GYNECOLOGY WARD REPORT

Thursday, April 8th 2021

Supervisors :
dr. Yudha Sudewo, M.Ked(OG), Sp.OG(K)

Residents:
dr. Andry Hamonangan Sipahutar
dr. Hariadi Supanto
dr. Armin Wijaya
dr. Benjamin Sihite
dr. Reni Hayati Hasibuan
dr. Rizka Amelia Sari

Department of Obstetric and Gynecology

Medical Faculty of Universitas Sumatera Utara
H. Adam Malik General Hospital
2021
1 PATIENT
1. Mrs. E, 35 yo, P3003

Diagnosis : Recto-Vagina Fistula

Supervisor : Dr. dr.Edy Ardiansyah, M.Ked (OG), Sp.OG(K)

Planning : Repair Fistula Surgery

THANK YOU
PATIENT 1
Mrs. E, 35 yo, P3003, Mandailing, Islam, Bachelor, Enterpreneur, married once at 27 yo, with
Mr. A, 38 yo, Mandailing, Islam, Bachelor, Civil Servant, came to Adam Malik Gynecology
Outpatient Clinic on April 6th 2021 with:

Cc : Stool pass through vagina

E : This has been experienced by the patient since 7 months before admitted to the
hospital. This happens every time the patient defecate. The patient had perineum
rupture grade IV after gave birth to her 3rd child, helped by a midwife. One week after
delivery, the patient had laceration repaired by OBS/GYN in Penyabungan Hospital.
History of intermenstrual bleeding (-). History of pain during intercourse (-). History
of abdominal pain (-). Micturition and defecation within normal limit.
Previous illness : -

Previous medication : -
Previous surgery : Repair perineum laceration grade IV (2020)

History of contraception : -
History of menstruation : Menarche at 13 yo, 28 cycle, regular 5 days, 2-3x
changing pads/day, menstrual pain (-)
Present State:
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 82 x/min Cyanosis : (-)
RR : 20 x/i Dyspnoe : (-)
Temp : 36,8 OC Edema : (-)

General condition : Moderate BW : 79 kg

Nutrition state : Obesity Height : 155 cm
Illness condition : Moderate BMI : 32.88 kg/m2

Generalized State:
Head : Conj. palpebra inferior pale (-), icteric (-)
Neck : No abnormalities
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rales (-)/(-)
Abdomen : Laxed, perisltaltic (+) normal
Extermity : Oedem (-/-), Cyanosis (-/-)
Localized State
Abdomen : Laxed, Peristaltic (+), Normal

Vaginal Bleeding : (-)

Gynecological State
Inspeculo : Portio was smooth, erotion (-), blood (-), F/A (-), discharge (-), mass (-)

VT : Uterus AF normosize, no palpable mass on right and left adnexa, right and left
parametrium were laxed. Cavum Douglas was not protruded.
TVS
TVS
 USG TVS
March 24th 2021

• Bladder was filled

• Uterine AF normosize, sized 6.5 x 3.5 x 3.8 cm
• E-line (+) thickness 2.7 cm
• Right ovary : normal, sized 2.3 x 1.4 cm
• Left ovary : normal, sized 1.8 x 1.4 cm

Conclusion : Uterine and ovary within normal

 Chest X-Ray
March 29th 2021

Conclusion :
Cor and pulmo within normal limit
 Laboratory findings
March 29th 2021
Hb : 14.1 N : 12-16 gr/dL
Leucocyte : 15.470 N : 4000-11000/u
Hematocrite : 40.7 N : 36,0-47,0/%
Platelet : 384.000 N : 150.000-450.000/uL
MCV : 89 N : 81-99
MCH : 30.7 N : 27-31
MCHC : 34.6 N : 31-37
RDW : 10.2
Neutrofil : 63.30 N : 50-70
Limfosit : 28.20 N : 20-40
Monosit : 4.40 N : 2-8
Eosinofil : 3.70 N : 1-3
Basofil : 0.50
Neutrofil abs : 9.79 N : 2.7-6.5x103/uL
Limfosit abs : 4.37 N : 1.5-3.7x103/uL
Monosit abs : 0.68 N : 0.2 – 0.4
Eosinofil abs : 0.57
Basofil abs : 0.06
NRBC : 0.0
 Laboratory Findings
March 29th 2021
Glucose adrandom : 92 N: <200 mg/dl
BUN : 10 N: 15-40
Ureum : 21 N: 13
Creatinin : 0.63 N: 0.6-1.2 mg/dl
Natrium : 136 N: 136-155 mmol/dl
Kalium : 4.0 N: 3.5-5.5 mmol/dl
Chlorida : 104 N: 95-103mmol/dl
PT : 11.4 C: 13,6 sec
INR : 0.91 C: 0.8 – 1.30
APTT : 28.8 C: 30.2 sec
TT : 14.8
pH : 7.410 N: 7.35 – 7.45
pCO2 : 32.0 N: 38 – 42
pO2 : 127.0 N: 85 – 100
HCO3 : 20.3 N: 22 – 26
Total CO2 : 21.3 N: 19 – 25
BE : -3.6 N: (-2) – (+2)
SO2 : 99.0 N: 95 - 100
HBsAg : Non-reactive
PCR SARS CoV-2 : Negative
Diagnosis : Recto-Vagina Fistula

Therapy : -

Planning : Repair Fistula Surgery(07/04/2021)

Report to supervisor Dr. dr. Edy Ardiansyah, M.Ked (OG), Sp.OG(K)  Approved
THANK YOU
Follow up April 06th 2021 (Gynecology)
S Prepare for surgery planning

O Presens state
Sens : Compos Mentis
BP : 110/70 mmHg
P : 82 bpm
RR : 20 x/min
T  : 36.80C
Localized state
Abdomen : Laxed, Peristaltic (+), Normal
Vaginal Bleeding : (-)
Micturition : (+)
Defecation : (-), Flatus (-)
A Retro-vagina fistula
P IVFD RL 20 dpm
Inj. Cefazolin 2gr IV
Dulcolax Supp No.II – klisma
Dulcolax tab No. II
Fasting 6-8 hours
Pray
Plan Repair fistula surgery (07/04/2021)
 Cardiology Department
April 6th 2021

A: Recto-Vagina fistula
P: Operating tolerance: low risk
 Pulmonology Department
April 6th 2021

A: Recto-Vagina Fistula
P: Operating tolerance: low to moderate risk
 Anaesthesiology Department
April 6th 2021

A: Recto-Vagina Fistula
P: Accept to give anasthesia in this patient
THANK YOU