OBSTETRIC OUTPATIENT

REPORT
Tuesday, November 20th, 2018
Residents:
Dr. Eka Handayani O
Dr. Ibnu Sina
Dr. Terry Mutia - Dr. Asep Nurul Huda
Dr. Aditya Rachman
Dr. M. Ath Thaariq. P - Dr. Febi Stevi Aryani

Supervisor:
Dr. Hj. Putri Mirani, OBGYN(C)
Recapitulation Obstetric Outpatient
th
Tuesday, November 22 , 2018
Physiology Patient 0
Pathology Patient 2
Total 2
Friday, November 16th 2018 – Thursday, November 22nd 2018

Physiology Pathology Total

Friday, Nov 16th 2018 0 1 1

Monday, Nov 19th 2018 0 0 0
Tuesday, Nov 20th 2018 1 0 1
Wednesday, Nov 21st, 2018 0 0 0
Thursday, Nov 22nd, 2018 0 2 2
Total 1 3 4
NO. IDENTITY DIAGNOSIS ICD-10 MANAGEMENT ICD-9
1. Mrs. NYI/ 34 G4P3A0 13 weeks gestational O98.711 CIE V08
y.o/ UA/ NS age with HIV, SLF intrauterine Ferrous sulfate tab 1 x 300 mg
Calcium lactate tab 3 x 500 mg

2 Mrs. APR/ 39 G6P2A3 38 weeks gestational O99.119 CIE 649.33

y.o/ RA/ age with non in labor with APS, D68.61 Ferrous sulfate tab 1 x 300 mg
SFL cephalic presentation Calcium lactate tab 3 x 500 mg
Mrs. NYI/ 34 y.o/ UA/NS BACK

Chief Complain Preterm pregnancy with HIV

Anamnesis Patient come to RSMH Fetomaternal Polyclinic for antenatal care of pregnancy. History of vomitting (-
), history of abdominal contraction spread to waist and back (-), history of bloody show (-), history of
amnionic leakage (-), hystory of post coital (-), urination and defecation was normal. Patient
diagnosed HIV since 2012 and went to voluntary counselling and testing (VST) routinely, history of
chronic diarrhea (-), history of chronic fever (-), history of oral candidiasis (-), history of recurrent oral
thrush (-). Patient admitted that her pregnancy was preterm and fetal movement (+).

Marital status 2x, First: 2002 – 2010, Second: 2017 – now

Reproduction status Menarche 12 yo, regular cycle, lasts 7 days, LMP: August 12th, 2018
Obstetric History 1. 2003, female, 3500 gr, vaginal delivery, Tiara Fatrin Hospital, health
2. 2007, female, 3650 gr, vaginal delivery, Bunda Fatima Hospital, health
3. 2009, male, 3400 gr, vaginal delivery, midwife, health
4. Current pregnancy

Past medicine history Neviral® since 2012

Duviral® since 2012

Past illness history HIV since 2012

Family illness history History of HIV in family (-)

Mrs. NYI/ 34 y.o/ UA/NS BACK

Physical Examination Vital Signs

Sens: Compos Mentis BP: 90/70 mmHg Pulse : 86 x/m T: 36,2 oC RR: 20 x/m BW 51 kg BH 168 cm
Head: normocephal, screal icterus (-), anemic conjuctiva (-),
Neck: JVP (5-2) cmH₂O
Thorax pulmo: symmetric, fremitus dextra = sinistra, resonant percussion, vesicular breath sound
Thorax cardio: ictus cordis not visible, ictus cordis not palpabled, normal first and secound heart
sound, heart reate 84 x/m
Extremities: CRT < 2 seconds, edema pretibial (-)

Obstetric Palpation: Flat, suffle, uterine fundal unpalpabled, tenderness (-), free fluid sign (-), uterine
Examination contraction (-), FHR 126 bpm

Laboratory
Mrs. NYI/ 34 y.o/ UA/NS BACK

US examination

Diagnosis G4P3A0 13 weeks gestational age with HIV, SLF intrauterine

Therapy CIE
Ferrous sulfate tab 1 x 300 mg
Calcium lactate tab 3 x 500 mg
Mrs. APR/ 39 y.o/ RA/ BACK

Chief Complain Control preterm pregnancy

Anamnesis Patient come to RSMH Fetomaternal Polyclinic complains nausea. History of vomitting (-), history of
abdominal contraction spread to waist and back (-), history of bloody show (-), history of amnionic
leakage (-), hystory of post coital (-), hystory post coital (-), hystory of fever (-), urination and
defecation was normal. Patient sufferd for APS (Antiphospolipid Syndrome) since 2007, controlled,
consumed Aspillet® routinely. Patient admitted that her pregnancy was preterm and fetal movement
(+).

Marital status 1x, 13 months

Reproduction status Menarche 14 yo, regular cycle, lasts 10 days, LMP: forget
Obstetric History 1. 2005, Abortus, 12 weeks gestational age, curettage (+) at Moh Hoesin Hospital
2. 2006, Abortus, 8 weeks gestational age, curettage (+) at Moh Hoesin Hospital
3. 2008, Abortus, 12 weeks gestational age, curettage (+) at Moh Hoesin Hospital
4. 2008, male, 2600 gr, caesarian section indicated by APS and transveresed lie position at
Muhammadiyah Hospital, health
5. 2016, male, 2700 gr, caesarian section indicated by APS at Moh Hoesin Hospital, health
6. Current pregnancy

Medicine History Aspillet® since 2007

Past illness history APS (Antipospholipid Syndrome) since 2007
Family illness history None
Mrs. APR/ 39 y.o/ RA/ BACK

Physical Examination Vital Signs

Sens: Compos Mentis BP: 120/80 mmHg Pulse : 80 x/m T: 36,5 oC RR: 20 x/m BW 56 kg BH 152 cm

Obstetric Palpation: Uterine fundal 3 fingers below procesus xypoideus (34 cm), longitudinal lie, left back,
Examination cephalic, floating, uterine contraction (-), FHR 145 bpm, EFW 3255 g

Laboratory
Mrs. APR/ 39 y.o/ RA/ BACK

US Examination

Diagnosis G6P2A3 38 weeks gestational age with non in labor with APS, SFL cephalic presentation

Therapy CIE
Ferrous sulfate tab 1 x 300 mg
Calcium lactate tab 3 x 500 mg
TERIMA KASIH