GYNECOLOGY WARD

Wednesday, September 6th 2023

Supervisor:
dr. M. Iman Syahputra, M.Ked(OG), Sp.O.G,

Residents:

dr Muhammad Fadli SYahdema

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Universitas Sumatera Utara General Hospital
2023
New Patient : 1 Patients
1. Mrs. Y, 47 yo, P4A0
Diagnosis : Post TAH d/t PUA-M+ POD-1
ICD X : N93.9 · Abnormal uterine and vaginal bleeding, unspecified
Supervisor : dr. M. Iman Syahputra, M.Ked(OG), Sp.O.G,
Planning : Chateter urine removal
Mobilization
PATIENT 1
Ms. Y, 47 yo, P4A0. The Patient was admitted from Gynecology Outpatient Clinic of USU General Hospital
on September 4th 2023 at 15.46 pm with:
Cc : Plan for TAH

E : History of vaginal bleeding (+), This has been experienced by the patient since 2 year ago
and getting worse last 1 month, frequency of 5-6x pad change. History of palpable abdominal
mass (-). Abdominal enlargement (-). History of vaginal bleeding (-), History of vaginal discharge
(-). History decrease of body weight (-). History of decrease of appetite (-). History of fever, cough,
and shortness of breath (-). Defecation and micturition within normal limit.
Previous illness :-
Previous Medication :-
Previous Surgery : Currettage (2020)
History of Contraception :-
History of Menstruation : Menarche on 12 yo, regular, 28 days cycle, duration 3-4 days, frequency 4 pads
change /day, Dysmenorrhea (+), LMP: on period
Vital Signs
Sens : Alert Anemia : (-)
BP : 118/78 mmHg Icteric : (-)
Pulse : 90 bpm Dyspnoe : (-)
RR : 20 bpm Cyanosis : (-)
Temp : 36,8°C Oedem : (-)

General state : Normal BW : 60 kg

Illness State : Normal BH : 155 cm
Nutritional State : Normal BMI : 24.97 kg/m2

Generalized State :
Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
Cor : Within no abnormality
Thorax : Respiratory sound : Vesicular
Additional sound : Rales (-/-), Wheezing (-/-)
Superior Ext/ Inferior Ext :Pretibial oedem (-/-)
Localized State:
Abdomen : Laxed, normoperistaltic, no mass palpable.
Vaginal Bleeding : (-)

Gynecology Examination
Inspeculo : Seen smooth ectocervix, hard on endocervix, bloodspot (+), mass (-), F/A (-)
VT : Uterus anteflexion normal size, no palpable mass both adnexa, both parametrium was
laxed, Douglas cavity was not protruded
 TAS
September 04th 2023
 TAS
September 04th 2023
 TVS
September, 4th 2023
‐ Bladder was not filled
‐ Uterus anteflexion size 84.9 x 39.6 x 67.7 mm
‐ E-line: (+) 12.4 mm
‐ Both ovaryis within normal limit
‐ Free fluid (-)
 Laboratory Findings
September , 04th 2023
• Hb : 10 N: 12-14 gr/dL
• Leukocyte : 7.970 N: 4.000-11.000/uL
• Hematocrite : 32 N: 36,0-42,0/%
• Platelet : 300.000 N: 150.000-400.000/uL
• MCV : 78.6 N: 82 – 92 fL
• MCH : 24.6 N: 27 – 33.7 pg
• MCHC : 31.3 N: 32 – 36 %
• Neutrofil : 59.2 N: 50.00 – 70.00%
• Limfosit : 24.1 N: 20.00 – 40.00%
• Monosit : 10 N: 2.00 – 8.00%
• Basophil : 5.5 N: 0 – 1%
• Neutrofil Abs : 4.72 N: 2,7-6,5 10^3/l
• Monosit Abs : 0.85 N: 0,2-0,4 10^3/l
• Eosinophyl Abs : 0,04 N: 0-0,1 10^3/l
• Basophyl Abs : 0,01 N: 0-0.1 10^3/l
 Laboratory Findings
September, 04th 2023
• PT : 13.9 C: 14.10”
• APTT : 33.6 C: 39.0”
• TT : 14.6 C: 15.0”
• Glucose ad random : 101 N: < 200
• Ureum : 44.60 N: 15-40 mg/dl
• Creatinin : 0.81 N: 0.6-1.1 mg/dl
• Natrium : 136 N : 136-146 mmol/L
• Kalium : 3.1 N : 3.5-5.1 mmol/L
• Chloride : 109 N : 98-106 mmol/L
• Anti HIV (Rapid) : Non-Reactive N: Non-Reactive
• HbsAg : Non-Reactive N: Non-Reactive
Diagnosis:
PUA-M

Therapy:
• IVFD RL 20 dpm
• Inj. Cefazoline 2gr  Profilaxys

Plan:
Elective TAH, On Tuesday September 05th 2023 with preparation 1 packs of PRC
Consult to Anesthesiology Departmenet

Reported to supervisor on duty dr. M. Iman Syahputra, M.Ked(OG), Sp.O.G, Approved

 Post TAH report d/t PUA-M
On Tuesday, September 05th 2023

• The patient was laid on the operation table with iv line inserted well, under spinal anesthesia foley catheter was inserted. Aseptic
and antiseptic was performed, then the abdomen was draped with sterile doek.
• John Cohen incision until below navel, ranging from kutis, subcutaneous, to open fascia with a length of 20 cm. And then insert
anatomical tweezers ensuring no muscle is attached underneath. The fascia is cut up and down, the muscle layer is bluntly dully
cut off.
• Peritoneum is clamped with peritoneum clamps, lifted and cut up and down, uterus, right and left adnexa within normal limits
• Then performed Total Abdominal Hysteretomy
• The abdominal cavity is rinsed with sterile water until it is clean, controlled bleeding.
• The abdomen cavity was closed layer by layer
• Surgical wounds are covered with supratule, sterile gauzed and hypafix.
• Operation completed, general state of mother post stable surgery.
• Uterus examination to the PA lab for hitopathological examination
Surgical Findings
Diagnosis:
Post TAH d/t PUA-M+ POD0

Therapy:
IUFD RL 20 dpm
Inj Ceftriaxone 1 gr/ 12hrs
Inj Ketorolac 30 mg/ 8 hrs
Inj. Ranitidine 1amp/12hrs

Plan:
Monitoring Vital Sign , Urine Output and Signs of Bleeding
Check CBC 2 hours after surgery

Reported to supervisor on duty dr. M. Iman Syahputra, M.Ked(OG), Sp.O.G  Approved

THANK YOU