Stage III B Cervical Cancer
Inadequate therapy
Intramural Uterus Myoma

6.

Mrs. LIS/54/UA/P4A0

Stage III B Cervical Cancer

7.

Mrs. FAT/53/UA/P2A2

Stages III C Ovarian Cancer

8.

Mrs. MAR/46/RA/P6A0

Stage III C Cervical Cancer

Management
Chemotherapy
Chemotherapy

Physician
NSR
FOR

Chemotherapy

FOR

Chemotherapy

JHN

Total hysterectomy of
intramral uterus myoma
Chemotherapy Paclitaxel
Carboplatin 3rd course
Plan for laparoscopy
second loop
Plan for radical

GIN
NSR
NSR
NSR

9.
10.
11.
12.
13.
14.

Mrs. SAR/56/UA/P3A1
Mrs. ALM/54/RA/P2A0
Mrs. MIS/55/RA/P2A0
Mrs. HAS/26/P3A1/UA
Mrs. MUR/54/P3A0/UA
Mrs. LIS/23/G1P0A0/RA

15.

Mrs. SIT/53/P0A0/UA

16.
17.
18.

Mrs. JEN/34/P2A0/RA
Mrs. KAR/63/ P4A0/RA
Mrs.FRI/55/P3A1/UA

19.
20.
21.
22.
23.
24.

Mrs. SUS/28 /P1A0/RA

1.

17.06.16

(post chemotherapy 3rd

course)
Residive Cervical Cancer
Stage II C Cervical Cancer
Stage II B Cervical Cancer
Stage IVA Cervical Cancer
Stage II B Ovarian Cancer
G1P0A0 20 weeks gestational
age with threatened abortion
Residive ovarian cancer
HGSIL
Stage II A ovarian cancer
Mixed solid ovarian cystic
neoplasm malignancy was
suspected + VES + Stage I
hypertension

hysterectomy
Chemotherapy
Chemotherapy
Chemotherapy
Chemotherapy
Chemotherapy
Medicilnalis

NSR
NSR
NSR
NSR
NSR
RZM

Chemotherapy

RAD

Plan for LEEP

Chemotherapy
Laparotomy FS

FOR
JHN
FOR

Chemotherapy

Chemotherapy

Ms.TUT/56/P2A0/UA/NSR
D/ Residive Ovarian Cancer
M/ Chemotherapy Oxaliplatine and Gemcirabine 6th course
Pathology No. PA 02/S/2014
High grade serosum carcinoma at left and right oavary, Metastasis to omentum and peritoneum
03:30 PM

2.

3.

16.06.16

Chemotherapy

07.00 PM

Mrs. ATK/29/ P0A1/RA/FOR

D/ Stage I Malignant Trofoblastic Tumor
M/ Chemotherapy Methotrexate Rescovulin 6th course

15.06.16

Chemotherapy

Mrs.HEN/50/P2A1/RA/FOR
D/ Stage II B Cervical Cancer + Post Radical Hysterectomy
M/ Chemotherapy Oxaliplatine and Gemcirabine 1st course
Pathology No. PA 2265/MI/2015
- Moderate differentiated non keratinizing squamous cell carcinoma ectocervi.
06:00 PM

4.

5.

6.

Corpus luteum and para ovarial cyst at ovary I

Lutein cyst at ovary II
Reactive hyperplasia in 2 right pelvic lymph glands
Reactive hyperplasia in 5 left pelvic lymph glands
17.06.16

Chemotherapy

05:00 PM

Mrs.HAY/66/P3A0/UA/JHN
D/ Stage IIIB Cervical Cancer Inadequate therapy
M/ Chemotherapy Ifosfamide Mesna - Cisplatin 2nd course

14.06.16
05.30 PM
US

Total hyterectomy oi intramural uterus myoma

Mrs.NUR/53/P2A1/RA/GIN
D/ intramural uterus myoma
M/ Total hyterectomy

18.06.16

Chemotherapy

07:00 PM

Mrs. LIS/54/UA/P4A0//NSR
D/ Stage III B Cervical Cancer
M/ Chemotherapy Paclitaxel Carboplatin 3rd course

Pathology No. PA. ??

7.

12.06.16

Plan for laparoskopi second loop

Mrs. FAT/53/UA/P2A2/NSR

00:40 PM

D/ Stages IIIC Ovarian Cancer

M/ Plan for laparoskopi second loop
Pathology No. PA 2325/MI/2016
I. Ovula nabothi cyst at cervix
Uterine leiomyoma with adenomyosis
II. Mucinous adenocarcinoma right ovarian
III. Mucinous adenocarcinoma left ovarian
IV. No malignancy found in omentum
V. Cytology: Adenocarcinoma
8.

19.06.16

Plan for radical hysterectomy

Mrs. MAR/46/RA/P6A0/NSR
03:40 PM
D/ Stage III C Cervical Cancer (post chemotherapy 3rd course)
M/ Plan for radical hysterectomy
Pathology No. 879/A/2016
Endocervical adenocarcinoma villo glandular type (from cervical biopsy)
Limfovascular invation (-)
9.

19.06.16

Chemotherapy
Mrs. SAR/56/UA/P3A1//NSR

07:00 PM

D/ Residive Cervical Cancer

M/ Chemotherapy paclitaxel-cysplatin 5th course
Pathology No. 367/C/2016
- Found no Malignant cell active
- Malignant cells degenerative effects of chemoradiation

10.

18.06.16

Chemotherapy

Mrs. ALM/54/RA/P2A0/JHN
D/ Stage II C cervical cancer
M/ Chemotherapy paclitaxel-cysplatin 2nd course
Pathology No. 0682/PA/CH/16
A and B epitheloid leiomyosarcoma poorly differentiated
DD/ High grade stromal sarcoma
Metaplastic carcinoma
07:00 PM

11.

18.06.16

Chemotherapy

Mrs. MIS/55/RA/P2A0/NSR
D/ Stage IIB Cervical Cancer
M/ Chemotherapy Paclitaxel Carboplatin 1st course
Pathology No. PA 2417/A/2016
Moderate differentiated squamous cell carcinoma portio, no limfovaskular invation
04:30 PM

12.

19.06.16

Chemotherapy
Mrs. HAS/26/UA/P3A1/NSR

04:24 PM

D/ Stage IVA Cervical Cancer

M/ Chemotherapy Paclitaxel Carboplatin 5th course
Pathology No. PA 905/A/2016
Moderate differentiated non keratinizing squamous cell carcinoma cervix, no limfovaskular invation
13.

19.06.16

Chemotherapy
Mrs. MUR/54/P2A1/UA/NSR

12.30 PM

D/ Stage IIB Ovarian Cancer

M/ Chemotherapy Paclitaxel Carboplatin 2nd course

Pathology No. PA 1933/A/2016
A. FS
High grade serous carcinoma in left ovary expand to left Fallopian tube
B. I. Non specific chronic cervisitis with ovula nabothi cyst
II. Reactive hyperplasia in 5 right pelvic lymph glands
III. Reactive hyperplasia in 2 left pelvic lymph glands
IV. No malignancy found in paraaortic mature fat tissue
V. No malignancy found in omentum
VI. Peritoneal fluid cytology:no exfoliative cells and malignancy found in peritoneal fluid
14.

15.

18.06.16

Medicinalis

04:33 PM

Mrs. LIS/23/ G1P0A0/RA/RZM

D/ G1P0A0 20 weeks gestational age with threatened abortion
(C56.9)
M/ Medicinalis
(Z51.11)

20.06.16

Chemotherapy
Mrs. SIT/53/P0A0/UA/RAD

11:32 AM

D/ Residive ovarian cancer

M/ Chemotherapy Oxaliplatine and Gemcirabine 4th course
Pathology No. PA 299/C/2016
Carsinoma metastatic seems an adenocarcinoma of peritoneal fluid cytology

16.

20.06.16

Plan for LEEP

Mrs. JEN/34/P2A0/RA/FOR

06:37 PM
17.

20.06.16

D/ HGSIL
M/ plan for LEEP
Chemotherapy

Mrs. KAR/63/ P4A0/RA/JHN

D/ Stage III A ovarian cancer
M/ Chemotherapy Paclitaxel-Cisplatin 4th course
Pathology No. PA 1430/A/2016
I. Grade II FIGO endometrioid adenocarcinoma in endometrium invaded up to tunica serosa layer of
the uterus, 1/3 lower uterine, right Fallopian tube, ovary, and parametrium.
II. Reactive mesothel in omentum
III and IV. Reactive hyperplasia in 16 lymph glands from right and left pelvic lymph glands found
V. Carcinoma cells found in ascites fluid
04:23 PM

18.

19.06.16
01:26 PM

19.

18.06.16

Laparotomy FS
Mrs.FRI/55/P3A1/UA/FOR
D/ Mixed solid ovarian cystic neoplasm malignancy was suspected + VES +
Stage I hypertension
M/ Laparotomy FS
Chemotherapy

Mrs. SUS/28/RA/P1A0/JHN
D/ Stage I GTN FIGO score 2
M/ Chemotherapy Methotrexate Rescovulin 2nd course
Pathology No. PA 1430/A/2016
Hidatidform Mole: Complete mole with severe proliferation trophoblast cells and focal atypical cells
leading to malignancy
03:30 PM

20.

21

21.06.16

Chemotherapy

03:00 PM

Mrs. TIN/32/RA/P1A1/RAD
D/ Stage I GTN FIGO score 10
M/ Chemotherapy Methotrexate Rescovulin 2nd course

21.06.16

Plan for radiotherapy and physiotherapy

Mrs. JAM/54/RA/P4A0/RAD
D/ Stage IIA Cervical Cancer + Post Radical Hysterectomy + urinary
retention
M/ Plan for radiotherapy and physiotherapy
Pathology No. PA 1207/A/2016
Moderately differentiated non keratinizing squamous cell carcinoma cervix and invasions has got to
low uterine segment, with limfovaskular invation.
11.37 PM

22.

18.06.16

Chemotherapy

07.26 PM

Mrs. LIS/54/UA/P4A0/FOR
D/ Stage IIA cervical cancer + Post Radical Hysterectomy

M/ Chemotherapy paclitaxel carboplatin 4th course

Pathology No. PA 1411/A/2016
Moderately differentiated non keratinizing squamous cell carcinoma with limfovaskular invation,
expand to endocervix.
- Reactive hyperplasia in 1 parametrium lymph glands
- Endometrial atrophy
- No malignancy found in both ovary and fallopian tube
- Reactive hyperplasia in 5 right iliaca lymph glands
- Metastasis carcinoma in 1 left iliaca lymph glands
- Reactive hyperplasia in 6 left iliaca lymph glands
24.

18.06.16

Chemotherapy
Mrs. DAR/45/RA/P2A0/JHN

02.17 PM

D/ Stage IIIB cervical cancer

M/ chemotherapy paclitaxel cyplatin 3rd course