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DUTY REPORT

Thursday, September 14th 2017

Supervisor :
dr. Melvin NG Barus, M.Ked(OG), Sp.OG

Residents : 1. dr. T. Larry Athit


2. dr. M. Iman Syaputra
3. dr. T. Amru Umara
4. dr. Sofyan Andri

Department of Obstetrics and Gynecology


Medical Faculty Universitas Sumatra Utara
RSUP H. Adam Malik
2017
NEW PATIENT : 2 PATIENT
1. Mrs. R, 38 y.o, G1P0A0
Diagnose : PE with severe features + AKI stadium failure +
Hepatitis B + PG + IUP (36-37) wga + head presentation + alive
fetus
Plan : C-Section immediately

2. Mrs. I, 26 y.o, G3P2A0


Diagnose : preterm labor + MG + IUP (30-31) wga + breech
presentation + alive fetus
Plan :
PATIENT 1
Mrs. R, 38 y.o, G1P0A0, Bataknese, Christian, Senior high school,
housewife, married to Mr. S, 38 y.o, Bataknese, Christian, Bachelor,
government employees.

CC : abdominal contraction
Experienced by the patient since 4 hours ago, and getting more frequent.
History of bloody show (+), since 8 hours ago. History of amniotic fluid
leakage (-). History of hypertension before (-). History of blurred vision (-).
Headache (-). Nausea (-), vomiting (-). Micturition and defecation within
normal limit. This patient was referred from other hospital with diagnose
severe PE + PG + IUP (aterm) + head presentation + alive fetus

History of previous ilness : (-)


History of previous medication : MgSO4, nifedipin
LMD : ? 12 - 2016
EDD : ? 09 - 2017
ANC : midwife 5x, obstetrician 2x

History of Pregnancy
1. Current Pregnancy
Present State
Cons : Alert Anemic : (-)
BP : 180/100 mmHg Icteric : (-)
HR : 74 times/min Cyanotic : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36,7 C Oedem : (-)

Localized state
Head : Anemic palpebra Conjuctiva (-), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Genitalia : no abnormality
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Obtetrical State

Abdomen : symetrically enlargement


Fundal Height : 3 finger below process xyphoideus
Tension part : left
Lower part : head
FHR : (+) 138 bpm, reguler
FM : (+)
Uterine contraction : (-)

Vaginal exam : cervix was closed


USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
Singleton pregnancy, head presentation, alive fetus
FHR (+) 128 bpm, FM (+)
BPD : 8,88 cm
HC : 31,31 cm
AC : 32,52 cm
FL : 6,68 cm
EFW : 2800 gr
S/D ratio : 3,96
AFI : 4,15 cm
Placenta fundal grade III

Conclusion:
IUP (36-37) wga + head presentation + alive fetus
LABORATORY FINDINGS on September, 14th ,2017
Hb : 10,3 N: 12-14 gr/dl
Ht : 31 N: 36-42 gr/dl
Leukocyte : 14.300 N:4000-11000/mm3
Platelet : 279.000 N:150000-400000/mm3
adRandom glucose : 64 N : < 200
Ureum : 101 N : > 50 mg/dl
Creatinin : 3,51 N : 0,6-1,2 mg/dl
Natrium : 129 N :135-155
Kalium : 4,2 N : 3.6-5.5
Cloride : 99 N : 96-106
HBsAg : Reactive N : non reactive
Anti HIV : non reactive N : non reactive
Diagnosis : PE with severe features + AKI stadium failure +
Hepatitis B + PG + IUP (36-37) wga + head presentation + alive
fetus

Therapy :
- IVFD RL 20 dpm
- Inj. Cefazoline 2 gr profilaxis

Plan:
- C-section immediately
THANK YOU
PATIENT 2
Mrs. I, 26 y.o, G3P2A0, Bataknese, moslem, Primary school, housewife,
married to Mr. M, 26 y.o, Javanesse, Moslem, Senior high school,
fisherman.

CC : labor contraction
Experienced by the patient since 1 day ago, and getting more frequent.
History of bloody show (+), since 10 hours ago. History of amniotic fluid
leakage (-). Micturition and defecation within normal limit.

History of previous ilness : (-)


History of previous medication : dexamethasone, nifedipine
LMD : ? 2 - 2017
EDD : ? 11 - 2017
ANC :
History of Pregnancy
1. Boy, preterm, ? gr, SVD, midwife, home, death (2014)
2. Boy, aterm, ? gr, SVD, doctor, Hospital, 2 y.o, healthy
3. Current Pregnancy
Present State
Cons : Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
HR : 80 times/min Cyanotic : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36,7 C Oedem : (-)

Localized state
Head : Anemic palpebra Conjuctiva (-), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Genitalia : no abnormality
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Obtetrical State

Abdomen : Asymetrically enlargement


Fundal Height :
Tension part : right
Lower part : breech
FHR : (+) 152 bpm
FM : (+)
Uterine contraction : 2x20/10

Vaginal exam : cervix axial, dilatation 1 cm, eff 80%, floating breech,
amniotic membrane (+) protruded
Gloves : slime (+), blood (+)
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
Singleton pregnancy, breech presentation, alive fetus
FHR (+), FM (+)
BPD : 8,15 cm
HC : 28,37 cm
AC : 26,27 cm
FL : 6,24 cm
EFW : 1771 gr
Placenta fundal grade II

Conclusion:
IUP (30-31) wga + breech presentation + alive fetus
LABORATORY FINDINGS on September, 14th ,2017
Hb : 10,6 N: 12-14 gr/dl
Ht : 33 N: 36-42 gr/dl
Leukocyte : 12.310 N:4000-11000/mm3
Platelet : 224.000 N:150000-400000/mm3
adRandom glucose : 85 N : < 200
Ureum : 28 N : > 50 mg/dl
Creatinin : 0,31 N : 0,6-1,2 mg/dl
Natrium : 137 N :135-155
Kalium : 3,6 N : 3.6-5.5
Cloride : 106 N : 96-106
HBsAg : N : non reactive
Anti HIV : N : non reactive
Diagnosis : preterm labor + MG + IUP (30-31) wga + breech
presentation + alive fetus

Therapy :
- IVFD RL 20 dpm
- Inj. Dexamethasone 6 mg/12 hours
- Nifedipine 20 mg (mitral dose) 4x10 mg maintenence

Plan:
- Expectative care
THANK YOU