Mrs. MUR/ 65 y.o./ BC/ dr.

PUM, SpOG(K)
(S) Patient was referred from Gynecology Outpatient Clinic Airlangga
University Hospital with Suspected malignant ovarian cyst planned for
TAH BSO + Surgical staging at 4/5/2021; LMP: Menopause since year
2000; Married 1x  50 years; (O) General Status: GCS 456, A(-)/ I(-)/
C(-)/ D(-); BP: 127/78, P: 88, RR: 20 SPO2 99& on room air, T: 36o C;
Weight: 76 kg; Height: 148 cm; BMI: 34,7; Cor: WNL Pulmo: WNL;
Gynecologic Status: v/v flx (+/-) flr (-) P: closed, atrophic, pushed toward
anterior; CU: AF ~ as high as 5/6 weeks pregnancy, AP D/S: cystic mass
size 25x20 cm, pain (-), CD: WNL; RT: anal sphincter tone (+), smooth
mucosa, lower tumor pole was palpated; Laboratory Results of Airlangga
University Hospital (May 4th 2021); Hb 13,1; WBC 7.660; NLR 0,99; Plt
463.000; BT/CT 1’/12’; BUN/SrCR 7/1.07; Na/K/Cl 141/4/104 Airlangga
University Hospital CT Scan Result (February 26th 2021): Multiloculated
ovarial cyst bilateral, dextra size 14,35x26,83x15,40 cm, sinistra size
22,97x10,81x10,29 cm; Lower pole dextra kidney cyst size 1,34x0,97 cm;
Subcentimeter Lymphnodes at paraaorta, mesenterica, and right ingunal;
Lumbal spondylosis; PCR Swab Covid-19 Sheila Medika Hospital (May
2nd 2021): Negative; CXR: Negative; Satgas Covid-19 team suggestion:
Non COVID; (A) Suspected malignant ovarian cyst + HT Stage I; (P)
Planned for SVH BSO; Durante op: Adnexa Dextra: Multiloculated cystic
mass size 25cm~; Adnexa S: Multiloculated cystic mass size 20cm;
Performed cyst decompression  clear fluid, +/- 3000cc; mass adhesion
toward intestine performed adhesiolysis; (I) Planned for TAH-BSO s/d
surgical staging at May 4th 2021; Amlodipin 1x10mg

Mrs. RIA/ 45 y.o./ BC/ dr. PUM, SpOG(K)

(S) Patient was referred from Gynecology Outpatient Clinic Airlangga
University Hospital with Endometrioma dd Suspected malignant Ovarian
Cyst; LMP: April 25th 2021; Married 2x  I. 13 years (divorced); II. 2013
– now; Contraception: (-); (O) General Status: GCS 456, A(-)/ I(-)/ C(-)/
D(-); BP: 120/70, P: 80, RR: 20 SPO2 98% on room air, T: 36o C; Weight:
64 kg; Height: 150 cm; BMI: 28,7; Cor: WNL Pulmo: WNL; Gynecologic
Status: v/v flx (+/-) flr (-) P: closed, fixed; CU: AF ~ WNL, AP D/S: :
mass (+) size 15 cm, pain (-), CD: WNL; RT: anal sphincter tone (+),
smooth mucosa, lower tumor pole was palpated; Laboratory Results of
Airlangga University Hospital (February 24th 2021); CEA: 0,95; Ca-125 :
42,9; (April 30th 2021); Hb 11,6; WBC 6.730; Plt 331.000; BT/CT 1’/10’;
Airlangga University Hospital CT Scan Result (February 18 th 2021): Solid
mixed cystic mass size +/- 14,1 x 12,2 x 12 cm at left and right adnexa
could be suspected as left and right malignant ovarial mass; Multiple
hepatic cystic; Multiple bilateral kidney cyst; Subcentimeter Lymphnodes
at paraaorta, mesenterica, and right ingunal; PCR Swab Covid-19 (May 3rd
2021): Negative; CXR: Negative; Satgas Covid-19 team suggestion: Non
COVID; (A) Suspected malignant ovarian cyst + HT Stage I; (P) Planned
for SOD + Adhesiolysis; Durante op; Enlarged left ovarium size +/- 15 cm
 ruptured, chocolate colored; adhesion toward rectum was found
released; (I) Planned for TAH-BSO today

Mrs. KAS/ 59 y.o./ BC/ dr. EGA, SpOG(K)

(S) Patient was referred from Gynecology Outpatient Clinic Airlangga
University Hospital with uterine fibroid + HT + DM type II; LMP:
Menopause at 2007; Married 1x  39 years; Contraception: (-); (O)
General Status: GCS 456, A(-)/ I(-)/ C(-)/ D(-); BP: 135/76, P: 98, RR: 20,
T: 36o C; Weight: 46 kg; Height: 148 cm; BMI: 21; Cor: WNL Pulmo:
WNL; Gynecologic Status: v/v flx (+/-) flr (-) P: closed, smooth, CU: AF
enlarged ~ 24 weeks, AP D/S: : mass (-), pain (-), CD: WNL; RT: anal
sphincter tone (+), smooth mucosa; Laboratory Results of Airlangga
University Hospital: Hb 16,9; WBC 5.930; Plt 312.000; FPG/OGTT:
265/370; BUN/SrCr: 13,8/0,31; Na/L/Cl: 139/3,5/104; USG result of 5th
floor delivery ward: Uterus size 18,3 x15,7 cm; ET 4,2 mm; Multiple
isoechoic lesion at posterior corpus size 9x7 cm, 8x7 cm; Ring of fire (+);
Suspected of multiple uterine fibroid; PCR Swab Covid-19 (May 4 th
2021): Negative; CXR: Negative; Satgas Covid-19 team suggestion: Non
COVID; (A) Multiple uterine fibroid + HT + DM type II; (P) Planned for
SVH- BSO; Durante op; Enlarged uterus~ 24/25 wga; AP D/S within
normal limit; Multiple intramural uterine fibroid was found; (I) Planned
for TAH-BSO today; (I) Candesartan tab 80 mg every 24 hours; Concor
tab 2,5mg every 24 hours; Inj. Novorapid 6-6-6 iu s.c.; Inj. Levemir 0-0-
10mg; Planned for TAH-BSO today; Morning blood glucose: 119