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  • Daily Preop Kamis Dian

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    This document contains summaries of two surgical cases from Monday, July 8th 2019. The first case was a 36-year-old woman who complained of abdominal lumps for 10 years. Physical examination and ultrasound confirmed diagnoses of adenomyosis uteri, bilateral endometriosis cysts, and internal genitalia adhesion. The planned procedure was laparoscopic surgery. The second case was a 51-year-old woman with a diagnosis of high-grade squamous intraepithelial lesion (HSIL). The planned procedure was laparoscopic hysterectomy.

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    This document contains summaries of two surgical cases from Monday, July 8th 2019. The first case was a 36-year-old woman who complained of abdominal lumps for 10 years. Physical examination and ultrasound confirmed diagnoses of adenomyosis uteri, bilateral endometriosis cysts, and internal genitalia adhesion. The planned procedure was laparoscopic surgery. The second case was a 51-year-old woman with a diagnosis of high-grade squamous intraepithelial lesion (HSIL). The planned procedure was laparoscopic hysterectomy.

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    28 views8 pages

    Daily Preop Kamis Dian

    Uploaded by

    pogimuda
    This document contains summaries of two surgical cases from Monday, July 8th 2019. The first case was a 36-year-old woman who complained of abdominal lumps for 10 years. Physical examination and ultrasound confirmed diagnoses of adenomyosis uteri, bilateral endometriosis cysts, and internal genitalia adhesion. The planned procedure was laparoscopic surgery. The second case was a 51-year-old woman with a diagnosis of high-grade squamous intraepithelial lesion (HSIL). The planned procedure was laparoscopic hysterectomy.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 8

    Central Operating Theatre I

    MONDAY, JULY 8th 2019

    No Identity Diagnosis ICD Planning ICD -9 OP


    10

    1 Mrs. EVI/ 25 YO/ P2A0 Cystic Ovarium neoplasm D27.9 Laparotomy FS 54.1 FB-AT

    Hysterectomy
    2 Mrs. SUT/ 47 YO/ P2A0 Intramural uterine myoma D25 68.9 IS
    laparotomy
    Central Operating Theatre II
    MONDAY, JULY 8th 2019

    No Identity Diagnosis ICD 10 Planning ICD -9 OP


    Dysmenorrhea c.b
    endometriosis cyst + N80.1 Laparoscopic
    1 Mrs. DIA/ 36 YO/ P1A0 65.14 IS
    adenomyosis uteri + internal N80.0 operatif
    genitalia adhesion

    Laparoscopic
    2 Mrs. IDA/ 51 YO/ P6A0 HGSIL R87.612 68.9 AT
    hysterectomy
    COT II
    (1) Mrs. DIA/ 36 YO/ P1A0
    Anamnase Physical Examination and supportive exam Diagnosis and
    Planning
    CC: Abdominal lump Menstrual: Menarche 12 YO, regular cycle Diagnosis:
    Marrital : Married 1x, 9 years Dysmenorrhea c.b
    Since 10 years before, Obstetric : P1A0 endometriosis cyst
    patient has been + adenomyosis
    complaining about Prior operation: 2011 – Mohammad Hoesin Hospital for laparoscopy e.c uteri + internal
    abdominal lump. Patient endometriosis cyst; 2013 – laparoscopic operation with PA result intramural uterine genitalia adhesion
    denied any history of myoma, bialteral endometriosis cyst; 2016 – Mohammad Hoesin Hospital LSCS and
    dyspareunia, post coital myoma-cyst operation Planning:
    bleeding, and vaginal Physical examination : Laparoscopic
    discharge but agreed for BP : 120/80 mmHg, HR: 88x/m, RR: 20x/m, T: 36.5ºC operatif
    having menstrual pain. General status : Normal
    Patient had normal urinary Doctor in charge :
    routine and bowel habits. Gynecologic status : IS
    Patient denied any weight Abdomen : Flat, supple, symmetrical, fundal of uterine not palpable, free fluid sign (-),
    lost or any loss of appetite. tenderness (-), mass (-)

    Vaginal Speculum exam: Portio non-livide, closed OUE, fluor (-), fluxus (-) non active
    bleeding, E/L/P (-)

    Vaginal Toucher: Elastic portio, closed OUE, CUT~normal, non tense right and left AP,
    no protrusion of cavum douglassi
    (1) Mrs. DIA/ 36 YO/ P1A0
    Anamnase Physical Examination and supportive exam Diagnosis and
    Planning
    USG Confirmation:
    ˗Uterus AF, normal shape and size
    ˗Posterior corpus: uncircumscribed hyperechoic mass, 1.7 x 3.2 cm in size suspected for
    adenomyosis
    ˗Right adnexa: cystic mass, 27.1 x 5.1 cm suspected for endometriosis
    ˗Left adnexa: mass (+) 5.17 x 2.11 cm, suspected for endometriosis cyst
    ˗Internal genitalia adhesion
    ˗Liver and both kidney in normal condition

    Conclusion: Adenomyosis uteri, bilateral endometriosis cyst, internal genitalia adhesion

    Laboratory examination:
    Hb 11.2 WBC 7900 PLT 314.000 SGOT 13 SGPT 14 GDS 99 Cr 0.76 Ur 19 Na 143 K
    4.0 AFP 1.36 CA 125 51.3
    (1) Mrs. DIA/ 36 YO/ P1A0
    (1) Mrs. DIA/ 36 YO/ P1A0
    Thank You

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