Identity Mrs.

THEIN /31 YO/ 970637 Palembang/DHA – AIS – JAY /PB

Chief Complaint preterm pregnancy with high blood pressure
History of present Patient was referred from SpOG with diagnosis G3P2A0 34 weeks gestational age not
illness in labor with prior CS 2x (oi severe preeclampsia) SLF cephalic presentation.
History of abdominal contraction radiates to waist (-), history of bloody show (-),
history of amniotic fluid leakage (-). History of blurry vision (+), epigastric pain (+),
hypertension before pregnancy (-), hypertension in prior pregnancy (+), hypertension
in current pregnancy (+). Patient admitted that she had aterm pregnancy with fetal
movement still can be felt .
Past illness history Patient had hypertension since 6 months gestational age but didnt consume any
medication
Married status Married 1x for 8 years
Reproduction Status Menarche 12 yo, regular, 4 days, LMP 28.3.2022
Obstetric History 1. 2016/ male/ 2600 g/ aterm/ CS/ SpOG/ healthy
2. 2020/ female/ 3100 g/ aterm/ CS/ SpOG/ RS Hermina/ healthy
3. Current pregnancy
Physical Examination BP : 170/100 mmHg, Pulse 88 x/minute, RR 20x/minute, T : 36,6 oC
Body weight: 80 kg, body height: 158 cm, IMT 32,04 (Obesse gr I)Head:
normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
IG 5 Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement
TDS 170: 2 (-)
TDD 100: 1 Thorax:
Proteniuria +2: 1 Cor: Normal I-II heart sound, murmur (-), gallop (-)
Pretibial edema: 1 Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: edema pretibial (+/+)
Obstetrical External examination :
examination Uterine fundal height at 2 fingers below xyphoid process (32 cm), longitudinal lie,
right fetal spine, cephalic, U 5/5, FHR 144 bpm, EFW 2945 g, contraction (-)
Speculum examination:
Livide portio, closed OUE, fluor (-), fluxus (-), E/L/P (-).
Vaginal Toucher:
Soft portio, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic and
denominator can’t be assessed yet
CTG examination
IGD

US Result - Single life fetus, cephalic presentation

- Fetal biometric:
- BPD 8.52 cm HC 30.56 cm
- AC 28.45 cm FL 6.43 cm
- EFW 2189 gr
- Sufficient amniotic fluid, SDP 3,74 cm

C/
- 34 weeks gestational age single life fetus cephalic presentation
Laboratory Result Hb : 12,5 wbc : 9.960 Ht : 36 PLT: 223.000 SGOT : 21 SGPT : 21 LDH : 200 Ur : 26
22.11.202 Cr : 0,72 Asam urat : 6,3 Mg : 1,80 Na : 142 K : 4,8 triple eliminasi : non reaktif
Urin : protein : +1,
CTG

Diagnosis  G3P2A0 34 weeks gestational age not in labor (Z3A.37)

 Prior CS 2x (oi severe preeclampsia)
 Severe preeclampsia
 Single life fetus cephalic presentation (O32.0)
Management · Observation of vital sign, contraction and FHR
· Stabilization
· Expectative management
· Lab examination
· US Confirmation
· Anti convulsant
· Anti hypertension
Follow up Obgyn S/
23.11.2022 preterm pregnancy with high blood pressure
04.00 PM
O/
BP : 150/90 mmHg, Pulse 88 x/minute, RR 20x/minute, T : 36,6 oC
External examination :
Uterine fundal height at 2 fingers below xyphoid process (32 cm), longitudinal lie,
right fetal spine, cephalic, U 5/5, FHR 144 bpm, EFW 2945 g, contraction (-)
 CTG examination : Category II

A/
 G3P2A0 34 weeks gestational age not in labor (Z3A.37)
 Prior CS 2x (oi severe preeclampsia)
 Severe preeclampsia
 Single life fetus cephalic presentation (O32.0)

P/
· Observation of vital sign, contraction and FHR
· Intrauterine resuscitation
· Expectative management
· US Confirmation
· Anti convulsant
· Anti hypertension
CTG examination
23.11.2022
04. PM

Follow up Obgyn S/
23.11.2022 Post Intrauterine resuscitation
05.00 PM

O/
BP : 150/90 mmHg, Pulse 88 x/minute, RR 20x/minute, T : 36,6 oC
External examination :
Uterine fundal height at 2 fingers below xyphoid process (32 cm), longitudinal lie,
right fetal spine, cephalic, U 5/5, FHR 144 bpm, EFW 2945 g, contraction (-)

CTG examination : Category II

A/
 G3P2A0 34 weeks gestational age not in labor (Z3A.37)
 Prior CS 2x (oi severe preeclampsia)
 Severe preeclampsia
 Single life fetus cephalic presentation (O32.0)
 Fetal distress

P/
· Observation of vital sign, contraction and FHR
· Intrauterine resuscitation
 · Expectative management
· US Confirmation
· Anti convulsant
· Anti hypertension
CTG examination
23.11.2022
05.00 PM

Follow up Obgyn S/
23.11.2022 Post Intrauterine resuscitation
06.00 PM

O/
BP : 150/90 mmHg, Pulse 88 x/minute, RR 20x/minute, T : 36,6 oC
External examination :
Uterine fundal height at 2 fingers below xyphoid process (32 cm), longitudinal lie,
right fetal spine, cephalic, U 5/5, FHR 144 bpm, EFW 2945 g, contraction (-)

CTG examination : Category II

A/
 G3P2A0 34 weeks gestational age not in labor (Z3A.37)
 Prior CS 2x (oi severe preeclampsia)
 Severe preeclampsia
 Single life fetus cephalic presentation (O32.0)
 Fetal distress

P/
· Observation of vital sign, contraction and FHR
· Intrauterine resuscitation
· US Confirmation
· Anti convulsant
· Anti hypertension
· Expectative management  Failed  LSCS

CTG examination
23.11.2022
06.00 PM
Operative report 07.50 PM operation started
23.11.2022  Patient on supine position under spinal anesthesia .
 Aseptic and antiseptic procedure on surgical site and its surroundin
g area was performed.
 Pfannenstiel incision was performed above prior cs. Abdominal wa
ll was incised further until the peritoneal cavity were exposed.
 LSCS was performed  vesicouterine pouch was opened, semilun
ar incision on lower uterine segment was performed. Amniotic flui
d (+)
 The baby was delivered by cephalic extraction

08.05 PM Life neonates was born, female, weight 2040 gram, length 46
cm, HC 32 cm A/S 8/9 PT AGA

08.10 PM Placenta was delivered completely, weight 450 gram,

umbilical cord length 45 cm, diameter 17x16 cm

Uterine cavity was explored with sterile gauze

Lower uterine segment closed with single layer continuous suture with P
GA 1
Bilateral Pomeroy tubectomy was performed using silk 2
Peritoneum was sutured with continuous suture using plain catgut 2.0
Muscle was sutured with continuous suture using plain catgut 2.0
Fascia was sutured with continuous suture using PGA 1
Subcutaneous layer was sutured with continuous suture using plain cat gu
t 2.0
Skin was sutured with subcuticular suturing using PGA 2.0

21.20 PM Operation finished

Ballard
Lubchenco

Recent diagnosis P3A0 post LSCS on indication fetal distress

Prior CS 2x (oi severe preeclampsia)
Severe preeclampsia
Post Pomeroy tubectomy
Recent condition The patient was stable in ward
Identity Mrs. Dwi Purwanti/ 25 YO/ 13012381/ Palembang/ FDI-LEO/ HD
Chief complain Preterm pregnancy with amniotic fluid leakage
Recent illness history Patient came with complained amniotic fluid leakage since 3 days before admission,
23.11.2022 clear color, smell (-), for 1x changing pad. History of abdominal contraction radiates
07.30 PM to waist (-). History of bloody show (-). Leucorrhea (-), history of tooth ache (-), fever
(-), cough (-), consume traditional medicine (-), trauma (-).

Patient admitted has preterm pregnancy with fetal movement still can be felt
Past Illness History -
Marital status Married 1x for 9 years
Reproduction status Menarche at 13 years old, regular, for 4-5 days, LMP : May, 01st 2022
Obstetric history 1. 2014, female, full term, 2900 gram, spontaneous delivery, midwife, healthy
2. 2022/12 weeks/abortion/curretage/ Kayuagung Hospital
3. Current pregnancy
Physical Examination BP: 130/80 mmHg Pulse: 86 bpm T: 36.8oC, RR: 20x/minute
BW 80 kg BH 153 cm BMI 34,18 kg/m2
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement (-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Obstetrical External examination
examination Uterine fundal height in 3 fingers above umbilicus (22 cm), longitudinal lie, right fetal
spine, cephalic, U 5/5, contraction (-), FHR 140x/minute EFW 1395 gram

Genitalia
Speculum examination
Livide portio, closed OUE, fluor (-), fluxus (+) amniotic fluid not active, E/L/P (-),
pooling sign (+), nitrazine test (+)
Vaginal toucher
Soft portio, posterior, closed OUE, eff 0 %, dilatation 0 cm, amniotic and denominator
can’t be assess yet
US examination - SLF cephalic presentation
23.11.2022 - Fetal biometric
BPD 7,45 cm. AC 24,85 cm
HC 26,91 cm. FL 5,36 cm
TCD 3,72 cm ~ 30w5d
EFW 1309 gram
PiMCA 1,17 PiUmb 1,06
- Amniotic fluid insufficient, AFI 3,90 cm ~ oligohydramnios
- Placenta at fundus of uterine
C/
30 weeks gestational age, SLF cephalic presentation
Laboratory Hb 11,2 g/dL; RBC 4.00 x 106/mm3; WBC 10.260/mm3; Ht 34%; PLT 310.000/µL
examination MCV 85,0 fL; MCH 28 pg; MCHC 33 g/dL; RDW-CV 14,80%; D/C 0/2/69/22/7;
23.11.2022
 PT 13,3 APTT 31,1 INR 0,93; SGOT 9 U/L SGPT 8 U/L; albumin 3,3 g/dL; LDH
139 U/L; BSS 73 mg/dL; Ureum 15 mg/dL; Creatinine 0,56 mg/dL; Na 137 mEq/L;
K 3,7 mEq/L; Cl 117 mmol/L; HsCRP 3,1 mg/L

HBsAg non reactive; TPHA non reactive; VDRL non reactive; Anti HIV non reactive

Urinalysis :
Bacteria (-); LEA (-); Nitrit (-); Leucocyte 0-1
CTG

Diagnosis  G3P1A1 30 weeks gestational age not in labor (Z34.30)

 Preterm pemature rupture of membrane 3 days (O42.11)
 Obese grade I (E66.1)
 SLF cephalic presentation (O32.0)
 Oligohydramnion (O41.0)
Management Observation of vital sign, contraction and FHR
Conservative management
Laboratory examination
CTG
Rehydration
Antibiotic
Lung maturation
US confirmation
Recent Condition Stable in ward

Identity Mrs. Mia Bt Iswan/ 23 YO/ 1064328/ Palembang/ FDI-LEO/ HD

Chief complain Preterm pregnancy with amniotic fluid leakage
Recent illness history Patient came with complained amniotic fluid leakage since 1 day before admission,
24.11.2022 clear color, smell (-), for 1x changing pad. History of abdominal contraction radiates
06.00 AM to waist (-). History of bloody show (-). Leucorrhea (-), history of tooth ache (-), fever
(-), cough (-), consume traditional medicine (-), trauma (-).

Patient admitted has fullterm pregnancy with fetal movement still can be felt
Past Illness History -
Marital status Married 1x for 5 years
Reproduction status Menarche at 13 years old, regular, for 4-5 days, LMP : March, 10th 2022
Obstetric history 1. 2018, male, full term, 2700 gram, LSCS oi anhydramnion, RSMH, healthy
2. Current pregnancy
Physical Examination BP: 130/80 mmHg Pulse: 86 bpm T: 36.8oC, RR: 20x/minute
BW 70 kg BH 153 cm
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement (-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Obstetrical External examination
examination Uterine fundal height in 3 fingers below proc. Xyphoideus (33 cm), longitudinal lie,
right fetal spine, cephalic, U 4/5, contraction (-), FHR 140x/minute EFW 3225 gram

Genitalia
Speculum examination
Livide portio, opened OUE, fluor (-), fluxus (+) amniotic fluid not active, E/L/P (-),
pooling sign (+), nitrazine test (+)
Vaginal toucher
Soft portio, posterior, opened OUE, eff 0 %, dilatation 1 cm multi, amniotic and
denominator can’t be assess yet

VBAC score 4

US examination - SLF cephalic presentation

24.11.2022 - Fetal biometric
BPD 9,66 cm. AC 33,08 cm
HC 34,17 cm. FL 7,18 cm
TCD 5,51 cm ~ 38w2d
EFW 3222 gram
PiMCA 0,84 PiUmb 0,76
- Amniotic fluid sufficient, AFI 10,68 cm
- Placenta at fundus of uterine
C/
38 weeks gestational age, SLF cephalic presentation
Laboratory Still in process
examination
24.11.2022
CTG

Diagnosis  G2P1A1 38 weeks gestational age not in labor (Z34.30)

 Pemature rupture of membrane 1 day (O42.11)
 Prior CS 1x oi anhydramnion (O34. 21)
 SLF cephalic presentation (O32.0)
Management Observation of vital sign, contraction and FHR
Laboratory examination
 CTG
Antibiotic
Anaesthesia assessment
Plan for LSCS

Identity Mrs. SEL/ 38 YO/ 802826/ Palembang/ FDI-LEO/ IS

Chief complain Inlabor
Recent illness history The patient complaint abdominal contraction radiates to waist (+) since 2 hours before
24.11.2022 admission. History of bloody show (+), History of amniotic fluid leakage (+), clear,
06.50 AM odor (-), History of post coital (-), Leucorrhea (-), consume traditional medicine (-),
history of trauma (-).

Patient admitted has fullterm pregnancy with fetal movement still can be felt
Past Illness History -
Marital status Married 1x for 11 years
Reproduction status Menarche at 13 years old, regular, for 4-5 days, LMP : March, 04th 2022
Obstetric history 3. 2013, male, full term, 3200 gram, spontaneous, RSMH, healthy
4. 2014, male, full term, 3200 gram, spontaneous, RSMH, healthy
5. Current pregnancy
Physical Examination BP: 120/80 mmHg Pulse: 86 bpm T: 36.8oC, RR: 20x/minute
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement (-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Obstetrical External examination
examination Uterine fundal height in 2 fingers below proc. Xyphoideus (33 cm), longitudinal lie,
right fetal spine, cephalic, U 4/5, contraction 2x/10’/25”, FHR 140x/minute, EFW
3100 g

Genitalia
Speculum examination
Patient refused
Vaginal toucher
Soft portio, medial, opened OUE, eff 75 %, dilatation 3 cm, amniotic (+) denominator
transverse sagital suture
US examination - SLF cephalic presentation
24.11.2022 - Fetal biometric
BPD 9,53 cm. AC 34,88 cm
HC 34,88 cm. FL 7,12 cm
TCD 5,41 cm ~ 38w0d
 EFW 3372 gram
- Amniotic fluid sufficient, SDP 6,71 cm
- Placenta at anterior of uterine
C/
38 weeks gestational age, SLF cephalic presentation
Laboratory Still in process
examination
24.11.2022
Diagnosis  G3P2A0 38 weeks gestational in labor latent phase stage I (Z34.38)
 SLF cephalic presentation (O32.0)
Management Observation of vital sign, contraction and FHR
Laboratory examination
Vaginal delivery

Gynecology

Identity Mrs. Nurmala Bt Namar/ 50 YO / 1302399/ Musi Rawas/ FDI-LEO-IKY/ IS

Chief complain Lower abdominal pain
Recent illness history Patient come with complained Lower abdominal pain since 1 week ago, patient also
23.11.2022 complained of abdominal enlargement since 1 month before admission. Patient felt
07.30 PM something like feces came out from vagina since 1 week ago.
history of decreased body weight (+), loss of appetite (+), nausea (+), vomitting (+).
Normal micturition and defecation
Past Illness History History of HTSOB on 2018 at Fatmawati Hospital Jakarta
History if external radiation 37x on 2018-2019
Marital status Married 1x for 30 years
Reproduction status Menopause 4 years ago
Obstetric history P2A0
Physical Examination BP: 130/70 mmHg Pulse: 92 bpm T: 36.8oC, RR: 20x/minute
BW 45 kg BH 155 cm
Head: normocephalic, pallor conjunctival (-/-), scleral icteric (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), thyroid glands enlargement
(-)
Thorax:
Cor: Normal I-II heart sound, murmur (-), gallop (-)
Lungs: normal vesicular sound (+/+), rhonchi (-/-), wheezing (-/-)
Extremities: pretibial edema (-/-)
Obstetrical Gynecology examination
examination External examination
Convex, supple, difficult to assess uterine fundus, tenderness (+), there was solid
mass palpable size 10 x 14 cm with upper border 2 fingers above umbilicus, right
border LMS dextra, left border LMA sinistra, free fluid sign (-)
Genitalia

Speculum examination

Bumpy vaginal stump, fragile, easily to bleed, mass invaded to 1/3 proximal vagina,
 feces (+)

Vaginal toucher

Bumpy vaginal stump, fragile, easy to bleed, mass palpable invade to 1/3 proximal
vagina

Rectal Toucher :
TSA normal, extraluminal mass was palpable, bumpy, smooth mucous, empty
ampulla recti.

US examination - Uterus and both adnexa was not visible ~ Post HTSOB
23.11.2021 - There was inhomogen solid mass at abdominopelvic cavity, irregular, with
size vascularization (+) size 10.49 cm x 14.17 x 10,49 cm ~ new growth mass
at abdominopelvic cavity
- There’s enlargement of the lymph nodes in left parailiacca 1,82 x 1,45 cm and
right parailiaca 1,17 x 1,37 cm
- Both ovaries were unvisualized
- Normal lymph nodes in the paraaorta
- Hepar and lien with normal limit
- There was dilatation of both calix and ureter ~ Hydronefrosis and hydroureter
bilateral
- Ascites (-)

C/
- New growth mass at abdominopelvic cavity
- Hydronefrosis and hydroureter bilateral
- Enlargement of the both parailiaca lymph nodes
Laboratory Hb 10,5 g/dL; RBC 3.94 x 106/mm3; WBC 10.860/mm3; Ht 32%; PLT 185.000/µL
examination MCV 85,0 fL; MCH 28 pg; MCHC 33 g/dL; RDW-CV 15,80%; D/C 0/3/73/14/10;
23.11.2022
PT 13,3 APTT 31,1 INR 0,93; SGOT 23 U/L SGPT 14 U/L; Albumin 3,3 g/dL; BSS
141 mg/dL; Ureum 66 mg/dL; Creatinine 3,97 mg/dL; Na 143 mEq/L; K 4,0
mEq/L; Cl 124 mmol/L;

HBsAg non reactive; TPHA non reactive; VDRL non reactive; Anti HIV non reactive
Diagnosis  Recurrent cervical cancer (C.53.9)
 Rectovaginal fistule was suspected (N82.3)
 AKI stage III dd/ acute on CKD (N18.30)
 Dehydration low intake (E86.0)
 Cancer pain (G89.3)
Management · Observation of vital sign
 · Laboratory examination
· Rehydration
· Analgetic
· Antiemetic
· Follow up biopsy result
· US Confirmation
· Join care with Internal medicine
· USG TUG
· Nephrosteril 1flash/24 hours during 3 days
Internal medicine A/
assessment
24.11.2022  Recurrent cervical cancer (C.53.9)
 Rectovaginal fistule was suspected
 AKI stage III dd/ acute on CKD ec obstructive uropathy
P/
 ACC jojn care
 USG TUG
 Nephrosteril 1flash/24 hours during 3 days
Recent Condition · Stable in ward