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, 35 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