Escolar Documentos
Profissional Documentos
Cultura Documentos
Supervised by:
dr. Arie Polim, Sp.OG K-FER
By:
Klarissa Chrishalim
2014-061-182
Sharon Issabel
2014-061-189
Felix Sumampow
2014-061-190
OBSTETRIC PATIENT
No
Date
admission
Name
First diagnosis
Final Diagnosis
Neonates
diagnosis
I: Male neonate, 36
weeks according to
NBS with birth
weight of 2150
1.
27/01/16
Mrs. Y
P3A0, 28 years
based on USG
prematurus by
examination, in labor,
spontaneous per
vaginam delivery,
post episioraphy
fetuses, cephalic
indicated by
presentation of both
perineum rupture
fetuses.
grade I
grams, length of 46
cm and APGAR
Score 7/9, with
diagnose healthy
neonate
II: Male neonate, 36
weeks according to
NBS with birth
weight of 2710
grams, length of 48
cm and APGAR
Score 7/9, with
diagnose healthy
neonate
28/01/16
Mrs. U
28/01/16
Mrs. H
G1P0A0 18 years old,
P2A0, 19 years
old, post partus
maturus by
38 weeks according
spontaneous per
to NBS, birth
vaginam labor,
weight of 3,150
post episioraphy
gram, length of 50
indicated by
perineum rupture
diagnose healthy
history of severe
neonate.
preeclampsia
P1A0, 18 years
39 weeks according
29/01/16
Mrs. N
maturus by
spontaneous per
vaginam labor,
post episioraphy
indicated by
perineum rupture
grade II, with
history of severe
preeclampsia
P1A0, 19 years
38 weeks according
maturus by
weight of 3035
with a single
vaginam delivery,
grams, length of 46
intrauterine living
post episioraphy
cm and APGAR
fetuses, cephalic
indicated by
presentation
perineum rupture
diagnose healthy
grade II
neonate.
CASE 1
G3P2A0, 28 years old, gravid 35-36 weeks based on USG examination, in
labor, 1st active phase, with two intrauterine living fetuses, cephalic
presentation of both fetuses.
Identity
Name
: Mrs. Y
Age
: 28 years old
Ethnic
: Sundanese
Religion
: Moslem
Education
: Bachelor Degree
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient complaints of abdominal discomfort since 3 hours before admission to
hospital
History of present illness:
Patient complaints of abdominal discomfort since 3 hours before admission to
hospital. She also feel contraction that become more frequent. According to the
mother, there are no bloody vaginal discharge and leakage of fluid. She has done
routine Antenatal Care with no pregnancy induced hypertension, anemia, and STDs. 2
days earlier, she was given dexamethasone injection 10 mg IM each day.
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
o History of surgery
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder
: Denied
: Denied
: Unknown
: Unknown
: Unknown
: Unknown
Habitual history
Marital History
years.
Obstetric history
No
1
2
3
Date
2005
2011
Gestational
Labor
Age
History
Sex
Result
Birth
Breast Feeding
9 months
Per
Weight
2500 gr
7 months
Vaginam
Per
1300 gr
35-36
Vaginam
-
Present
weeks
Contraception History
Last used
: Injections
: 2011
pregnancy induced hypertension (-), anemia (-), tetanus toxoid (-), sexual transmitted
disease (-)
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 110/70 mmHg
Pulse rate
: 72 beats/minutes
Respiratory rate
: 16 breaths/minutes
Body temperature
: 36.3C
Height
: 153 cm
: 21,19 kg/m2
: 62 kg
: 12 kg
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-
Abdomen
Inspection
Auscultation
Palpation
Extremities
Physiologic reflex
++ ++ , pathologic reflex-++-
Obstetrics examination
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
++ ++
Vaginal toucher
Inspeculo
Cardiotocography
1st baby (back on the left side)
Baseline
: 150 bpm
Variabilitas
: normal
Acceleration
: (+)
Deceleration
: (-)
Fetal movement
Uterine contraction
: (-)
Interpretation
: NST reactive
: 120-130 bpm
Variabilitas
: normal
Acceleration
: (+)
Deceleration
: (-)
Fetal movement
: (+)
Uterine contraction
: (-)
Interpretation
: NST reactive
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
BT
CT
: 11,9 g/dL
: 36 %
: 11.800/L
: 197.000/L
: O/Rh (+)
: (-)
: 2 mins
: 4 mins
Blood glucose
: 85 mg/dL
Initial Diagnosis
G3P2A0, 28 years old, gravid 35-36 weeks based on USG examination, in labor, 1 st active
phase, with two intrauterine living fetuses, cephalic presentation of both fetuses.
Planning
Pro Spontaneous per-vaginam labor
Final Diagnosis
P3A0, 28 years old, post partus prematurus by spontaneous per vaginam delivery, post
episioraphy indicated by perineum rupture grade I
Neonatal Diagnosis
I: Male neonate, 36 weeks according to NBS with birth weight of 2150 grams, length of 46
cm and APGAR Score 7/9, with diagnose healthy neonate
II: Male neonate, 36 weeks according to NBS with birth weight of 2710 grams, length of 48
cm and APGAR Score 7/9, with diagnose healthy neonate
Placenta
Placentas size 32x32x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), Calcification (-),
umbilical chords length 59 cm and 63 cm, umbilical cord are implanted in two places:
marginal and central, bleeding 200 cc, placental weight 900 gram.
Therapy
Post-partus:
-
Cefadroxil 3 x 500 mg PO
Mefinal 3 x 500 mg PO
Methergin 3 x 0,125 mg PO
CASE 2
G2P1A0, 19 years old, gravid 37-38 weeks based on the first day of last
menstruation period, with severe Preeclampsia, in labor 1st active phase,
with single intrauterine living fetuses, cephalic presentation
Identity
Name
: Mrs. U
Age
: 19 years old
Ethnic
: Javanese
Religion
: Moslem
Education
: Elementary School
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient complain of abdominal discomfort since 9 hours before admission to
the hospital
o
o
o
o
o
o
o
o
History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of hematologic disease
History of urinary tract/kidney disease
History of trauma
History of surgery
Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder
Habitual history
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: 15 years old
: Regularly, every 28 days, with duration
Marital History
Obstetric history
N
o
1
Date
2012
Gestation
Labor
al Age
History
Sex
9 months
Per
Vaginam
2
Prese
nt
Birth
Weight
2600 gr
Result
Breast
Feeding
+
Notes
Preeclamps
ia (+)
Contraception History
: None
(+), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 180/90 mmHg
Pulse rate
: 120 beats/minutes
Respiratory rate
: 24 breaths/minutes
Body temperature
: 37.4C
Height
: 160 cm
: 20.3 kg/m2
: 62 kg
: 10 kg
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities
: Pale conjunctiva +/+, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/: Convex, linea nigra (+), striae gravidarum (+)
: Bowel sounds (+), 8 x/min
: Supple, pain with palpation (-)
: Warm extremities,
Edema -++-
Physiologic reflex
++ ++ , pathologic reflex-++++ ++
Obstetrics examination
Vaginal toucher
Inspeculo
Cardiotocography
Baseline
: 150 bpm
Variabilitas
Acceleration
: (+) 2x in 20 minutes
Deceleration
: (-)
Uterine contraction
: (+), 4x in 10 minutes
Interpretation
: CST negative
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
BT
CT
Blood glucose
SGOT
SGPT
HbsAg
: 7.2 g/dL
: 26 %
: 15,000/L
: 268,000/L
: A/Rh (+)
: 2 minutes
: 4 minutes
: 84 mg/dL
: 20 U/l
: 5 U/l
: (-)
Urinalysis:
Protein
: ++
Initial Diagnosis
G2P1A0, 19 years old, gravid 37-38 weeks based on the first day of last menstruation period,
with severe Preeclampsia, in labor 1st active phase, with a single intrauterine living fetuses,
cephalic presentation
Planning
Maintenance dose of MgSo4 1gr/hour
Pro spontaneous per vaginam delivery
Final Diagnosis
P2A0, 19 years old, post partus maturus by spontaneous per vaginam labor, post episioraphy
indicated by perineum rupture grade II, with history of severe preeclampsia
Neonatal Diagnosis
Male neonate, 37-38 weeks according to NBS, birth weight of 3,150 gram, length of 50 cm,
and APGAR Score 9/9, with diagnose healthy neonate.
Placenta
Placentas size 21x21x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), kalsifikasi (-),
umbilical chord length 57 cm, umbilical cord are implanted in the center, bleeding 90 cc,
placental weight 360 gram.
Therapy
Post-partus:
-
CASE 3
G1P0A0 18 years old, gravid 38-39 weeks based on first day of the last menstruation
period with severe preeclampsia, in labor with prolonged 2nd phase, with a single
intrauterine living fetus, cephalic presentation.
Identity
Name
: Mrs. H
Age
: 18 years old
Ethnic
: Javanese
Religion
: Moslem
Education
Occupation
: Seller
Anamnesis
Chief complaint:
Patient was referred from primary car with prolonged 2nd stage.
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder
: Denied
: Denied
: Unknown
: Unknown
: Unknown
: Denied
Habitual history
: 13 years old
: regularly, every 30 days, with duration
Marital History
Obstetric history
No
Date
Gestationa
Labor
Result
l Age
1
present
History
Sex
Birth
Breast
Weight
Feeding
38-39
weeks
Contraception History
: None
(+), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 150/90 mmHg
Pulse rate
: 90 beats/minutes
Respiratory rate
: 30 breaths/minutes
Body temperature
: 37.2C
Height
: 150 cm
: 22,2 kg/m2
: 57 kg
: 7 kg
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st & 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/: Convex, linea nigra (+), striae gravidarum (+)
: Bowel sounds (+), 5 x/min
: Supple, pain with palpation (-)
Extremities
: Warm extremities,
Edema
-++-
Physiologic reflex ++ ++
++ ++
, pathologic reflex-++-
Obstetrics examination
Inspeculo
Cardiotocography
Baseline
:130 bpm
Variability
: Normal
Acceleration
:+
Deceleration
Fetal movement
:-
Uterine Contraction
: (+) 2x in 10 minutes
Interpretation
: Non-reassuring
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
GDS
SGOT
SGPT
Ur/Cr
Cr
Bleeding time
Clotting time
: 12,2 g/dL
: 37 %
: 24.200/L
: 328.000/L
: B/Rh (+)
: (-)
: 110
: 13
:7
: 10
: 0.6
: 3 minutes
: 5 minutes
Urinalysis
Protein
:+++
Initial Diagnosis
G1P0A0 18 years old, gravid 38-39 weeks based on first day of the last menstruation period
with severe preeclampsia, in labor with prolonged 2 nd phase, with a single intrauterine living
fetus, cephalic presentation.
Planning
Initial loading dose of MgSo4 4g in 100cc of saline solution
Pro spontaneous per vaginam delivery
Final Diagnosis
P1A0, 18 years old, post partus maturus by spontaneous per vaginam labor, post episioraphy
indicated by perineum rupture grade II, with history of severe preeclampsia
Diagnosa Neonatus
Male neonate, 38-39 weeks according to NBS with birth weight of 3130 grams, length of 49
cm and APGAR Score 8/9, with diagnose of a healthy neonate.
Placenta
Placentas size 18x18x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), kalsifikasi (-),
umbilical chord length 48 cm, umbilical cord are implanted marginally, bleeding 580 cc,
placental weight 340 gram.
Therapy
-
Cefadroxil 3 x 500 mg PO
Mefenamic Acid 3 x 500 mg PO
Maintenance MgSo4 1 gr/hour IV
CASE 4
G1P0A0 19 years old, gravid 37-38 weeks based on USG, in labor with prolonged 1st stage
with a single intrauterine living fetuses, cephalic presentation
Identity
Name
: Mrs. N
Age
: 19 years old
Ethnic
: Javanese
Religion
: Moslem
Education
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient was referred by primary care because of prolonged 1 st phase from
primary care unit
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
: Denied
: Denied
: Unknown
Habitual history
: Unknown
: Unknown
: Denied
: 13 years old
: regularly, every 30 days, with duration
Marital History
Obstetric history
No
Date
present
Gestationa
l Age
Labor
History
Sex
Result
Birth
Weight
Breast
Feeding
37-38
week
Contraception History
: None
(-), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 120/70 mmHg
Pulse rate
: 80 beats/minutes
Respiratory rate
: 20 breaths/minutes
Body temperature
: 36.5C
Height
: 151 cm
: 20.8 kg/m2
: 55 kg
: 8 kg
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st & 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-
Abdomen
Inspection
Auscultation
Palpation
Extremities
: Warm extremities,
Edema -++-
Physiologic reflex
++ ++ , pathologic reflex-++++ ++
Obstetrics examination
Vaginal toucher
Inspeculo
Fetal Station: +1
: not performed
Cardiotocography
Baseline
:140 bpm
Variability
Acceleration
:+
Deceleration
:-
Fetal movement
: 2x in 20 minutes
Contraction
: (+) 3x in 10 minutes
Result
: reassuring
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
GDS
: 9.3 g/dL
: 28 %
: 14.200/L
: 399.000/L
: O/Rh (+)
: (-)
: 91 mg/dL
Initial Diagnosis
G1P0A0 19 years old, gravid 37-38 weeks based on USG, in labor with prolonged 1 st stage
with a single intrauterine living fetuses, cephalic presentation
Planning
Therapy
Post-Partus
-
Cefadroxil 3 x 500 mg PO
Asam Mefenamat 3 x 500 mg PO
No.
Date of
Admission
Identity
Working Diagnosis
P3A0, 45 years old, with
1.
24/01/16
Mrs.S
Final Diagnosis
P3A0, 45 years old, with post
bilateral cystectomy suspect
endometriosis
27/01/16
Mrs. MI
cyst dextra
P6A0 42 years old,with
30/01/16
Mrs. SR
menometorrhagia
menometorrhagia
31/01/16
Mrs. SU
inflammatory disease
31/01/16
Mrs.MA
GYNECOLOGY PATIENT
CASE 1
P3A0, 45 years old, with bilateral ovarian cyst
Identity
Name
: Mrs. S
Age
: 45 years old
Ethnic
: Javanese
Religion
: Moslem
Education
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient felt pain in her lower abdominal part especially when she had a second
day of menstruation.
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Habitual history
: 15 years old
: Regularly every 28 days, with duration
Marital History
years
Obstetric history
Date
No
1
1991
Result
Birth
Gestation
Labor
al Age
History
Sex
9 months
Spontaneo
Male
Weight
3400 g
Feeding
Yes
Femal
2900 g
Yes
3300 g
Yes
Breast
us
2
1992
9 months
pervaginal
Spontaneo
us
1997
9 months
pervaginal
Spontaneo
e
Male
us
pervaginal
Contraception History
:-
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Weight
Blood pressure
: 120/80 mmHg
Pulse rate
: 72 beats/minute
Respiratory rate
: 16 breaths/minute
Body temperature
: 36.4C
: 61 kg
Height
: 160 cm
BMI
: 23.8 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/-
Abdomen
Inspection
Auscultation
Palpation
Percution
-++-
Gynecology examination
Vaginal toucher
: Not performed
Inspeculo
: Not performed
Laboratory examinations
Hemoglobin
: 14.6g/dL
Hematocrit
: 43%
Leucocyte
: 5,200/L
Platelets
: 250,000/L
Blood glucose
: 95
Blood type
: A/Rh (+)
Bleeding Time
:2
minutes
Clotting Time
:4
minutes
SGOT
: 11
U/L
SGPT
: 10
U/L
Ureum
: 14
mg/dL
Creatinin
: 0.7
mg/dL
Natrium
:137
mmol/L
Kalium
: 3.77
mmol/L
Calcium
: 1.18
mmol/L
Chloride
:108
mmol/L
HbsAg
: (-)
mg/dL
First Diagnosis
P3A0, 45 years old, with bilateral ovarian cyst
Final Diagnosis
P3A0, 45 years old, with post bilateral cystectomy suspect endometriosis
Final Treatment:
-
Cefadoxil 3x500 mg
Mefenamic acid 3x500 mg
Ketroz sup 2x1
Ranitidine 2x 150 mg
CASE 2
P0A0, 28 years old, with endometrium cyst dextra
Identity
Name
: Mrs. MI
Age
: 28 years old
Ethnic
: Javanese
Religion
: Moslem
Education
: Elementary School
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient felt pain in her lower abdominal part since 8 years before the admission
to the hospital.
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
: Denied
: Denied
Habitual history
: 12 years old
: not regularly, with duration of 7 days,
Marital History
years
Obstetric history
Date
No
Gestation
Labor
al Age
Contraception History
History
-
Sex
-
Result
Birth
Weight
-
Breast
Feeding
-
: No
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 120/80 mmHg
Pulse rate
: 96 beats/minute
Respiratory rate
: 20 breaths/minute
Body temperature
: 36.5C
Bpdy weight
: 70 kg
Height
: 155 cm
BMI
: 29.1 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/: Convex, linea nigra (-), striae gravidarum (-)
: Bowel sounds (+), 5 x/ minute
Palpation
ascites (-). There was a mass with the size 10 cm x 10 cm, immobile, tender
-++-
Gynecology examination
Vaginal toucher
: Not performed
Inspeculo
: Not performed
Laboratory examinations
Hemoglobin
: 12.3g/dL
Hematocrit
: 40%
Leucocyte
: 10,700/L
Platelets
: 412,000/L
Blood glucose
: 118
Blood type
: B/Rh (+)
Bleeding Time
:2
minutes
Clotting Time
:4
minutes
PT
: 13.6
APTT
: 30.4
mg/dL
SGOT
: 22
U/L
SGPT
: 29
U/L
Ureum
: 21
mg/dL
Creatinine
: 0.6
mg/dL
Natrium
:132
mmol/L
Kalium
:4
mmol/L
Calcium
: 1.17
mmol/L
Chloride
:109
mmol/L
HbsAg
: (-)
USG Abdomen
There was a hypoechoic image in the right endometrium, suspect of cyst with the size of 11.3
cm x 10.49 cm.
First Diagnosis
P0A0, 28 years old, with endometrium cyst dextra pro cycstectomy per laparotomy
Final Diagnosis
P0A0, 28 years old, with post cystectomy per laparotomy indicated by endometrium cyst
dextra
Treatment post op:
-
Kaen mg 3: RL = 2:1
Ceftriaxone 2 x 1 gr IV
CASE 3
P6A0 42 years old, with menomettorrhagia
Identity
Name
: Mrs. SR
Age
: 42 years old
Ethnic
: Javanese
Religion
: Moslem
Education
: SMP
Occupation
: Employee
Anamnesis
Chief complaint:
Patient complaints of vaginal bleeding 2 weeks before admission to hospital
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
o History of diabetes mellitus
: Denied
: Denied
37
Habitual history
Marital History
Obstetric history
No
Date
1992
2
3
Result
Birth
Gestational
Labor
Age
History
Sex
9 months
Spontaneous
Male
Weight
3000
Feeding
+
9 months
per vaginam
Spontaneous
Male
grams
3100
9 months
per vaginam
Spontaneous
Male
grams
3000
Femal
grams
3000
e
Male
grams
3000
+
+
1996
1998
2006
9 months
per vaginam
Spontaneous
2009
9 months
per vaginam
Spontaneous
9 months
per vaginam
Spontaneous
Femal
grams
3000
per vaginam
grams
2012
Contraception History
Breast
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 140/90 mmHg
Pulse rate
: 80 beats/minute
Respiratory rate
: 18 breaths/minute
38
Body temperature
: 36.5C
Body weight
: 58 kg
Height
: 147 cm
BMI
: 26,8 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities
Physiologic reflex
++ ++ , pathologic reflex-++++ ++
Gynecologic examination
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
Bleeding time
Clotting time
Pregnancy test
: 10.6 g/dL
: 32 %
: 8.400/L
: 245.000 /L
: 2 minutes
: 4 minutes
: (-)
First Diagnosis
P6A0 42 years old,with menometorrhagia
39
Final Diagnosis
P6A0, 42 years old, with menometorrhagia
Final Treatment:
-
IVF
Oral therapy :
Progynova 2x2 mg PO
Pospargin 2x 0,125 mg PO
40
CASE 4
P5A0 43 years old, with pelvic inflammatory disease
Identity
Name
: Mrs. SU
Age
: 43 years old
Ethnic
: Javanese
Religion
: Moslem
Education
: Elementary
Occupation
: Employee
Anamnesis
Chief complaint:
Patient complaints of lower abdominal pain 2 months before admission to hospital
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
Familial history:
o History of hypertension
: Denied
: Denied
Habitual history
Marital History
years.
Obstetric history
No
Date
1989
Gestational
1991
Labor
Result
Birth
Breast
Age
History
Sex
9 months
Spontaneous
Femal
Weight
3000
Feeding
+
9 months
per vaginam
Spontaneous
e
Male
grams
3100
Male
grams
3000
2000
11 months
per vaginam
Spontaneous
2003
9 months
per vaginam
Spontaneous
Male
grams
3000
2005
9 months
per vaginam
Spontaneous
Femal
grams
3000
per vaginam
grams
Contraception History
Physical Examination
General appearance
Level of consciousness
: Compos mentis
Vital signs:
Blood pressure
: 110/70 mmHg
Pulse rate
: 80 beats/minute
Respiratory rate
: 22 breaths/minute
Body temperature
: 36.6C
Body weight
: 50 kg
Height
: 150 cm
BMI
: 22,22 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities
Physiologic reflex
++ ++ , pathologic reflex-++++ ++
Gynecologic examination
Laboratory examinations
Hemoglobin
Hematocrit
Leucocyte
Platelets
LED
Diff count
SGOT
SGPT
Ureum
Creatinine
GDS
Natrium
: 10 g/dL
: 33 %
: 15.100/L
: 510.000/L
: 100 mm/hour
: 0/1/1/73/17/8
: 12 U/L
: 7 U/L
: 10 mg/dL
: 0.6 mg/dl
: 94 mg/dl
: 136 mmol/L
Kalium
Calcium
Chloride
: 4 mmol/L
: 1.13 mmol/L
: 105 mmol/L
Urinalysis
Glucose
Protein
Bilirubin
Uroblinogen
pH
BJ
Occult blood
Ketone
Leucocyte
Sediments
Thorax x-ray
CT abdomen
USG abdominal
:::: normal
: 6.0
: <1005
: +1
:: +1
: eritrocyte 5-6/ / Lpb
: Leucocyte 3-4 / Lpb
: normal
: adnexitis bilateral especially right (PID)
: peritonitis local lower abdomen and lymphadenopathy
mesenterica abdomen 1,1x0,6 suggestif chronic PID/ adnexitis
Hydronephrosis right grade 1-2 ec suspect compression of
ureter because of PID.
First Diagnosis
P5A0 43 years old,with PID
Final Diagnosis
P5A0, 43years old, with PID
Final Treatment:
-
Metronidazole 3x500 mg PO
CASE 5
P3A0, 50 years old, with myoma uteri, hipertension stage 1, CHF NYHA I
Identity
Name
: Mrs. MA
Age
: 50 years old
Ethnic
: Javanese
Religion
: Moslem
Education
: Elementary
Occupation
: Housewife
Anamnesis
Chief complaint:
Patient was scheduled for operation hysterectomy.
o
o
o
o
o
History of epilepsy
History of hematologic disease
History of urinary tract/kidney disease
History of trauma
History of surgery
Familial history:
o History of hypertension
o History of diabetes mellitus
Habitual history
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: 12 years old
: Regularly every 30-40 days, with duration
Marital History
Obstetric history
No
1
Date
1992
Gestationa
Labor
l Age
History
Sex
10 months
Spontaneou
Male
s
2
1996
10 months
vaginam
Spontaneou
s
1998
10 months
per
per
Weight
2900
Breast
Feeding
+
grams
Male
per
vaginam
Spontaneou
Result
Birth
3100
grams
Male
3000
grams
vaginam
Contraception History
Physical Examination
General appearance
Level of consciousness
Vital signs:
: Compos mentis
Blood pressure
: 130/90 mmHg
Pulse rate
: 72 beats/minute
Respiratory rate
: 20 breaths/minute
Body temperature
: 36C
Weight
: 65 kg
Height
: 155 cm
BMI
: 28.8 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/-
Abdomen
Inspection
Auscultation
Palpation
Percution
-++-
Gynecology examination
Vaginal toucher
: Not performed
Inspeculo
: Not performed
Laboratory examinations
Hemoglobin
: 12.5g/dL
Leucocyte
: 3.400/L
Platelets
: 364.000/L
Blood glucose
: 102
Blood type
: AB/Rh (+)
Bleeding Time
:2
minutes
Clotting Time
:4
minutes
SGOT
: 28
U/L
SGPT
: 13
U/L
Ureum
: 23
mg/dL
Creatinin
: 0.8
mg/dL
HbsAg
: (-)
mg/dL