GYNECOLOGY WARD REPORT

Tuesday, August 19th 2017

Residents:
1. dr. Rina Sinta Danu
2. dr. Novi Rindi
3. dr. Ormias Pratama
4. dr. Alfiani Sari R. Cy

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Pirngadi General Hospital
2017
Ward Patients : 2 patients
1. Mrs. P, 57 yo, PA
Diagnosis : Post SOS d/t Ovarian tumor abscess + D4
Supervisor : dr. Christoffel L Tobing, M.Ked(OG), Sp.OG.K

Resident : dr.

Planning : continous therapy, Mobilization

2. Mrs. R, 62 yo, P6A0

Diagnosis : Post BSO d/t Ovarian cyst + D3

Supervisor : dr. Christoffel L Tobing, M.Ked(OG), Sp.OG.K

Resident : dr.

Planning : continous therapy, Mobilization

Patient 1
Follow up Friday , 2017

Cons : Alert Anemic : (-)

BP : 120/80 mmHg Icteric : (-)

HR : 100 x/min Cyanosis : (-)

RR : 24 x/i Dyspnoe : (-)

Temp : 37 OC Edema : (-)

Localise state:

Abdomen : lax, peristaltic (+) normal

Vaginal Bleeding : (-)

Micturition : (+)

Defecation : (+)
Diagnose : Post SOS d/t Ovarian tumor abscess + D3
Planning : continous therapy, mobilization
Patient 2
Follow up Friday , 2017

Cons : Alert Anemic : (-)

BP : 110/70 mmHg Icteric : (-)

HR : 84 x/min Cyanosis : (-)

RR : 22 x/i Dyspnoe : (-)

Temp : 37 OC Edema : (-)

Localise state:

Abdomen : lax, peristaltic (+) normal

Vaginal Bleeding : (-)

Micturition : (+)

Defecation : (+)
Diagnose : Post BSO d/t Ovarian cyst permagna + D2
Planning : continous therapy, mobilization
Mrs. R, 62 yo, P6A0, Moeslem, Primary School, Farmer, married to
Mr. B, 65 yo, Primary School, Farmer

CC : Abdominal Enlargement
This has been experienced since 2 years ago. Times to times
getting bigger. History of abdominal pain (-). History of vaginal
bleeding (+), History of leukorhea (-), history of abdominal
massage (+), History consumption of herbal remedies (+), History
of losing weight (+), History of decreased appetite (-). Micturition
and defecation no abnormality.
Previous illness : Hypertension
Previous medical :-
Contraception history : implants

Menstruation history: Menarche 13 y.o, underpad

changing around 1-2 times/day, regularly,
dismenorrhea: (-), menopause since 5 year ago
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 : distension (+), palpable solid mass, immobile, smooth surface, with
upper pole at processuss xipoideus, lower pole at symphisis, tenderness
(-), shifting dullness (-)
Vaginal bleeding : (+)
Ginecology state :
Inspeculo : Portio difficult to identified, pushed by mass to
anterior, looks blood in vaginal introitus, cleaned
not flow, F/A (-)

Vaginal toucher : portion is smooth to anterior, UT difficult to

identified, Palpable solid mass as big as aterm
pregnancy, immobile, smooth surface: mass origin
difficult to identified, both adnexa difficult to
identified, both parametrium are lax, Douglas
cavity not protruded
 LABORATORY FINDINGS on July 21st 2017 :
Hb : 12,1 N: 12-14 gr/dl
Leukocyte : 10.330 N:4000-11000/mm3
Hematocrit : 26,10 N: 36,0-42,0/%
Platelet : 364,000 N:150000-400000/mm3
Post Prandial Glucose : 144 N : 76-140 mg/dL
Ureum : 29,54 N : > 50 mg/dl
Creatinin : 0,94 N : 0,6-1,2 mg/dl
CA-125 : 48,61 N : 0-35 U/ml
 LABORATORY FINDINGS on July 31st 2017 :

Natrium : 146 N :135-155

Kalium : 4,70 N : 3.6-5.5
Cloride : 107 N : 96-106
 LABORATORY FINDINGS on August 14th 2017 :
Hb : 11,5 N: 12-14 gr/dl
Leukocyte : 7.240 N:4000-11000/mm3
Hematocrit : 34,60 N: 36,0-42,0/%
Platelet : 241,000 N:150000-400000/mm3
Glucose ad random : 90 N : 76-140 mg/dL
Ureum : 19 N : > 50 mg/dl
Creatinin : 0,32 N : 0,6-1,2 mg/dl
Natrium : 144 N :135-155
Kalium : 3,20 N : 3.6-5.5
Cloride : 110 N : 96-106
USG TAS
 USG TAS
Uterus was not seen
There was cystic mass in the pelvic and fulfilled
cavum abdomen
Some features seen as hyperechoic

Conclusion : ovarian cyst permagna

Diagnosis:
Adnexa tumor permagna DD : Intraabdominal tumor

Plan : TAH BSO on August 16th 2017

 Total Abdominal Histerectomy +
Bilateral Salphingo-ovorectomy Report
The patient was laid on the operation table with iv line installed
well, under general anesthesia and endotracheal intubation Foley
catheter was inserted. Aseptic and antiseptic was performed, then
the abdomen was draped with sterile clothes.
A Midline-type skin incision was made. The abdomen was opened
in layers. Upon entering the peritoneal cavity, there was adhesion
on peritoneum, muscle, and omentum, and bowel, adhesiolisis was
done, evaluation the utrus, seems bigger than ussual, there was cyst
on the left adnexa, and no mass on the right adneksa, decided to
TAH-BSO. the uterus was held with traction using 2 large Kelly
The round ligament on the right side was clamped, cut, and
suture ligated with 0 Vicryl suture ligature. This procedure was
then repeated on the opposite side. The infundibulopelvic
ligament on the right side was clamped, cut, and suture ligated
with 0 Vicryl suture ligature, and the procedure was repeated
on the opposite side. The uterine artery and blood vessels were
then skeletonized, clamped, cut, and suture ligated with 0 Vicryl
suture ligature bilaterally.
The cardinal ligament was then clamped, cut, and suture ligated
with 0 Vicryl suture ligature in 2 separate bites bilaterally.
The cervix was then whirled off of the vagina. The specimen
including the uterus, cervix, were handed to the circulating
nurse. A figure-of-eight suture ligature was placed at each angle
of the vagina to incorporate the cardinal ligament for
support. The vaginal cuff was then closed with a 0 Vicryl suture
ligature in a continuous fashion locking every stitch for
hemostasis.
 The excess blood was cleaned from the peritoneal cavity. The
peritoneum was then irrigated using normal saline. No bleeding
was noted. The lap and instrument counts were noted to be
correct, and the fascia was closed with 0 Vicryl in continuous
fashion locking every stitch, the skin were closed and sterile
dressing was applied. The patient condition after operation was
stable.
Thank You