Professional Documents
Culture Documents
I. Duty Report
:
: Dr. Sarlita Indah Permata Sari
V. PKBRSOutpatient Report
a. FER
Outpatient
:
Operating Patient
b. Gynecology I
:
c. Gynecology II
d. Urogynecology
e. Obstetri
f. Fetomaternal
:
g. Fetomaternal
:
X. Emergency Operating Theater Report
Atthariq
Date
23.01
.17
IDs Patient
Mrs. BOI/
56/RA/P3A0
Diagnosa
Endometrial
carcinoma stg
IIIC
ICD
-10
C54.
1
Management
Plan for
platosin
chemotherapy
weekly
ICD
9
V58.
11
Radiotherapy
2
23.01
.17
Mrs.SRI/42/
RA/P1A0
Post evacuation
hydatiform
mole
O01
.9
B-hCG
evaluation
87.3
C56.
9
Pap Smear
evaluation
72.3
2
23.01
.17
Mrs.FIT/38/RA/P2
A0
Post radical
hysterectomy
oi Cervical
cancer stg IB
23.01
.17
Mrs.NUR/59/RA/P
3A0
Ovarian cancer
stg IIIC
complete
therapy
C56.
9
CA-125
evaluation
88.7
23.01
.17
Mrs.MAR/390/
RA/P2A1
O01
.9
Plan for
chemoteraphy
MER 5th course
V58.
11
23.01
.17
Mrs.HEN/51/ RA /
P2A1
Ovarian cancer
stg IC complete
therapy
C56.
9
CA-125
evaluation
88.7
23.01
.17
Mrs. SUR/54
/RA/P2A1
Ovarian cancer
stg IC complete
C56.
9
CA-125
evaluation
88.7
V58.
11
54.1
23.01
.17
23.01
.17
Mrs.HER/39/RA/P
5A1
Cervical cancer
stg IIB
C53.
9
Pro
chemoterapy
Paclitaxel
Carboplatin 4th
course
Mrs. MUT/
64/RA/P3A0
Solid ovarian
plasma
malignancy
was suspected
C53.
9
Plan for
laparotomy FS
1
0
1
1
23.01
.17
23.01
.17
Mrs.NUR/58/
UA/P4A0
Cervical cancer
stg IIIB
complete
therapy
C53.
9
Pap smear
evaluation
72.3
2
Mrs.SUR/54/RA/P
2A0
Cervical cancer
stg IIB
complete
therapy
C53.
9
Pap Smear
evaluation
72.3
2
Management
ICD
9
Date
IDs Patient
Diagnosa
ICD10
Laboratorium
exam
Tumor marker
23.01
.17
Mrs. BAS/
42/RA/P2A0
Cervical
cancer stg IIB
was suspected
C53.
9
Chest X-ray
V72.
62
US
confirmation
88.0
1
V58.
11
23.01
.17
Mrs. ERL/40/
RA/P1A2
Cervical
cancer stg IIB
was suspected
C53.
9
Chest X-ray
V72.
62
US
confirmation
88.0
1
V58.
11
23.01
.17
Mrs.SUM/53/RA/P
1A0
Endometrial
carcinoma
inadequate
C54.
1
Labor
examination
V72.
62
Tumor marker
Chest X-ray
staging
US
Confirmation
4.
23.01
.17
Ms.KAS/52/UA
Solid ovarian
mass
malignancy
was suspected
US
confirmation
N83.
29
Laboratorium
exam
Tumor marker
88.0
1
V72.
62
88.0
1
US
Confirmation
23.01
.17
Mrs.DAI/54/
RA/P2A0
Endometrial
cancer stg II
was suspected
C54.
1
Labor
examination
V72.
62
Tumor marker
88.0
1
Plan for
surgical
staging
23.01
.17
23.01
.17
Ms.MUT/64/ RA
Mrs.SRI/57/
RA//P1A0
Labor
examination
Sold ovarian
neoplasm
malignancy
was suspected
C53.
9
Borderline
endometrioid
ovarian tumor
N83.
2
Tumor marker
US
Confirmation
IHK
examination
V72.
62
88.0
1
V72.
62
COT
N
o
Identity
Preop
Diagnosis
Post op
diagnosis
Procedure
Pres
ent
statu
s
Mrs.NUR/ 57
yo / P3A0/RS
Cervical
cancer stage
III B (post
NAC 6th
course)
(C53.9 +
99.25)
Ms.ERI/48yo
/AT
Recurrent
ovarian
cancer
(C56.9)
Cervical cancer
stage III B + post
radical
hysterectomy
(post NAC 6th
course)
Radical
hysterectomy
+ bilateral
pelvic
lymphadenect
omy
(C53.9 + 68.9)
(68.9 +
40.30)
Recurrent ovarian
cancer + post
secondary
optimal debulking
Secondary
optimal
debulking
Stabl
e in
ward
Stabl
e in
ward
(54.3)
(C56.9 + 54.3)
- case
Physiological patient
- case
Pathological patient
- case
GYNECOLOGY PATIENT
1 case
Total cases
1 case
Gynecology Patient
No Identity
.
1
Mrs.
ADE/37/
Diagnosis
Cervical Carcinoma stage III A
with severe anemia and low
ICD
10
Procedure
ICD
9
C53.9
D64.9
Rehydration
99.0
99.25
UA
intake dehydration
Transfusion
Plan
for
radiation
dan
chemotherapy
pacli-carbo 4th
series
Total
23 Jan
2017
Total
10
10
IUD insertion
Implant insertion
Tubal ligation
1-20 Jan
2017
Counselling contraception :
Another contraception
Interval contraception
DMPA
Total patients consult
to Contraceptive Outpatient
25
31
FAMILY PLANING
N
o.
Identity
Diagnosis
ICD10
Manage
ment
ICD-9
1.
Mrs.
FIT/40
yo/UA
O36
.4
Tubal
ligation
V25.
2
2.
Mrs.
JUM/33
yo/UA
O03
.4
IUD
insertion
Z97.5
Mrs.
DES/33
yo/UA
O03
.4
IUD
insertion
Z97.5
Mrs.
BAR/26
yo/RA
O65
.5
DMPA
Z30.0
13
Mrs.
LID/21
yo/RA
O36
.4
DMPA
Mrs.
FAT/40
yo/UA
O03
.4
DMPA
Identity
Diagnosis
ICD10
Manage
ment
Mrs.IDA/ 40
yo/ UA
O90.
3
Tubectomy V25.2
3.
4.
5.
6.
N
o
1.
(1st day)
(1st day)
Injection
(2nd day)
Injection
Injection
Z30.0
13
Z30.0
13
ICD-9
Identity
1.
Mrs.
DEW/19
yo/RA
Diagnosis
ICD-10
Manageme
nt
ICD-9
Hospitalized
(6th day)
Delivery Room
NO
Identity
Diagnosis
1.
Mrs.
ELI/26/UA
G2P1A022 weeks
gestational agewith
threatened labor+ prior
CS 1x(oi prolonged
labor) SLF intrauterine
Mrs.
FER/34
/UA
Mrs.
TRI/30/UA
ICD-10
Management
ICD-9
Conservative
management
O60.00
O34.21
G4P2A130 weeks
gestational age not
inlabor with PPROM 2
days SLF cephalic
presentation +
anhydramnios
O42.119
G3P1A129 weeks
gestational agewith
threatened labor+ post
cerclage removal SLF
O60.00
Antibiotic
injection
Conservative
management
99.21
74.1
cephalic presentation
4
ICU
Mrs.LEN/28
/UA
G2P1A029 weeks
gestational age not
inlabor with APH ec
placenta previa
marginalis + prior CS 1x
SLF cephalic
presentation
O44.3
O34.21
Expectative
management
Pre-Operative
IDs
Patient
23-01- Mrs.
17
EMI/27/P0A0 /
UA
23-01- Miss.ROS/34/
17
RA
23-01- Mrs.NUR/53/
17
P2A0/UA
Diagnosa
ICD10
Endometriosis N80.1
ASRM grade
IV
Paten tubes
bilateral
Adenomyosis
Intramural
uterine
myoma
N
80.0
Management
ICD
9
leuprolide
acetate
injection
2nd course
793.
99
leuprolide
acetate
injection
1st course
793.
99
leuprolide
acetate
injection
3rd course
793.
99
D25.0
N80.1
Endometriosis
ASRM grade
IV
N
Left
Endometriosis 80.1
cyst
23-01- Mrs.EVI/29/
17
P0A0/RA
Endometriosis N
80.1
ASRM grade
III
N97.7
Primary
infertile 2
years
Wound
care
Identity
Mrs. DEV/
25/P0A0/
AA
Pre-op
Diagnosis
Dysmeno
rrhea ec
left
endometr
iosis cyst
Uterine
adenomy
osis
Primary
infertile
16
months
( N80.1 + N80.0
+ N97)
Post op
diagnosis
Endocerv
ix polyp
Endomet
riosis
ASRM
grade III
Genitalia
internal
adhesion
Arcuate
uterus
Right
paratuba
l cyst
Patent
both
tube
(84.1 + N80.1
+ Q51.810 +
N83.8)
Procedure
Hysterosc
opy
curettage
Laparasco
py
adhesiolys
is
Cytectomy
Chromotu
bation
(68.12
+54.21)
Pre
sen
t
stat
us
Stab
le in
war
d
Mrs.
AZI/29/P0
A0/RA
Chronic
pelvic
pain
Normal
internal
genitalia
Hysterosc
opy
diagnostic
Primary
infertile
2.5 years
Patent
both
tubee
Primary
infertile
2.5 years
Laparosco
pic
diagnostic
Chromotu
bation
(R10.2+ N97.9)
(R10.2+ N97.9)
Stab
le in
war
d
(68.12 +54.21)
Gynecology I
Outpatient
N
O
IDENTITY
DIAGNOSIS
ICD
10
Mrs. CAH/ 46 /
UA
Cervicitis
N72
TREATMENT
ICD 9
795.09
Gynecology II
N
O
IDENTITY
DIAGNOSIS
ICD
10
TREATMENT
ICD 9
1.
Mrs.ASN/
69/P6A1/UA
Post Menopause
bleeding
N95.
0
P/ Hysteroscopy
D&C
68.12
Tumor marker
evaluation
2.
Mrs.SRI/
39/P2A0/ RA
N83.
29
P/ HDLO
V64.41
Identitas
Diagnosis
ICD10
1. Mrs. MAH/61/
P11A1/UA/CGH
70.5 Medicin
alis
2. Mrs.EMI/33/
Z48. Medicin
02
alis
P0A0/UA/CGH
Treatme IC
nt
D9
Diagnosis
ICD10
Treatment
ICD-9
Identity
1.
Mrs.MAY /37
/UA
st
2017
Diagnosis
G1P0A0 6 weeks
gestational age SLF
intrauterine.
ICD-10
Management
ICD-9
Z34.02
Folic acid
400mcg / 24 hours
V28.81
2.
Mrs. DES/
32/UA
G3P2A0 38 weeks
Z34.03
Q 41.0
Ferrous sulphate
100 mg/24 hours
88.78
Calcium 500mg/24
hours
Q.62.0
Fetomaternal
N
o
Diagnosis
US examination
1.
2.
3.
36 weeks of gestational
age SLF cephalic
presentation
4.
No internal genitalia
abnormality
5.
No new growing
malignancy mass
6.
No new growing
malignancy mass
7.
Total
Fetomaternal
N
o
Diagnosis
US examination
ICD-10
1.
Z34.01
2.
O20.0
3.
O60.0
4.
O60.0
5.
O42.0
6.
C56.9
7.
ovarian cancer
inadequate staging
C56.9
TOTAL
: 0 case
Gynecology patient
: 0 case
Total Patient
: 0 case
Obstetric
No
Identity
Pre Op Diagnosis
ICD-10
Procedure
ICD-9
Post Op
Diagnosis
Patient
status
Post Op
Diagnosis
Patient
status
Gynecology
No
Identity
Pre Op Diagnosis
ICD-10
Procedure
ICD-9