GYNECOLOGY WARD REPORT

Thursday, December 7th 2016

Residents:
1. dr. Devi Meliana Syam
2. dr. Luthfi Aditia Rahman
3. dr. Ria Suci Nurlianti

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Haji Adam Malik General Hospital
2016

Ward Patient : 2 patients

1. Mrs.N, 69 years old, P4A0

Diagnosis
: Post Transvaginal Hysterectomy + Post anteriorposterior
colporaphy d/t Uterine Prolapse grd III +
Cystocel grd III +
Rectocel grd III + day 2
Plan
: Oral therapy, catheter installed
Supervisor in charge : dr. Edy Ardiansyah, Mked(OG), SpOG.K
Resident in charge : dr. Ria Suci
Duration of hospitalization: 4 days
2. Mrs. S, 25 yo, P1A1
Diagnosis
: Post curetage due to Hydatidiform mole
spontaneous
abortion
Planning
: - Check -HcG post curetage

PATIENT 1

Mrs. N, 69 yo, P4A0, Javanesse, moslem, employer wife of Mr. A , 73

yo, Javanesse, moslem, retired, married 1x, 25 yo, youngest child:
26 yo
Cc : Feeling of fullness or heaviness in the pelvic
Its experienced since 1 year ago, urinary stress incontinence
(+). History of abdominal pain (-). History of palpable mass from
the abdomen (-), History of abdominal massage (-). History of
vaginal bleeding (-), History of vaginal discharge (-). Defecation
(+) normal.
Previous disease
:Previous medicine
:History of period
: Menarche at 15 yo, regular, 3-5 days,
volume 2-3 times
changing pad/day,
dysmenorrhea (-)
History of contraception : History of operation
:-

Present Status
Cons : full alert
BP
: 120/80 mmHg
Pulse : 72 x/min
RR
: 18 x/min
Temp : 36,7OC

Anemic
: (-)
Icteric
: (-)
Cyanosis : (-)
Dyspnoe : (-)
Edema : (-)

Localise state:
Head
: Eye: Pale Inferior Conj palpebra (-/-), sclera icteric
(-/-)
Neck
: Lymph node enlargement (-)
Thorac
: Breath sounds : Vesicular
Additonal breath sounds : (-)
Abdomen : lax, peristaltic (+) N
Vaginal bleeding : (-)

Laboratory Result

Hb : 14,0 g/dL
L : 4960/mm3
Ht : 45 %
T : 190.000/mm3
PT : 19,9 (14) detik
APTT : 34,6(33) detik
TT : 18,4(17) detik
INR : 1,34
Fasting Glucose: 87mg/dl
2 hours PP BG : 114 mg/dL
Na : 142mEq/L
K : 3,3mEq/L
Cl : 106 mEq/L

Ureum : 24 mg/dl
Creatinin : 0,43 mg/dl
Albumin
: 4,3 g/dL
HBsAg : non-reactive
HIV
: non-reactive

Diagnose :
Uterine Prolapse grd III + Cystocel grd III + Rectocel
grd III
Plan
:
Transvaginal Hysterectomy + Anterior-posterior
colporaphy

Follow-up Dec 7th 2016

S : pain from operation wound
O : Sens : CM HR: 84x/i Temp: 36,5
BP: 120/70 mmHg RR: 18x/I
Localized State:
Abdomen : lax, peristaltic(+)
Vaginal bleeding : UOP
: via catheter 70cc/hr , yellowish clear
Defecation
: (-) , flatus(+)
A: Post Transvaginal Hysterectomy + Post Anterior-posterior
colporaphy + Day 2
P: Cefadroxil tab 2 x 500 mg
Mefenamic acid 2 x 500 mg
Catheter instlled

Laboratory Result

Hb :
L :
Ht :
T :

13,8 g/dL
7560/mm3
36 %
190.000/mm3

Transvaginal Hysterectomy + Anterior Posterior

Colporaphy

Patient was in lithotomy postion on the operating table under spinal anesthesia
Genitalia and the surrounding area was done asepsis and antisepsis prosedure
Portio was clamped with tenaculum, and pulled out from the introitus
Remove the uterus through the vagina.
Triangle incision was made in the anterior vaginal mucosa, followed by circularly on vaginal mucosa and
around the cervix
Vaginal mucosa was released bluntly, with using a finger, wrapped in gauze
Bladder and rectum was pushed upwards
Cardinal ligament and sacrouterina was clamped to the right and left, then, cut and tied
Vasa right and left uterine was identified and, clamped, cut and tied
Cavity of Douglas was identified and, opened and widened sharply
Vesico uterine fold was recognized and opened sharply
The base of the tube and the ovarian ligament and rotundum ligament was clamped to the right and left
Ligament of the right and left was identified, and clamped, cut and tied
The base of the tube and propium ovarian ligament was cut and tied
Uterus was removed
Measurement was taken to made sure there was no bleeding in the pedicle, followed by reperitonisation
by stitching Tabac sach
Colporaphy anterior was carried out
Tip of the vagina was sewn with using vicryl no.1 and hung on the complex sacrouterina -cardinal
ligament and rotundum
Colpoperineorafi was done

PATIENT 2

Mrs. S, 25 yo, P4A0

Follow up, Dec 6th 2016
Present Status
Cons : full alert
Anemic
: (+)
BP
: 110/70 mmHg Icteric
: (-)
Pulse : 72 x/min
Cyanosis : (-)
RR
: 18 x/min
Dyspnoe : (-)
Temp : 36,7OC
Edema : (-)
Localise state:
Head
: Eye: Pale Inferior Conj palpebra (-/-), sclera icteric (-/-)
Neck
: Lymph node enlargement (-)
Thorac
: Breath sounds : Vesicular
Additonal breath sounds : (-)
Abdomen : simetrically enlargment
Fundal height : 2 fingers above navel

Vaginal bleeding : (-)

Laboratory Result

Hb : 14,0 g/dL
L : 4960/mm3
Ht : 45 %
T : 190.000/mm3
PT : 19,9 (14) detik
APTT : 34,6(33) detik
TT : 18,4(17) detik
INR : 1,34
Fasting Glucose: 87mg/dl
2 hours PP BG : 114 mg/dL
Na : 142mEq/L
K : 3,3mEq/L
Cl : 106 mEq/L

Ureum : 24 mg/dl
Creatinin : 0,43 mg/dl
Albumin
: 4,3 g/dL
HBsAg : non-reactive
HIV
: non-reactive
T3
FT4
TSH

-HcG

Thorax photo:
No abnormality in cor and pulmo
Diagnosis : Hydatidiform Mole
Planning
: - Transfusion 3 bag PRC
- Evacuate after stabilization

Mrs. S, 25 yo, P4A0

Follow up, Dec 7th 2016
Present Status
Complain: abdominal cramps
Cons : full alert
Anemic
: (+)
BP
: 90/60 mmHg
Icteric
: (-)
Pulse : 70 x/min
Cyanosis : (-)
RR
: 18 x/min
Dyspnoe : (-)
Temp : 36,5OC
Edema : (-)
Localise state:
Head
: Eye: Pale Inferior Conj palpebra (-/-), sclera icteric (-/-)
Neck
: Lymph node enlargement (-)
Thorac
: Breath sounds : Vesicular
Additonal breath sounds : (-)
Thorac
: Breath sounds : Vesicular
Additonal breath sounds : (-)
Abdomen : simetrically enlargment
Fundal height : 2 fingers above navel
Vaginal bleeding : (+)

Inspeculo:
eye fish tissue visible in the vagina, active bleeding
VT:
Open cx
Diagnosis : Hydatidiform mole spontaneous abortion
Planning

: Emergency curetage

THANK YOU