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DUTY REPORT

Wednesday, Desember 5th 2018, 3.30 PM to


Thursday, Desember 6th 2018, 07.00 AM
Consultant on Duty :
Dr. H. A. Abadi, OBGYN(C)

Resident on Duty :
Obstetrical chief: Dr. M. Fauzi Chairul Husna
Gynecological chief: Dr. Arief Krisnadhi
Dr. Chaerannisa Akmelia
Dr. Willyyam Danles
Dr. Riyan Wira Pratama
Dr. Rivai Baharuddin
Dr. Mughan Sukardo
Dr. Wadhit Taubah
D. M. Atthariq Prasetiyo
Dr. Sonia Prima Arisa Putri

1
Duty Report
Wednesday, Desember 5th 2018, 3.30 PM to
Thursday, Desember 6th 2018, 07.00 AM

• Physiologic obstetrical patient : 1 case


• Pathologic obstetrical patient : 7 case
• Gynecological patient : 2 case
• Passed Away : 1 case
Total patients : 11 cases

• Obstetric ward patients : 35 patients


• Gynecology and Oncology ward patients : 38 patients
• ICU / HCU/ P1 patient : -/1/1 patients
Total patients : 75 patients

2
Obstetric Patients
No Identity Diagnosis ICD Procedure ICD
. 10 9
1 Mrs. G4P3A0 33 weeks gestational age O26.9 - VBAC 654.2
KAR/29/UA inlabor 1st stage active phase O14.3 P/ vaginal
with PPROM 4 hours + prior CS O34.21 delivery
1x oi SLF cephalic presentation

2 Mrs. NUR G2P1A0 38 weeks gestational age O14.3 - VBAC 654.2


/30/RA in labor 1st stage active phase O14.9 - Stabilization
with PROM 8 hours + severe O34.21 1-3 hours]
preeclampsia + prior CS 1x oi
- Antihyperten
severe preeclampsia SLF
cephalic presentation sion
- P/ vaginal
delivery

3 Mrs. G1P0A0 40 weeks gestational age O26.93 - Antibiotics 74.1


RUS/31/RA not inlabor with PROM 2 days O14.3 - LSCS
SLF cephalic presentation
anhydramnios
4 Mrs. ELI/32/ G3P2A0 32 weeks gestational age O26.9 - LSCS 74.1
UA not inlabor with APH ec total O44
placenta previa + recurrent
bleeding + asthma attack + H/
Hypertyroid uncontrolled + THD
NYHA 2 + moderate anemia SDF
cephalic presentation
5 Mrs. G3P2A0 38 weeks gestational age O26.93 - LSCS 650
LEN/37/UA inlabor 1st stage latent phase with O14.3
PPROM 4 hours + prior CS 2x SLF O34.21
cephalic presentation

6 Mrs. G1P0A0 37 weeks gestational age O26.9 - Partial 644.21


MEG/19/UA inlabor 2nd stage SLF breech Extraction
presentation
7 Mrs. G1P0A0 34 weeks gestational age not O26.9 - Expectative 644.0
FIT/26/UA inlabor with APH cb low lying O44 management
placenta SLF cephalic precentation - US confirmation
Gynecology Patients
No. Identity Diagnosis ICD 10 Procedure ICD 9
1 Mrs. Left humerus neoplasm with D16.0 Assessment
MAR/60/UA malignancy was suspeted OB/GYN

2 Mrs. FAR Ascites ec cirrhosis hepatic was K74.60 Assessment


/31/UA suspected OB/GYN
Moderate anemia
trombocytosis
Passed Away Patient
No. Identity Diagnosis ICD 10 Procedure ICD 9
1. Mrs. HER/38/RA P4A0 post LSCS oi antepartum Medicinalis 637.9
hemorrhage cb total placenta Resuscitation with 427.5
previa + prior LSCS 2X + fetal RJP
distress + moderate anemia +
anhydramnios + pulmonary
edema + CAP
Obstetric Patients
Identity 1. Mrs. KAR/29 yo/ UA
Chief complaint Inlabor with preterm pregnancy, watery discharge and prior cesarean section
History ± 4 hours before admission, patient complain about abdominal contraction(+). history of
5.12.18 bloody show (+), history of amniotic leakage (+) 1x changing napkins. history of abdominal
() massage (-), history of post coital (-), history of leucorrhea (+), history of abdominal trauma (-
), history of toothache (-). history of fever (-). She admitted that her pregnancy was preterm
and and fetal movement (+). Patient went to Moh. Hoesin hospital
Marital status Married 1 time 17 years
Reproduction status Menarche since 13yo, regular cycle 28 days, 7 days, LMP: 09 04 2018
Obstetric history 1. 2007. male. 2900g. Spontaneous. Midwife, healthy
2. 2012. male. 2800g. LSCS oi breech presentation. Healthy
3. 2014, male 2900g, Spontaneous. Midwife, healthy
4. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP: 120/80mmHg, HR: 82x/m, RR: 20x/m, T: 36.7 oC
Obstetric examination Palpation:
Fundal height 3 fingers below Proc.xyphoideus (32 cm), longitudinal lie, left back, head, U
4/5, uterine contraction (3x/10’/30”), FHR: 133 x/minute, EFW: 2945 g.
Inspeculo
Portio Livide, external uterine ostium opened, fluor (-), fluxus (+) amniotic fluid not active,
Nitrazine test + red blue, erosion/laceration/polyp (-)
VT
Portio soft, posterior, eff 100 %, 4cm of dilatation, cephalic, H I, amnionic membrane and
denominator cannot be determined yet
Identity 1. Mrs. KAR/29 yo/ UA
US (ER) There’s SLF cephalic presentation
Fetal biometry:
BPD 8.42 cm AC 28.14 cm EFW 2361g
HC 30.43cm FL 7.25 cm
Placenta at posterior corpus
Amnionic fluid minimal
C/ 33 weeks of gestational age SLF cephalic presentation
Diagnosis G4P3A0 33 weeks gestational age inlabor 1st stage active phase with PPROM 4 hours + prior
VBAC score : 9 CS 1x oi breech presentation SLF cephalic presentation

Laboratory Hb: 10.8 g/dl, WBC: 24.300/mm3, PLT: 370.000/mm3 Ht: 33%,
examination

Management • Observation vital signs ,FHR, and labor


• IVFD RL gtt xx/m
• Laboratory examination
• Plan for vaginal delivery
Identity
Mrs.NUR/30 yo/RA
Chief complaint Inlabor with high blood pressure and amniotic leakage, prior cesarean section BACK
05/12/18
20.20 AM
History 8 hours before admission, Patient admitted history of amniotic leakage (+) clear, odor (-), 3x change napkin. History
of abdominal contraction spreading to waist and back (-), bloody show (+), Hypertension in current pregnancy (-),
hypertension before pregnancy (-), hypertension in previous pregnancy (+), hypertension in family (-), severe
headache (+) nausea (-), vomiting (-), epigastric pain (-), blurry vision (-). History of abdominal massage (-). History
of abdominal trauma (-). History of traditional drugs consumption (-), history of leukorrhea (+), post coital (-), history
of toothache (-), history of fever (-)
She admitted that her pregnancy was aterm and fetal movement (+).

Marital status Married 1 time 6 years


Reproduction status Menarche since 12 yo, regular cycle 28 days, for 3 days, LMP : 22-2-2018
Obstetric history 1. 2013. female. 3100g. Aterm. LSCS oi severe preeclampsia. Healthy. Bari Hospital
2. This pregnancy
Past iIlness history (-)

Vital Sign BP 160/100 Pulse : 88x/m T: 36.5 RR: 20x/m


Obstetrical examination Palpation:
GI 5 Fundal height 3 fingers below Proc.xyphoideus (32 cm), longitudinal lie, left back, head, U 4/5, uterine contraction
BS: 2 (2x/10’/25”), FHR: 146 x/minute, EFW: 3100g.
Inspeculo
Portio Livide, external uterine ostium opened, fluor (-), fluxus (+) amniotic fluid not active, Nitrazine test + red
blue, erosion/laceration/polyp (-)
VT
Portio soft, anterior, eff 100 %, 4cm of dilatation, cephalic, H I, amnionic membrane (-) clear odor (-), HI-IIand
denominator left transverse occiput
Identity Mrs.NUR/30 yo/RA
US ER (CNN) • SLF cephalic presentation
• Fetal Biometry
• BPD 9.38 mm , HC 33.11 mm, AC 34.16mm, FL 7.55 mm EFW 3520g
• Placenta at anterior corpus
• Amnionic fluid sufficient
C/ 38 weeks of gestational age SLF cephalic presentation
Lab results (5-12-18) Hb: 11.7 g/dL, WBC: 17.500/mm3, PLT: 235.000/mm3, LDH 302 U/Cr 11/0,6 OT/PT:22/16, CRP 28

Diagnosis G2P1A0 38 weeks gestational age in labor 1st stage active phase with PROM 8 hours + severe preeclampsia +
VBAC 6 = 77% prior CS 1x oi severe preeclampsia SLF cephalic presentation
Management • Stabilization 3 hours
• Observation vital signs ,FHR, and labor
• IVFD RL gtt xx/m
• Nifedipine 10 mg/8 hours PO
• MgSO4 40% according to protocols
• Inj. Ampicillin 1 gr/6 hours IV
• Urinary catheter, monitor I/O
• Consult to Internal medicine Dept, Opthalmology Dept
• P/ Vaginal delivery
Interna dept A : Gestational hypertention

P: Methyldopa 3x250 mg

Ophthalmic dept A : there was no retinophaty and chriodiopathy hypertention

P :informed consent
Hypertention regulation as OBGYN
Reassesment if was decreasing of visus
Identity Mrs. RUS/31 yo/ RA
Chief complaint Aterm pregnancy with watery discharge
History ± 2 days before admission, patient complain about history of amniotic leakage (+)clear, odor
5.12.18 (-) >3x changing napkins. abdominal contraction(-). history of bloody show (-). history of
(8.49 PM) abdominal massage (-), history of post coital (-), history of leucorrhea (+), history of
abdominal trauma (-), history of toothache (-). history of fever (-). She admitted that her
pregnancy was preterm and and fetal movement (+). Patient went to Moh. Hoesin hospital
Marital status Married 1 time 11 months
Reproduction status Menarche since 13yo, regular cycle 30 days, 7 days, LMP: 22 02 2018
Obstetric history 1. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP: 120/80mmHg, HR: 82x/m, RR: 20x/m, T: 36.7 oC
Obstetric examination Palpation:
Fundal height 3 fingers below Proc.xyphoideus ( 29 cm), longitudinal lie, left back, W uterine
contraction (-), FHR: 133 x/minute, EFW: 2745 g
Inspeculo
Portio Livide, external uterine ostium closed, fluor (-), fluxus (+) amniotic fluid not active,
Nitrazine test + red blue, erosion/laceration/polyp (-)
VT
Portio soft, posterior, eff 0 %, 0cm of dilatation, breech, above spina ischiadica, amnionic
membrane and denominator cannot be determined yet
Identity Mrs. RUS/31 yo/ RA
US ER (CNN) There’s SLF breech presentation
Fetal biometry:
BPD 8.42 cm AC 28.14 cm EFW 2361g
HC 30.43cm FL 7.25 cm
Placenta at anterior corpus
Amnionic fluid minimal
C/ 40 weeks of gestational age SLF breech presentation + anhydramnios
Diagnosis G1P0A0 40 weeks gestational age not inlabor with PROM 2 days SLF breech presentation +
anhydramnios

Laboratory Hb: 8.7 g/dl, WBC: 13.600/mm3, PLT: 207.000/mm3 Ht: 27%
examination

Management • Observed vital sign, FHR, contraction


• IVFD RL xx bpm
• Laboratory examination
• Urinary catheterization
• Ceftriaxon 1g/ 12 hours IV
• Plan for abdominal termination
Followup female life baby born BW: 2500 g, BL: 46 cm, A/S 8/9 PTAGA
6/12/2018 Placenta delivered completely PW: 450 g, PL: 46 cm Ꝋ 17x16 cm
02.10 AM
Identity
Mrs.ELI/31/RA
Chief complain preterm pregnancy with vaginal bleeding
History Since ± 6 hours before admission patient complain vaginal bleeding. 2x sanitary napkins was performed, H/
03.12.18 abdominal contraction (-), bloody show -, watery discharged -. history of abdominal massage -, abdominal
00.30 AM trauma -, consume drug or traditional medicine, leukorhea -, post coital -.
Patient admit preterm pregnancy and fetal movement (+).
Marital status Married 1 x, 10 years
Reproduction status Menarche since 13 yo, ireguler cycle , LMP forgot

Obstetric history 1. 2008, male, 3000gr, Vacum extraction, RSMH, death


2. 2010, male, 2500gr, spontaneous delivery, midwife, healthy
3. current pregnancy
Past iIlness history H/ Hypertyroid uncontrolled
Physical Examination Vital sign: BP = 120/80mmHg, HR = 88 x/m, temp = 36.8 C, RR = 18x/m
Obstetrical examination Palpation: Fundal height ½ umbilical-processus xyphoideus (26 cm), longitudinal lie , right back, head, 5/5,
contraction -, FHR 140x/mt, EFW 2170gr
Inspeculo: portio livide, OUE closed, fluor -, fluxus +, not active bleeding. E/L/P -

17
Identity Mrs.ELI/31/RA
US Confirmation - Single life fetus cephalic presentation
- Fetal Biometry: BPD 78.6 mm AC 284 mm EFW: 1993 gr
HC 294.3 mm FL 60.9 mm
- Placenta at anterior corpus extend spreading to OUI
- Amniotic sufficient, SDP 4,25 cm
-C/ 34 weeks gestational age SLF cephalic spresentation + total placenta previa
Lab results Hb 7.1 Leu 26.100 Plt 273.000 Ht 25 HBsAg non reactive, anti HIV non reactive T3 3.53 Free T4 3.06 TSHs 0.0020

Diagnosis G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
uncontrolled + moderate anemia SLF cephalic presentation
Theraphy Expectative management
Obs vital sign, His, FHR, bleeding sign
Nifedipine 10mg/6 h po
Inj. dexamethason 6mg/12 h IV
Assesment interna department
Plan for US confirmation
Assesment interna A/ Asthma attack in pregnancy
department Hypertyroid subklinis
Index wyne 3 P/ Nebu ventolin 1 resp/8 hours
Burch wartoschcy 30 Metylprednison 2x4mg PO
Faal Tyroid examination
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation
P/ expectative management
US confirmation
Consult to internal department

18
Identity Mrs.ELI/31/RA
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation
14.30 P/ Nebulizer with ventolin

Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation +fetal distress
15.10 P/ intrauterine resuscitation
Informed consent
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
15.30 P/ for abdominal termination
Consult to internal and anesthesiology
Internal department A/ impending thyroid storm
Hypertension st II
Anemia
Thyroid heart disease NYHA II
P/ PTU 100mg/8 hours
Digoxin 0.25 mg
Metyldopa 500mg/ 8 hours
Furosemide 40 mg/ 24 hours
Lugolization 8 gtt / 6 hours
Anesthesiology A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
uncontrolled + moderate anemia SDF cephalic presentation
P/ collaboration with internal department
Plan for PRC transfusion
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
4/11/2018 uncontrolled + THD NYHA 2 + moderate anemia SDF cephalic presentation
06.00 P/ observation vital sign. bleeding
Identity Mrs.ELI/31/RA
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
5/11/2018 uncontrolled + THD NYHA 2 + moderate anemia SDF cephalic presentation
06.00 P/ observation vital sign. bleeding

Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
5/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
17.10 P/

Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
15.30 P/ for abdominal termination
Consult to internal and anesthesiology
Operative report Male death baby born BW 2100g BL 40 cm A/S 0 PTAGA
22.00 Placenta delivered completely PW : 400g UL 45 cm Ꝋ 17x18cm
Identity Mrs. LEN/27 yo/ UA
Chief complaint Inlabor with high blood pressure and prior cesarean section
History Patient referred from SpOG with G3P2A0 aterm not inlabor with high blood pressure and
5.12.18 prior cesarian section. patient complain about abdominal contraction(+). Hypertension in
() current pregnancy (-), hypertension before pregnancy (-), hypertension in previous pregnancy
(-), hypertension in family (-), severe headache (-) nausea (-), vomiting (-), epigastric pain (-),
blurry vision (-) history of bloody show (+), history of amniotic leakage (-). history of
abdominal massage (-), history of post coital (-), history of leucorrhea (+), history of
abdominal trauma (-), history of toothache (-). history of fever (-). She admitted that her
pregnancy was preterm and and fetal movement (+). Patient went to Moh. Hoesin hospital
Marital status Married 1 time 4 years
Reproduction status Menarche since 13yo, regular cycle 28 days, 7 days, LMP: forgot
Obstetric history 1. 2014. female. 2300g. CS. Bunda hospital, healthy
2. 2017 female. 2700g CS . Az-Zahra hospital. Healthy
3. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP: 120/80mmHg, HR: 82x/m, RR: 20x/m, T: 36.7 oC
Obstetric examination Palpation:
Fundal height 3 fingers below Proc.xyphoideus (33 cm), longitudinal lie, right back, head, U
4/5, uterine contraction (2x/10’/20”), FHR: 133 x/minute, EFW: 3100 g.
VT
Portio soft, medial, eff 25%, 2cm of dilatation, cephalic, H I, amnionic membrane and
denominator cannot be determined yet
Identity Mrs. LEN/27 yo/ UA
US (ER) There’s SLF cephalic presentation
Fetal biometry:
BPD 9.37 cm AC 33.63 cm HC 32.56 cm FL 7,2 cm cm
Placenta at fubdus
Amnionic fluid minimal
C/ 38 weeks of gestational age SLF cephalic presentation
Diagnosis G3P2A0 38 weeks gestational age inlabor 1st stage latent phase with PPROM 4 hours + prior
CS 1x oi breech presentation SLF cephalic presentation

Laboratory Hb: 11.5 g/dl, WBC: 9700/mm3, PLT: 311.000/mm3 Ht: 34%
examination

Management • Observation vital signs ,FHR, and labor


• IVFD RL gtt xx/m
• Laboratory examination
• Urine chateterization
• Nifedipine 10mg / 6 hours
• Ceftriaxone 1g/ 12 hours IV
• Plan for abdominal termination
Operative report • 04.35 AM : female life baby born BW 3100g BL 47cm A/S 7/9 FTAGA
• 04.40 AM : Placenta delivered completely PW 510g UL 48cm o 17x18cm
Identity Mrs. MEG /19/UA 5.12.2018 06.00 AM
Chief complain Inlabor with breech presentation
History History of : abdominal contraction (+), bloody show (+), amniotic leakaged (+), history of abdominal
massage (-), history of post coital (-), history of leucorrhea (+), history of abdominal trauma (-),
history of toothache (-). history of fever (-)
Patient admitted that her pregnancy was aterm and she can felt the movement of the fetus

Marital status 1x :1 years,


Reproduction status Menarche since 14 yo, regular cycle 28 days, for 5 days. LMP : 18 03 2018
Obstetric history 1. This pregnancies
Physical exam BP : 120/80 mmHg, P : 94 x/min, T : 36.5 C, RR : 20 x/min, Weight 53 kg, Height 155 cm
Obstetrical Inspection & Palpation :
examination Fundal height was 3 fingers below proc. Xypoideus (28 cm), left longitudinal lie, U 2/5, breech, His
(4/10’/40’), FHR: 138x/m, EFW : 2616g
VT: full of dilatation, breech, amniotic membrane (-) and left tranverse sacrum

Laboratory Hb: 12.8 g/dl, wbc 10.300/ mm3, trombosit 244.000/mm3, Ht 39%, Proteinuria +2, LDH 309, SgOT 69,
Examination SgPT 40, ureum 17, Cr 0.7
Identity 7. Mrs. RAN /30/UA 7.4.2018 01.00 AM
Diagnosis G1P0A0 37 weeks gestational age inlabor 2nd stage SLF breech Presentation
Therapy • IVFD RL gtt xx/m
• Laboratory examinataion
• Plan for vaginal delivery
• Conduct the labor

Delivery report 06:20 AM : Male life baby, Weight 2500 g, Height 43 cm, A/S 8/9 FTAGA
06:25 PM : complete placenta, PW 380 g, UC 40 cm, Ø 15 x 16 cm
Perform tubectomy
Identity Mrs. FIT/26/UA
Chief complaint preterm pregnancy with vaginal bleeding
5/12/2018
09.00 PM
History 1 hours before admitted patient complain vaginal bleeding, reddish 1x change napkins, h/ amniotic leakage(-).
abdominal contraction regulerly (-), H/ post coital (-) h/ trauma (-) h/ Abdominal massage (-) H/ Leukorrhea (-),
Patient admitted that pregnancy was preterm and fetal movement (+)

Marital status Married 1 time 10 months


Reproduction status Menarche since 13yo, reguler cycle 28 days, 7 days, LMP 15-04-2018
Obstetric history 1. Current pregnancy
Past iIlness history (-)
Physical Examination Vital sign: BP = 120/80mmHg, HR = 98x/m, temp = 36C, RR = 20x/m BL 159 cm, BW 56kg
Obstetrical examination Palpation: fundal height was 4 fingers below px (27 cm), longitudinal lie, left back, head, U 5/5, contraction (-)
FHR 143bpm, EFW 2170g
Insp : Portio Livide OUE was closed, Flour (-), Fluxus (+) not active bleeding E/L/P (-)

US ER - Single life fetus cephalic presentation


- Fetal Biometry: BPD: 83 mm AC: 279 mm EFW: 2037g
- HC: 295 mm FL: 60 mm
-Placenta at posterior Corpus covered the OUI
-Amniotic fluid sufficient
-C/ 33 weeks gestational age single life fetus cephalic presentation + Totalis Placenta previa
Lab exam Hb 11.3 WBC 14.600 Plt 385.000
Diagnosis G1P0A0 34 weeks gestational age not inlabor with APH cb low lying placenta SLF cephalic precentation
Planning • Observed vital sign, FHR, bleeding sign
• IVFD RL xx /m
• Urine chateter
• Dexametason 12 mg/ 24 hours IV
• p/ US Confirmation
Gynecology Patients
ASSESSMENT
Identity Mrs.MAR/60 yo/UA
Chief complaint Mass in upper hand
5/12/18
07.00 PM
History Since 2 months before admission. Patient admitted that she had a mass on the neck, lower back and left
upper arm. Redness (-), tenderness (+). Patient went to AK Ghani hospital, underwent surgery for upper left
arm mass with PA result no. 1098/HISTO/118 : metastatic carcinoma on left humerus. 2 weeks before
admission, there is a recurrent mass on upper left arm. There is other mass on head, chin, abdomen, and left
thigh. Getting bigger. Tenderness (+) fever (+) shiver (+) difficult to urinate and defecate. Anorexia (+)
decrease of body weight (+). 1 weeks before admission, upper left arm mass was rupture, blood (+) pus (+)
os went to RSMH
Marital status 1x, 40 years (the husband passed away on 2015)
Reproduction status Menopause since 10 years ago
Obstetric history P7A0

Past iIlness history Tubectomy (25 years ago) on Kayuagung hospital


Underwent operation in kayuagung hospital for benign tumor in uterine ( there is no PA result)
Vital Sign BP 100/60 Pulse : 134 x/m T: 36.5 RR: 24x/m
examination Inspection & Palpation : Abdominal asymmetric, Fundal height unpalpable, mass (+), multiple, mobile,
1cm x 1cm s/d 2cmx2cm, tenderness (+), free fluid sign (-)
Inspeculo : portio atrophy, OUE was closed, fluor (-), fluxus (-), Erotion (+) at 3 o’clock/L/P (-)
VT : portio atrophy, FUT hardly asessed, left right adnexa not tense, unproturent of cavum Douglas.
RT : TSA good, empty ampula recti, Intralumen mass (-), unproturent of cavum Douglas.
Identity Mrs.MAR/60 yo/UA
Laboratory • Hb 10.1 g/dL, Ht 30%, WBC 16.600/mm3 Plt 243.000/mm3, Ur 27, Cr 1.29 Na 141 K 5.1

US ER (CNN) Uterine small in size and shape, 2.63x1.8 cm in size – post menopause
Both ovarium – post menopause
Liver within normal limit
Right kidney within normal limit
Left kidney : hydronefrosis
Ascites (-)
k/ there is no abnormality in gynecologic
Diagnosis Left humerus neoplasm with malignancy was suspeted

Management There is no medical treatment from OBGYN department


Identity Mrs. FAR/31 yo/UA
Chief complaint Dyspnea
5/12/18
17.00 PM
History Since 2 months before admission. Patient complain about dyspnea, severe with activity, history of vaginal
bleeding (-), history of melena (-), history of malaise (+), history of decrease body weight (+), history of
anoreksia (-). 1 day before admission patient complain about dyspnea. Patien went to RSMH.

Marital status 1x, 7 years


Reproduction status Menarche since 13 years old, regular cycle, 3 -4 days, LMP 14 11 2018
Obstetric history P2A0

Past iIlness history -

Vital Sign BP 140/100 Pulse : 104 x/m T: 36.5 RR: 28x/m


examination Inspection & Palpation : Abdominal flat, symmetric, Fundal height unpalpable, mass (-), tenderness (-),
free fluid sign (-)
Inspeculo : portio not livide, OUE was closed, fluor (+), fluxus (-), E/L/P (-)
VT : portio firm, left right adnexa not tense, unproturent of cavum Douglas.
RT : TSA good, empty ampula recti, Intralumen mass (-), unproturent of cavum Douglas.
Identity Mrs. FAR/31 yo/UA
Laboratory • Hb 7.4 g/dL, Ht 24%, WBC 11.100/mm3 Plt 2671.000/mm3, Ur 13, Cr 0.62

US ER (CNN) Uterus both size and shape within normal limit, 6.94x3.91 cm, endometrial line (+)
Both ovarium within normal limit
Hepar, Lien within normal limit
Right kidney within normal limit
Left kidney = Hydronephrosis
Ascites (+)
k/ there is no abnormal in gynecologic
Diagnosis Ascites ec cirrhosis hepatic was suspected
Moderate anemia
trombocytosis
Management There is no medical treatment from OBGYN department
PASSED AWAY
Identity Mrs. HER /38 y.o/ RA
Nov 22nd 2018 at
10.55 AM
Chief complain Preterm pregnancy with vaginal bleeding and placenta covering birth canal
History 9 hours before admission, patient complain about vaginal bleeding (+) 3 times
changing underpad. patient complained abdominal contraction spreading to waist and
back (+) infrequently. History of amniotic leakage (-) hystory of trauma (-), hystory of
post coital (-), patient referred from Ogan Ilir hospital. Patient admitted that her
pregnancy is preterm and she can still feel the movement of the fetus.
Marital status 1x, 12 years
Reproduction Menarche since 13 yo, irregular cycle, LMP : forgot
status
Obstetric history 1. 2007. female. 2600 g. Midwife. Spontaneus delivery. healthy
2. 2012. female. 4500 g. CS oi hydrocephalus. Moh Hoesin hospital, +
3. 2012. female. 2600 g. CS oi prior CS 1x. Moh Hoesin hospital. healthy
4. This pregnancy
Identity Mrs. HER /38 y.o/ RA
Physical Sens: Compos mentis
examination BP : 110/70 mmHg, P : 100 bpm, T : 36.0 C, RR : 20 bpm BW: 62 kg BH: 150 cm

Obstetrical Inspection & Palpation :


examination Fundal height was in ½ between umbilical – proc xypoideus (22 cm), external
ballotement (+) Uterine contraction 2x/10’/20”, FHR: 146 x/m, EFW : 1395g

Insp : portio livide, closed OUE, fluor (-), fluxus (+) non active bleeding, E/L/P (-)
US ER - Single life fetus intrauterine
- Fetal Biometry: BPD 6.70 cm AC 24.86 cm EFW: 1250g
HC 22.53 cm FL 5.05 cm
- Placenta at posterior corpus extended covering OUI
- Amniotic fluid SDP: 0.95 cm

C/ 26 weeks gestational age SLF intrauterine + placenta covering OUI + anhydramnios


+ placenta percreta was suspected
Diagnosis G4P3A0 26 weeks gestational age with 2nd trimester bleeding cb placenta covering OUI
+ prior CS 2X + severe anemia, SLF intrauterine + anhydramnios
Identity Mrs. HER /38 y.o/ RA
Lab Examination Hb 4.6, WBC 1.560, HT 14 %, PLT 260.000, PT: 14.70 INR: 1.11 APTT: 31.0 Fibrinogen :
23/11/2018 359 D-Dimer: 2.16
Therapy • Observed vital sign, FHR, uterine contraction, vaginal bleeding
• IVFD RL 500 ml + MgSO4 40% 6 g XX dpm
• Lung maturation with inj dexamethasone 12 mg/ 24 hours IV
• Informed consent
• Bed rest
• PRC tranfusion
05.00 PM G4P3A0 26 weeks gestational age with 2nd trimester bleeding cb placenta covering OUI
DJJ I 104x/m + prior CS 2X + severe anemia, SLF intrauterine + anhydramnios+ fetal distress
DJJ II 96x/m • P/ emergency LSCS
DJJ III 92x/m
Operative Report 05.50 PM Female life baby, BW 1200 g, BL 30 cm cm, A/S 8/9 PTAGA
05.55 PM placenta was delivered completely, PW 200 g, UCL 30 cm, diameter 15x14
cm
D/P4A0Post LSCS oi anhydramnios + prior CS 2x
Identity
Laboratorium Post Op Hb: 10,9g/dl
23/11/2018 WBC: 16.000/mm3
Trombosit: 132.000/ mm3
Ht: 16%
d/c: 0/0/89/6/5
Ur/Cre: 150/ 5.79
BSS: 109
LED : 26
Ca/Mg/Na/K/Cl: 7,0/3,40/144/5,45/116
SpJP CXR : Suspek Infiltrate Hb: 10 Global normokinetik
Echo : EF 60 % Hiperdinamik
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction
24/11/2018 O:. GCS: E4M6Vt , BP: 119/79 mmHg, HR: 112x/m RR: 20x/m - Intubation
06.00 SpO2: 98% - Inj. Ceftriaxon 2gr/12 hours/iv
Day II Abd: Fundal height 2 fingers below umbilical, contraction - Inj. Omeprazole 30mg/12hours/iv
good, active bleeding (-) - Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total placenta - Plan for tranfusion PRC
previa + prior LSCS 2X + fetal distress + moderate anemia +
anhydramnios + pulmonary edema
Laboratorium Hb: 8,3 g/dl WBC: 16.000/mm3 Trombosit: 112.000/ mm3
23/11/2018 Ht: 23% d/c: 0/0/92/6/2
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction
25/11/2018 O:. GCS: E4M6Vt , BP: 115/78mmHg, HR: 82x/m RR: 20x/m - Intubation
06.00 SpO2: 97% - Inj. Ceftriaxon 2gr/12 hours/iv
Day III Abd: Fundal height 2 fingers below umbilical, contraction - Inj. Omeprazole 30mg/12hours/iv
good, active bleeding (-) - Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total placenta - Plan for tranfusion PRC
previa + prior LSCS 2X + fetal distress + moderate anemia +
anhydramnios + pulmonary edema
Identity

Cultur Microscopic : gram (+), coccus (+), WBC 10 – 15 /LP.


antibiotic : Vancomycin

Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction


26/11/2018 O:. GCS: E4M6Vt , BP: 123/83 mmHg, HR: 84x/m RR: 20x/m SpO2: 97% - Intubation
06.00 Abd: Fundal height 2 fingers below umbilical, contraction good, active - Inj. Ceftriaxon 2gr/12 hours/iv
Day IV bleeding (-) - Inj. Omeprazole 30mg/12hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total placenta previa + - Inj. Paracetamol 500mg/12 hours/iv
prior LSCS 2X + fetal distress + moderate anemia + anhydramnios + - Plan for tranfusion PRC
pulmonary edema - Inj. Levofloxacin 500 mg/24 hours iv
- Vancomycin 1 g / 12 hours iv
Thorx PA C/ Cardiomegali
25-11-18 Pulmonary edema

Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction


27/11/2018 O:. GCS: E4M6Vt , BP: 125/84 mmHg, HR: 82x/m RR: 22x/m SpO2: 97%  IInj. Omeprazole 30mg/12hours/iv
06.00 Abd: Fundal height 2 fingers below umbilical, contraction good, active  Inj. Tranexamat acid 500mg/8hours/iv
Day IV bleeding (-)  Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total placenta previa +  Inj. Levofloxacin 500mg/24 hours/iv
prior LSCS 2X + fetal distress + moderate anemia + anhydramnios +  Sucralafat syrup 30 mg/24 hours/NGT
pulmonary edema  Plan for PRC tranfusion 3 colf
- Inj. Levofloxacin 500 mg/24 hours iv
- Inj. Vancomycin 1 g / 12 hours iv
Lab Hb: 10.7 g/dl Albumin 2.5
27-11-18 WBC: 16.600/mm3 Ur/Cr 45/0.52
Trombosit: 219.000/ mm3 Ca/Na : 9/144
Ht: 32% K/Cl 3.2/106
d/c: 0/1/84/11/4 GDS 169
PT 14.1
aPTT 25.3
INR 1.05
Identity
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding,
28/11/2018 O:. GCS: E4M6Vt , BP: 120/84 mmHg, HR: contraction
06.00 82x/m RR: 22x/m SpO2: 97% Balance : 108  IInj. Omeprazole 30mg/12hours/iv
Day V Abd: Fundal height 2 fingers below umbilical,  Inj. Tranexamat acid 500mg/8hours/iv
contraction good, active bleeding (-)  Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage  Inj. Levofloxacin 500mg/24 hours/iv
cb total placenta previa + prior LSCS 2X + fetal  Sucralafat syrup 30 mg/24 hours/NGT
distress + moderate anemia + anhydramnios + - Inj. Furosemide 40 mg/24 hours iv
pulmonary edema - Inj. Vancomycin 1 g / 12 hours iv
Lab 30-11-2018 Hb: 10,6 g/dl Analisa Gas darah:
(Cek ulang) WBC: 40.600/mm3 Temperatur: 37,0 C
Trombosit: 299.000/ mm3 pH:7,396
Ht: 32% HCO3: 27,3
d/c: 0/0/89/8/3 BE:1,9
FIO2: 70%
pCO2: 46.0 mmHg
pCO2tc: 46.0 mmHg
pO2: 72,8 mmHg
pO2tc: 72,8 mmHg
SO2%: 94,1%
Lactat: 3.0
pHtc: 7.396
Hct: 33
Hb: 11.0
Identity
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction
29/11/2018 O:. GCS: E4M6Vt , BP: 120/84 mmHg, HR: 82x/m RR: 22x/m  IInj. Omeprazole 30mg/12hours/iv
06.00 SpO2: 97% Balance : 108  Inj. Tranexamat acid 500mg/8hours/iv
Day VI Abd: Fundal height 2 fingers below umbilical, contraction  Inj. Paracetamol 500mg/12 hours/iv
good, active bleeding (-)  Inj. Levofloxacin 500mg/24 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total  Sucralafat syrup 30 mg/24 hours/NGT
placenta previa + prior LSCS 2X + fetal distress + moderate - Inj. Furosemide 40 mg/24 hours iv
anemia + anhydramnios + pulmonary edema - Inj. Vancomycin 1 g / 12 hours iv
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction
30/11/2018 O:. GCS: E4M6Vt , BP: 120/84 mmHg, HR: 82x/m RR: 22x/m  IInj. Omeprazole 30mg/12hours/iv
06.00 SpO2: 97% Balance :- 310  Inj. Tranexamat acid 500mg/8hours/iv
Day VII Abd: Fundal height 2 fingers below umbilical, contraction  Inj. Paracetamol 500mg/12 hours/iv
good, active bleeding (-)  Inj. Levofloxacin 500mg/24 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total  Sucralafat syrup 30 mg/24 hours/NGT
placenta previa + prior LSCS 2X + fetal distress + moderate - Inj. Furosemide 40 mg/24 hours iv
anemia + anhydramnios + pulmonary edema - Inj. Vancomycin 1 g / 12 hours iv
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding, contraction
01/12/2018 O:. GCS: E4M6Vt , BP: 120/84 mmHg, HR: 82x/m RR: 22x/m  IInj. Omeprazole 30mg/12hours/iv
06.00 SpO2: 97% Balance : - 248  Inj. Tranexamat acid 500mg/8hours/iv
Day VIII Abd: Fundal height 2 fingers below umbilical, contraction  Inj. Paracetamol 500mg/12 hours/iv
good, active bleeding (-)  Inj. Levofloxacin 500mg/24 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage cb total  Sucralafat syrup 30 mg/24 hours/NGT
placenta previa + prior LSCS 2X + fetal distress + moderate - Inj. Furosemide 40 mg/24 hours iv
anemia + anhydramnios + pulmonary edema - Inj. Vancomycin 1 g / 12 hours iv
Identity
Thorax photo C/ Cardiomegali
29-11-18 Pulomary edema dd/ Pneumonia
Spesialis A : Edema paru dd/ CAP
Paru P : inj. Furosemid 40 mg/24 jam iv
Dr. Inj. Dexametason 5 mg / 8 jam iv
Natalie,SpP
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding,
02/12/2018 O:. GCS: E4M6Vt , BP: 120/84 mmHg, HR: contraction
06.00 82x/m RR: 22x/m SpO2: 97% Balance : - 228  IInj. Omeprazole 30mg/12hours/iv
Day VIII Abd: Fundal height 2 fingers below umbilical,  Inj. Tranexamat acid 500mg/8hours/iv
contraction good, active bleeding (-)  Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage  Inj. Levofloxacin 500mg/24 hours/iv
cb total placenta previa + prior LSCS 2X + fetal  Sucralafat syrup 30 mg/24 hours/NGT
distress + moderate anemia + anhydramnios + - Inj. Furosemide 40 mg/24 hours iv
pulmonary edema - Inj. Vancomycin 1 g / 12 hours iv
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding,
03/12/2018 O:. GCS: E4M6Vt , BP: 118/74 mmHg, HR: contraction
06.00 88x/m RR: 22x/m SpO2: 97% Balance : - 808 ml  Inj. Omeprazole 30mg/12hours/iv
Day IX Abd: Fundal height 2 fingers below umbilical,  Inj. Paracetamol 500mg/12 hours/iv
contraction good, active bleeding (-)  Sucralafat syrup 30 mg/24 hours/NGT
A: P4A0 post LSCS oi antepartum hemorrhage - Inj. Furosemide 40 mg/24 hours iv
cb total placenta previa + prior LSCS 2X + fetal - Inj. Vancomycin 1 g / 12 hours iv
distress + moderate anemia + anhydramnios + - N-asetilsistein 200 mg/8 hour iv
pulmonary edema + CAP - Cotrimozole 960 mg/12 hours ngt
- Fluconazole 400 mg/24 hour iv
- Metiprednisolon 40 mg/ 24 hours iv
Identity
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding,
04/12/2018 O:. GCS: E2M2Vt , BP: 108/74 mmHg, HR: contraction
06.00 82x/m RR: 22x/m SpO2: 97% Balance : - 178  IInj. Omeprazole 30mg/12hours/iv
Day X Abd: Fundal height 2 fingers below umbilical,  Inj. Tranexamat acid 500mg/8hours/iv
contraction good, active bleeding (-)  Inj. Paracetamol 500mg/12 hours/iv
A: P4A0 post LSCS oi antepartum hemorrhage  Inj. Levofloxacin 500mg/24 hours/iv
cb total placenta previa + prior LSCS 2X + fetal  Sucralafat syrup 30 mg/24 hours/NGT
distress + moderate anemia + anhydramnios + - Inj. Furosemide 40 mg/24 hours iv
pulmonary edema + CAP - Inj. Vancomycin 1 g / 12 hours iv
Follow Up S: post LSCS P: Observation of Vital Sign and bleeding,
05/12/2018 O:. GCS: E2M2Vt , BP: 98/64 mmHg, HR: contraction
06.00 88x/m RR: 22x/m SpO2: 97% Balance : - 452 ml  Inj. Omeprazole 30mg/12hours/iv
Day XI Abd: Fundal height 2 fingers below umbilical,  Inj. Paracetamol 500mg/12 hours/iv
contraction good, active bleeding (-)  Sucralafat syrup 30 mg/24 hours/NGT
A: P4A0 post LSCS oi antepartum hemorrhage - Inj. Furosemide 40 mg/24 hours iv
cb total placenta previa + prior LSCS 2X + fetal - Inj. Vancomycin 1 g / 12 hours iv
distress + moderate anemia + anhydramnios + - N-asetilsistein 200 mg/8 hour iv
pulmonary edema + CAP - Cotrimozole 960 mg/12 hours ngt
- Fluconazole 400 mg/24 hour iv
- Metiprednisolon 40 mg/ 24 hours iv
Identity 1. Mrs. HER/38/RA

05-12-18 S : decrease of conciousness


OBGYN O : St. Present
Sens : E1M1Vt 92/67, HR: 72 x/m, RR: 25x / menit, T: 36.4, SpO2:
63%, balance (-0)
A/ P4A0 post LSCS oi antepartum hemorrhage cb total placenta
previa + prior LSCS 2X + fetal distress + moderate anemia +
anhydramnios + pulmonary edema + CAP
P/
Obs vital sign
IVFD RL gtt xx/m
Urine chateterization
N asetyl cysteine 200mg/ 8 hours
Omeprazole 40 mg/ 24 hours
Paracetamol 500mg/ 8 hours
Fluconazole 400mg/24 hours IV

50
RR SpO2%
TD N T Tindakan,
Tgl/jam Sens (x/mnt
(mmHg) (x/mnt) (ºC) cairan,obat-obatan
)
05/12/20 E1M1VT 92/67 72 25 36,40 92/67 Drip dobutamine 1 amp dalam
18 NaCl 0,9% 100cc gtt X/m
15.00
E1M1VT 72/50 68 17 36,20 72/50 Drip dobutamine 1 amp dalam
15.15 NaCl 0,9% 100cc gtt X/m

16.00 E1M1VT 52/3 42 12 35,60 52/34 Drip dobutamine 1 amp dalam


4 NaCl 0,9% 100cc gtt X/m

16.15 E1M1VT Tak teraba Tak teraba - - Tak teraba

16.20 EKG 12 lead : Asystole


Pupil Midriasis

- - Asystole Apnea - 0 Pasien dinyatakan


meninggal dihadapan
dokter perawat dan
keluarga
29-11-2018
Thorax PA

C/ Pulmonary
edema dd/
pneumonia
Cardiomegaly
25-11-2018

C/Pulmonary Edema
Cardiomegaly
x

x x

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