GYNECOLOGY OUTPATIENT

REPORT
Monday, June 4th 2018

Resident:
Dr. Raissa Nurwany

Doctor in Charge:
Dr. Hj Fatimah Usman, OBGYN (C)
Supervisor:
Dr. Amirah Novaliani, OBGYN (C)
 Monday, June 4th 2018
Consultant
No. Identity Diagnosis ICD 10 Therapy ICD 9
In charge

Ms. MER /
1. Leucorrhea N89.8 Vaginal Swabs - FU
27yo/ RA
Identity Ms. MER / 27yo/ RA
Chief complain White dicharge and from vagina
History Patient was consulted to gynecology clinic from internal department with diagnosed
: Thyroid heart disease + hypertension heart disease + asthma + graves disease +
fluor albus.
Since 1 month ago patient felt there is clear to white discharge from vagina, itchy (-),
odor (-). history of vaginal bleeding/spotting (-). history of pain on menstruation (-),
of using IUD (-), urinary and defecation was normal.
History of last post coital (+) 5 years ago
Reproduction status menarche 13 y.o. irregular cycle. LMP 18/05/2018
Obstetric history unmarried
Past iIlness history Graves disease since 2015.
Current medication : PTU 3 x 100 mg, digoxin 1 x ½ tab, spironolactone 1 x 12,5 mg,
furosemide 1 x ½ tab, neurodex 1 x 1 tab.
Physical Examination Vital sign: BP = 140/90mmHg, HR = 94x/m, temp = 36.5 C, RR = 20x/m, BL 157cm,
BW 45kg
gynecology abdomen flat, FUT unpalpabled, free fluid sign -, tenderness -
examination Insp and VT was not allowed by patient

Diagnosis Leucorrhea
planning Swab Vagina
Control with swab result
3
Thank You