DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

FERTILITY ENDOCRINOLOGY REPRODUCTIVE

OUTPATIENT REPORT

Monday, February 01st 2021

Resident on Duty:
Dr. Wisman Agustian
Dr. Octaria Saputra
Dr. M. Ath Thaariq Prasetiyo

Doctor In charge :
Dr. Awan Nurtjahyo, SpOG (K)-FER
Supervisor :
Dr. Awan Nurtjahyo, SpOG (K)-FER
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
RECAPITULATION FER OUTPATIENT REPORT

Month Total visit Case Note

New Old
January 45 19 26 -

Date Total visit Case Total Note

New Old
st
Feb, 01 2 1 1 2
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
FER OUTPATIENT REPORT
Monday, February 01st 2021
No. Identification Examination Assessment Planning

1 Mrs. RIS/ 23 YO/ 1 01.02.2021 Endometriosis ASRM Leuprolide acetate inje

191206/ BANYUAS Patient has been diagnosed with Endo grade IV ( ASRM scor ction 3,75 mg 2nd cours
IN/ P0A0/ OSP- HE metriosis ASRM grade IV, and planne e 40, EFI score 5) e
d for leuprolide acetate injection 3,75
Continued leuproli mg. Patient has underwent leuprolide ICD 10 ICD 9
de acetate injection acetate 3,75 mg 1st course of January, N80.9 – endometriosis 99.24 – hormonal thera
07th 2021. ( unspecified) py

Right now, patient didn’t had subjecti

ve complained and come for continue
d 2nd course of leuprolide acetate injec
tion 3,75 mg

Past illness history

Patient has underwent operative laparo
scopy on December, 30th 2020 with
PA result ( 4007/A/2020)
I. Endometriosis cyst in left ovary
II. Endometriosis cyst in right ovary
III. Para-tubal simple cyst in right fall
opian tube

Gynecology examination
External examination
Flat abdomen, symetric, supple, tender
ness (-), mass was not palpabled , free
fluid sign (-),
2 Mrs. NUR/ 37 YO/ 01.01.2021 Hyperprolactinemia ca Head MRI
1000395/ PALEMB Since 2-3 months before admission, p used by SOL was susp Neurology consult
ANG/ P2A0/ OSP- atient complained had blurry vision, a ected dd/ hypophysis a
RS nd started had headache until vertigo. denomyoma ICD 9
Patient admitted has menstruation eve 88.91 – MRI of brain a
Breast milk leakag ry months, blood spotting, for 1x chan ICD 10 nd brain stem
e, blurry vision, he ging pad, for 6-7 days. E22.1 – hyperprolactin 89.09 – consultation
adache, vertigo an emia
d little menstruatio 2 weeks before admission, patient adm
n itted there was breast milk comes fro
m her breast, like when she was breast
feeding. Patient went to OB/Gyn ( Dr.
H. Rizal Sanif, OB/Gyn ( C), Onc, M
ARS, PhD) and done prolactin hormo
ne examination with result 368,21 and
referred to Moh. Hoesin Hospital

General examination
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
Chest : there was enlargement of brea
t, with active breast milk (+)

Gynecology examination
External examination
Flat abdomen, symetric, supple, tender
ness (-), mass was not palpabled , free
fluid sign (-),
Speculum examination
Unlivide portio, opened OUE for 1 c
m, fluor (-), fluxus (-), E/L/P (-)
Vaginal toucher
Firmed portio, opened OUE, 1 cm, bot
h AP was supple, douglas pouch didn’
t bulging
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
Last Visit: Monday, 1st February 2021
ANAMNESIS
Identification Mrs. RIS/ 23 YO/ 1191206/ BANYUASIN/ P0A0/ OSP- HE
Chief Complain Continued leuprolide acetate injection
History Patient has been diagnosed with Endometriosis ASRM grade IV, and planned for leuprolide
01.02.2021 acetate injection 3,75 mg. Patient has underwent leuprolide acetate 3,75 mg 1st course of
January, 07th 2021.

Right now, patient didn’t had subjective complained and come for continued 2nd course of
leuprolide acetate injection 3,75 mg
Histoy of treatment Patient has underwent operative laparoscopy on December, 30th 2020 with
PA result ( 4007/A/2020)
I. Endometriosis cyst in left ovary
II. Endometriosis cyst in right ovary
III. Para-tubal simple cyst in right fallopian tube
Menstrual Status Menarche 14 yo, 28 days cycle, 3-5 days; LMP : Forget
Marital Status Married 1x for 2 years
Obstetric history P0A0
Physical Examination
General Examination Sensorium compos mentis, BP 125/84 mmHg, pulse 87x/minute RR 20x/minute
Height 158 cm; weight 57 cm (BMI Index  22,83 kg/m2  normalweight
External examination Flat abdomen, symetric, supple, tenderness (-), mass was not palpabled , free fluid sign (-),
Inspection Not performed
Vaginal toucher Not performed
Diagnosis Endometriosis ASRM grade IV ( ASRM score 40, EFI score 5)
Planning Leuprolide acetate injection 3,75 mg 2nd course
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
Last Visit: Monday, 1st February 2021
ANAMNESIS
Identification Mrs. NUR/ 37 YO/ 1000395/ PALEMBANG/ P2A0/ OSP-RS
Chief Complain There was breast milk leakage, blurry vision, headache, vertigo and little menstruation
History Since 2-3 months before admission, patient complained had blurry vision, and started had
01.02.2021 headache until vertigo. Patient admitted has menstruation every months, blood spotting, for
1x changing pad, for 6-7 days.

2 weeks before admission, patient admitted there was breast milk comes from her breast,
like when she was breastfeeding. Patient went to OB/Gyn ( Dr. H. Rizal Sanif, OB/Gyn
( C), Onc, MARS, PhD) and done prolactin hormone examination with result 368,21 and
referred to Moh. Hoesin Hospital
Histoy of treatment (-)
Menstrual Status Menarche at 12 years old, regular, for 6-7 days, LMP : January, 22 nd 2021; December, 28th
2021; and November, 26th 2021
Marital Status Married 1x for 16 years
Obstetric history P2A0
Physical Examination
General Examination Sensorium compos mentis, BP 125/84 mmHg, pulse 87x/minute RR 20x/minute
Height 158 cm; weight 57 cm (BMI Index  22,83 kg/m2  normalweight
Chest : there was enlargement of breat, with active breast milk (+)
External examination Flat abdomen, symetric, supple, tenderness (-), mass was not palpabled , free fluid sign (-),
Inspection Unlivide portio, opened OUE for 1 cm, fluor (-), fluxus (-), E/L/P (-)
Vaginal toucher Firmed portio, opened OUE, 1 cm, both AP was supple, douglas pouch didn tbulging
Diagnosis Hyperprolactin caused by SOL was suspected dd/ hypophysis adenomyoma
Planning Head MRI
Neurology consult