You are on page 1of 17

DAILY REPORT

Tuesday, Januari 24th 2017

I. Duty Report

: Dr. R. A. Kesuma Andini

II. Oncology Outpatient Report

: Dr. Endrianus Jaya Putra

III. Elective Operating Theater Report


COT

:
: Dr. Sarlita Indah Permata Sari

IV. Emergency Room Report

: Dr. Venny Melinda

V. PKBRSOutpatient Report

: Dr. Al Muhir Yuliansyah

VI. Delivery Room Report


Arjanggi

: Dr. KGS. Irawan Satria

VII. Intensive Care Unit Report

: Dr. M.Ardianto Airlangga

VIII. PreOperative Report

: Dr. Arief Krisnadhi Prasojo

IX.. Outpatient 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

Dr. Cordova Arridho


: Dr. Roza Maulindra
Dr. Miranni Indah kosim
: Dr. Eric Tjahyadi
: Dr. Canggih Naluri
: Dr. Dwi Antono
Dr. Fachrul Irsan
Dr. Kms. M. Aditya Fitrandi
: Dr. Fitrah Tindar

Oncology outpatient Report


N
o

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

GTD stg I FIGO


score 9

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

Onkologi Outpatient Incomplete Examniation


N
o

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

Plan for BNOIVP

V58.
11

Plan for Clinical


Staging
Laboratorium
exam
Tumor marker

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

Plan for BNOIVP

V58.
11

Plan for Clinical


Staging
3

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)

EMERGENCY ROOM REPORT


Monday, January 23th 2017
Recapitulation of Patient
Total Cases
OBSTETRICS PATIENT

- 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

PKBRS Out patient report


Identity

Total

23 Jan
2017

Total

10

10

IUD insertion

Implant insertion

Tubal ligation

1-20 Jan
2017

Counselling contraception :

Another contraception

Interval contraception

Control post 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

P8A0 post spontaneus


delivery (3rd day)

O36
.4

Tubal
ligation

V25.
2

2.

Mrs.
JUM/33
yo/UA

Post post curettage due to


incomplete abortion

O03
.4

IUD
insertion

Z97.5

Mrs.
DES/33
yo/UA

Post post curettage


incomplete abortion

O03
.4

IUD
insertion

Z97.5

Mrs.
BAR/26
yo/RA

P1A0 post LSCS due to


infection intrapartum

O65
.5

DMPA

Z30.0
13

Mrs.
LID/21
yo/RA

P1A0 post spontaneus


delivery (3rd day)

O36
.4

DMPA

Mrs.
FAT/40
yo/UA

Post curettage due to death


conceptus (2nd day)

O03
.4

DMPA

Identity

Diagnosis

ICD10

Manage
ment

Mrs.IDA/ 40
yo/ UA

P6A2post spontaneous delivery


+ protubectomy(2nd day)

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

LACTATION and PUERPURAL


No.

Identity

1.

Mrs.
DEW/19
yo/RA

Diagnosis

ICD-10

P1A0 post spontaneus


delivery + retensio
urinae

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

Plan for abdominal


delivery

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

FER Outpatient Report


N
Date
o
1

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

FER Operative Report


N
o

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

Plan for pap


smear

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

Left cyst ovarian


neoplasm

N83.
29

P/ HDLO

V64.41

Urogynecology Outpatient Report


N
O

Identitas

Diagnosis

ICD10

1. Mrs. MAH/61/
P11A1/UA/CGH

Post posterior colporaphy oi


cystocele grade II + uterine
prolaps grade I + rectocele
grade II

70.5 Medicin
alis

2. Mrs.EMI/33/

Post hecting vaginal


laceration

Z48. Medicin
02
alis

P0A0/UA/CGH

Treatme IC
nt
D9

Uroginekologi Operative Report


NO

Diagnosis

ICD10

Treatment

ICD-9

OBSTETRIC OUTPATIENT REPORT


Monday , january 23
NO

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

gestational age not inlabor


SLF cephalic presentation
with atresia jejunum
suspected + hydronefrosis
dextra.

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.

Cervical cancer stage II B


was suspected

Cervical malignancy mass


was suspected

2.

1st trimester pregnancy

6 weeks of gestational age


SLF intrauterine

3.

3rd trimester pregnancy


with schizophrenia

36 weeks of gestational
age SLF cephalic
presentation

4.

Post menopause bleeding

No internal genitalia
abnormality

5.

Ovarian cancer stage III C


complete theraphy

No new growing
malignancy mass

6.

Post hystrectomy o.i


endometrial cancer st I B

No new growing
malignancy mass

7.

Cervical cancer stage II B


was suspected

Cervical malignancy mass


was suspected

Total

Fetomaternal
N
o

Diagnosis

US examination

ICD-10

1.

1st trimester Pregnancy


with HEG grade II

6 weeks of gestational age


SLF intrauterine

Z34.01

2.

2nd trimester Pregnancy


with threatened abortion

14 weeks of gestational age


SLF cephalic presentation +
subchorionic hematome

O20.0

3.

2nd trimester Pregnancy


with threatened preterm
labor

24 weeks of gestational age


SLF intrauterine + cervical
length 2,54 cm

O60.0

4.

3rd trimester Pregnancy


with threatened preterm
labor

35 weeks of gestational age


SLF cephalic presentation

O60.0

5.

3rd trimester Pregnancy


with PPROM

31 weeks of gestational age


SLF cephalic presentation +
anhydramnion

O42.0

6.

Advance stage ovarian


cancer

Malignancy Cyst ovarian


neoplasm + internal genital
adhesion

C56.9

7.

ovarian cancer
inadequate staging

Malignancy solid ovarian


cancer + liver metastase
was suspected

C56.9

TOTAL

Emergency Operating Theater Report


Monday, January 23rd 2017
Obstetrics patient

: 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