CLINICAL REPORT

THURSDAY, JULY 6, 2017

DOCTOR IN CHARGE:
1. dr. Erna Ashlihah Rochmat ENA
2. dr. Syahrodi Darul Hanafi ODI
3. dr. Bob Irsan BOB
4. dr. Dedy Tisna Amijaya DED
5. dr. Sunu Ajiasmara SUN
6. dr. Alun Dhika Pratama ADP
7. dr. Raden Artheswara Sidhajati DEN
8. dr. Erlina Wulandari WDR

Emergency Room : dr. Muhammad Villiandy Suryatman VIL

Action Supervisor : dr. Rika Dewi Rahmawati Putri RDR
Operating Supervisor : dr. Nurul Fuada NUP
Chief on Duty : dr. Syauqi Kashira Yoshi Akhmadi SKY
Super Chief : dr. Lani Munawir Holis LAN
General Consultant : dr. Irwan Taufiqur Rachman, OBSGYN WAN
dr.Muhammad Luthfi, OBSGYN MIA
dr. Rukmono Siswishanto, OBSGYN , M.Kes RK

I. DELIVERY ROOM
A. PHYSIOLOGIC DELIVERY
IMP 1. Mrs.Restu Era Setiana,33yo, 41wks Lab
6/7/17 MR. 01298192 WBC 16,22
15.00 RBC 4,53
DPJP WAN Hb 10,8
JKN Non PBI At 15.00 baby delivered spontaneously, female, BW 3180 g, HCT 32,6
BH 50 cm, HC/CC 34/33 cm, AS 8/9 PLT 343
G3P2A0 PPT 14/13,9
LMP 22/9/16 At 15.05, placenta delivered spontaneously complete, size APTT 40,3/29,1
EDC 29/6/17 20x20x2 cm, weight 500 gr, CL 48 cm, paracentalis INR 1,02
GA 41wks insertion, calsification (-) Blood type B
HbsAg (non
BP 110/70 mmHg reactive)
HR 76 bpm
RR 22 bpm
T 36.4 C

BH 153 cm
BW 61 kg
BW 11 kg
BMI 26.05
B. PATOLOGIC DELIVERY (1)
IMP 1. Mrs.Mumtanahanah, G1P0A0, 30 yo
6/7/2017 MR 01.44.65.17
07.30
DPJP DR dr. Ica supervised by dr.Rika with assistant dr Deddy had
performed spontaneus delivery, breech presentation, IUFD
1
G1P0A0 with history of induction with misoprostol
LMP 5/12/2016 50mcg/4hours/vaginal tab 2 seri I o/i IUFD, hydrops fetalis,
EDD 12/9/2017 P1A0
GA 30weeks 3
days At 07.30 baby delivered spontaneously,IUFD, male, BW 2400
gr, BH 48 cm, HC/CC 32/34 cm, maceration grade II
BP 110/70 mmHg
HR 88 bpm At 07.40 placenta delivered spontaneously, size 19x19x1 cm,
R 20 bpm weight 450 gr, CL 47cm, paracentralis placental hydrops
T 36,5C

BW 54,4 kg
BH 150 cm
BB kg
BMI 24,17 kg/m2

Obgyn Clinic Chronology : Lab

4/7/2017 Patient came for planning of ascites reduction every 2 WBC 8,91
14.30 weeks.Patient had followed ascites reduction and intrauterine RBC 4,00
DPJP DR transfusion since 16/6/2017. There was no complaint, Hb 10,1
G1P0A0 contraction (-), mucous and blood (-), amniotic fluid leakage (-) HCT 31,2
LMP 5/12/2016 fetal movement rare. PLT 249
EDD 12/9/2017 History of ANC : routine at OBGYN doctor PPT 12,8/13,9
GA 30weeks 1 day History of operation (-) APTT 27,9/29
History of asthma, DM, HT, alergy, renal disease (-) INR 0,91
BP 117/84 mmHg Obstetric history : I. This pregnancy HbsAg (non
HR 84bpm reactive)
R 22 pm O : general performance : good, conscious
T 36,5C Palpation : singleton baby, breech presentation Peripheral blood
BE: not performed smear :
BW 54,4 kg Anaemia normocytic
BH 150 cm A : Breech presentation, Hydrops Fetalis, Primigravida 30 normochromic with
BB kg weeks 1 day pregnant with fetal Bradicardia inflammation
BMI 24,17 kg/m2 process/bacterial
P: infection suspicion
His (-) - Suggestion for admission with planning of ascites reduction
FHR 90 bpm - Laboratory examination at ward
- Consultation with dr.Diah Rumekti, OBGYN(C) Acc dx tx

USG :
Singletone baby,
longitudinal
Breech
presentation,
FHR (+), fetal
movement (-).
Placenta at fundus
extended to corpus
grade II. Seen scalp
edema, lead to
hydrops fetalis.

2
BPD 6,68
AC 32,92
EFW 1961gr

3
NST
FHR baseline 90
bpm
Variability > 5
Acceleration (-)
Deseleration (-)
Fetal movement (+)
Category II

4
IMP Have been performed examination at maternal ward BE: not performed
4/7/17 S: contractions (+), fetal movements(+)
16.30 O: GC good, alert
Palp: singleton baby, breech presentation
BP 120/70 mmHg A: Breech presentation, Hydrops Fetalis, Primigravida 30+1
P 112 bpm weeks pregnancy with bradycardi fetus
RR 20 pm P: Plan for ascites reduction tomorrow morning
T 36,6 Preparing equipment and informed consent

FHR 98 bpm
His (-)

IMP S: contractions (-), BE: not performed

5/7/17 O: GC good, alert
05.00 A: Breech presentation, Hydrops Fetalis, Primigravida 30+2
weeks pregnancy with bradycardi fetus
BP 120/70 mmHg P: Plan for amnior eduction today
P 68 bpm
RR 24 pm
T 36,4 C

FHR 88 bpm
His (-)

IMP S: fetal movements decrease BE: not performed

5/7/17 O: GC good, alert
11.40 A: Breech presentation, Hydrops Fetalis, Primigravida 30+2
weeks pregnancy with bradycardi fetus
BP 120/80 P: - O2 3 lpm
P 70 bpm - Lay to the left side
RR 20 pm
T 36,6 C

FHR 54 bpm
His (-)

IMP S: (-) BE: not performed

5/7/17 O: GC good, alert
12.30 A: Fetal death, Breech presentation, Hydrops Fetalis,
Primigravida 30+2 weeks pregnancy with bradycardi fetus
BP 120/80 P: - Consultation with dr.Diah Rumekti, OBGYN
P 78 bpm - Informed consent
RR 20 pm
T 36,6 C

FHR not found

His (-)
IMP S: (-) BE: v/u normal,
5/7/17 O: GC good, alert vaginal wall smooth,
15.15 A: Fetal death, Breech presentation, Hydrops Fetalis, cervix rigid at
5
 Primigravida 30+2 weeks pregnancy with bradycardi fetus posterior, 0 cm,
BP 120/80 P: - Suggestion : Induction with misoprostol 25 mcg/6 bloody show (-)
P 96 bpm hours/vaginal
RR 20 pm - Consultation with dr. Diah rumekti, OBGYN , advise :
T 36,6 C - Not acc
- Induction with misoprostol 50 mcg/ 4 hours/ vaginal
FHR(-) - Consultation for evaluation next 4 hours
His (-)

15.30 - Start induction with misoprostol 50 mcg/4 hours/vaginal

- Evaluation 4 hours(19.30), consultation With DPJP
IMP S: contraction (+) BE: v/u normal,
5/7/17 O: GC good, alert, not anemic vaginal wall smooth,
19.30 A: IUFD, Breech presentation, Hydrops Fetalis, Primigravida cervix soft at
30+2 weeks pregnancy post induction with misoprostol 50 posterior, eff 0%,
BP 120/80 mcg/4 hours/vaginal tab I, not in labor 0 cm, breech at S-4,
P 96 bpm P: - Suggestion : Induction with misoprostol 50 mcg/4 bloody show (-)
RR 20 pm hours/vaginal tab II seri I BS I
T 36,6 C - Consultation with dr. Diah rumekti, OBGYN , telephone not
connected, whatsapp not replied
FHR(-)
His 3-4x/10/20/
weak
IMP S: regular contraction (+) BE: v/u normal,
6/7/17 O: GC good, alert, not anemic vaginal wall smooth,
02.00 A: IUFD, Breech presentation, Hydrops Fetalis, Primigravida cervix soft at middle,
30+3 weeks pregnancy in stage 1 labor laten phase on induction eff 75%, 1 cm,
BP 117/70 with misoprostol 50 mcg/4 hours/vaginal tab II seri I breech at H1, AM
P 83 bpm P: (+), bloody show
RR 20 pm - Consultation with dr. Diah rumekti, OBGYN , telephone not (+), AF (-)
T 36,5 C connected
- Evaluation in 4 hours (06.00)
FHR(-)
His 4x/10/30/
medium

IMP Evaluation BE: v/u normal,

6/7/17 S: regular contraction (+) vaginal wall smooth,
06.00 O: GC good, alert, not anemic cervix soft at front,
A: IUFD, Breech presentation, Hydrops Fetalis, Primigravida eff 80%, 4 cm,
BP 117/70 30+3 weeks pregnancy in stage I labor active phase on breech at H1, AM
P 83 bpm induction with misoprostol 50 mcg/4 hours/vaginal tab II seri I (+), bloody show
RR 20 pm P: (+), AF (-)
T 36,5 C Consultation with dr. Diah rumekti, OBGYN , advice :
- Observation for his
FHR(-) - Evaluation of labor in 4 hours (10.00)
His 4x/10/30/
medium

IMP Evaluation BE: v/u normal,

6
6/7/17 S: mother wanted to strain (+) vaginal wall smooth,
07.15 O: GC good, alert, not anemic cervix not palpable
Vulva opened, bulging perineum breech at H4, bloody
BP 110/70 A: Stage II show (+)
P 84 bpm P: - Lead to bearing down
RR 20 pm
T 36,5 C

FHR(-)
His 3x/10/40/
strong

Resume of delivery
Length of delivery Amount of bleeding
1st stage: 5 hours 15min 1st stage: 30ml
2nd stage: 15min 2nd stage: 50ml
3rd stage: 5min 3rd stage: 80ml
5 Hours 35min 160ml

7
Baby and placenta
pictures

8
9
10
11
 II. OPERATING THEATRE
A. MAJOR OBSTETRIC(1)
OK 4.04 1. Mrs.Nevi Dwi Lestari, G1P0A0, 22 yo, 39 weeks 1 day
6/7/2017 MR. 01.74.16.29 (DR)
08.00 AM
JKN Non PBI dr. Diah Rumekti, OBGYN assisted by dr. Syahrodi and dr
Wisnu had perfomed Elective C-Section o/i IUGR, with fetal
G2P1A0(live child aritmia, P2A0, Day 1
0)
LMP 6/10/2016 At 08.35 baby delivered abdominaly, female, 2800 gr, 47cm,
EDC 13/07/2017 HC/CC 33/31 cm, A/S 7/9.
GA 39 weeks 1 day
At 08.40, placenta delivered abdominaly complete, size
BP 110/70 mmHg 20x20x2 cm, weight 450 gr, CL 45 cm, paracentalis insertion,
HR 84bpm calsification (-)
RR 20 bpm
T 36,5 C

BH 156 cm
BW 65 kg
BMI 26,7 kg/m2

Clinic Chronology: Lab 4/7/2017

4/7/2017 Patient was referred from RSIA Adinda (dr.Diah Rumekti, WBC 12,70
G2P1A0 (live child OBGYN) with diagnosis Aterm Pregnancy, G2P1A0, IUGR RBC 4,49
0) with aritmia. Hb 12,,6
LMP 6/10/2016 Patient felt 9 months pregnant, irregular contractions (+), HCT 38,1
EDC 13/07/2017 mucous and blood (-), amnion fluid leakage (-), fetal movement PLT 278
GA 38 weeks 6 (+). PPT 13,5/13,9
days History of ANC at OBGYN 6 times. APTT 30,1/29
History of Hypertension, DM, renal disease, heart disease, INR 0,98
BP 110/70 mmHg allergy (-). RBG 70
HR 84bpm History of contraceptive (-) Na 140
RR 20 tpm History of marriage : 1 time for 3 years K 3,54
T 36,5 C Obstetrics history: Cl 105
I. 2016, female, aterm, died 1 hour after born HbsAg (non
BH 156 cm II. This pregnancy reactive)
BW 65 kg
BMI 26,7 kg/m2 Physical Examination: good, concious, not anemic
Palpation: singleton baby, longitudinal lie, cephalic
presentation, head palpated 4/5 parts His (-)
FHR 146 bpm

BE: v/u normal, vaginal wall smooth, cervix soft, 0 cm, AM

(+), cephalic presentation, bloody show (-), AF (-).

Dx: IUGR, Aterm Pregnancy, G2P1A0 not in labor with aritmia

Tx: - Planned for Elective C-Section Thursday, July 6, 2017

- Consultation to Anestesiology and Perinatology
Department
12
 - Laboratory examination in ward
- Repeat NST in ward
- Consultation with dr.Diah Rumekti, OBGYN : Acc dx tx

USG :

Singletone baby
Longitudinal
Cephalic
presentation
FHR (+), fetal
movement (+),
sufficient AF.

BPD 8,33 cm
HC 31,1 cm
FL 6,31 cm
EFW 2336 gram

13
USG from RSIA
Adinda
No expertition

14
NST
FHR baseline 150
bpm
Variability >5
Acceleration (+)
Deceleration (-)
Movement (+)
NST reactive

15
IMP S: complaint (-), contraction (-), fetal movement (+)
5/7/17
05.00 O: General performance ; good, conscious, not anemic

A: IUGR, Aterm Pregnancy G2P1A0 not in labor with aritmia

BP 110/80 mmHg
N 68 bpm P: - Admission for C-Section today
R 28 pm - Consultation to Anestesiology and Perinatology
T 36,7 C

His (-)
FHR 140 bpm

16
NST
FHR baseline 130
bpm
Variability >5
Acceleration (+)
Deceleration (-)
Movement (+)
NST Category 1

17
IMP Evaluation
6/7/17 S: fetal movement (+)
05.00
O: General performance ; good, conscious, not anemic
BP 110/70 mmHg
N 89 bpm A: IUGR, Aterm Pregnancy G2P1A0 not in labor with aritmia
R 24 pm
T 36,5 C P: - Pro Elective C-Section today

His (-)
FHR 139 bpm
Condition This Morning
Vital Sign: Fluid balance: Hb post op:
BP: mmHg IF ml 11,5
P: bpm OF ml
RR bpm IWL ml
T 0C FB ml
UO ml/h
B. MAJOR GYNECOLOGIC (3)
OK 4.03 1. Mrs. Aniatik, P2A0, 44 yo Lab:
06/7/2017 MR 01.80.95.96 WBC 7,80
JKN Non PBI RBC 4,19
DPJP MIA Hb 12,1
P2A0 dr.M. Luthfi, OBSGIN and dr.Fahmi, OBGYN with assistant dr. HCT 37,4
LMP 14/6/17 Rayan and dr. Odi had performed bilateral laparoscopy cystectomy PLT 336
Youngest child 16 and adhesiolisis o/I bilateral chocolate cyst with APS superficial PPT 13.3/14.3
yo bridging APTT 31.6/29.5
Blood type
Alb 4,33
BP 110/80 mmHg Dx pre op : Bilateral Chocolate Cyst with APS superficial BUN 8,4
N 70 kpm myocardial bridging Cr 0,64
R 20 kpm Dx post op: Bilateral Chocolate Cyst with APS superficial SGOT 22
T 36.6 C myocardial bridging SGPT 29
RBG 146
ECG Durante op: Na 143
SR, HR 70 bpm - Routine operation procedure K 3,61
- Preparation of operation field Cl 105
- Laparoscopy :
Sperm Analysis HbsAg (non
- Uterus size and shape within normal limit, uterus posterior
reactive)
attached with peritoneum parietale adhesiolisis
HSG
- Right tuba within normal limit, right ovarium changed to cystic
mass sized 8x7x7 cm,cyst capsule was opened the , leakage of thick
chocolate fluid established right chocolate cyst performed right
cystectomy PA
- Left tuba within normal limit, left ovarium changed to cystic mass
size 6x6x5 cm, the left cyst capsule was openedleakage of
chocolate porridge established left chocolate cyst performed
left cystectomy PA
- Bleeding control (-)
- Washing of cavum abdomen with naCl 0,9%
- Operation done

18
USG ( dr. M.
Lutfi , OBGYN
USG-TV(4/07/17)
VU filled enough,
normal uterus
shape and size.
Seen bilateral
chocolate cyst,
right chocolate cyst
size 3.9 cm x 3,1
cm. Left chocolate
cyst size 6.8 x6.5
cm.

Conditon this morning

Vital Sign: Fluid balance: Hb Post Op
BP: mmHg IF ml
P: bpm OF ml
RR bpm IWL ml
T 0C FB ml
UO ml/h
OK 4.04 2. Mrs.Nur Zaitun, P2A1, 46 yo Lab:
6/07/2017 MR 01.81.25.83 WBC 7.48
JKN RBC 4.59
DPJP H Dr.Heru, OBSGIN with assistant dr.Rika and dr. Darma had Hb 13.0
performed Radical Histerectomy and Limphadenectomy Iliaca dextra HCT 39.5
P2A1, 46 thn et sinistra o/I Ca cervix IB1 PLT 193
LM March 2017 PPT 13.8/14.3
Youngest child 19 APTT 36.9/29.5
yo Dx pre op : Ca Cervix IB1 INR 1.00
Dx post op: Ca Cervix IB1 SGOT 18
TD 160/93 mmHg SGPT 12
N 71 kpm Durante op: BUN 7.40
R 20 kpm - Routine operation procedure Creat 0.69
T 36.7 C - In narcose stage, perform the incision of linea mediana until 1 Alb 4.24
finger under umbilicus HbsAg (non
- Incision deepened layer by layer until peritoneum parietale
BW 61 kg reactive)
- After opened peritoneal parietale, perform identification and
BH 150 cm exploration
BMI 27,1kg/m2 - Seen uterus size and shape within normal limit
- Seen ovarium and left/right tuba within normal limit
ECG - Deciden to do radical histerectomy and lymphadenectomy bilateral
SR, HR 75 bpm inguinal
- Ligamentum rotundum left/right c/c/s
Thorax Rontgen - Plica vesico uterina opened and set aside
Cor and pulmo - Ligamentum infundibulum pelvicum opened
within normal - Performed lymphadenectomy inguinal bilateral PA
limit. - Identification of left/right ureter
- Ligamentum infundibulum pelvicum right/left c/c/s
- Identification of A/V uterina ight/left c/c/s
IVP : normal both - Ligamentum sacrouterina right/left c/c/s
renal anatomy and
19
function, both - Identification of cervix
ureter within - Uterus being cut as high as top of vagina PA
normal limit - Top of vagina being sutured continous locked one layer
- Reperitonealisation
- Abdomen being washed with NaCl
CIL : Not seen
- Parietal reperitonealisation
indentation or - Abdominal wall sutured layer by layer
colitis image. Not - Skin sutured subcuticular
seen bone - Operation done
metastasis.

USG
VU filled enough,
seen uterus size 4.9
x 4.4 x2,2 cm, not
seen adnexa mass.

Conditon this morning

Vital Sign: Fluid balance: Hb Post Op
BP: mmHg IF ml 11,7
P: bpm OF ml
RR bpm IWL ml
T 0C FB ml
UO ml/h
OK 5.03 3. Mrs. Parjiyem, P2A0, 45 yo Lab
6/7/2017 MR 01.80.95.96 WBC 8.19
JKN NON PBI RBC 4.67
DPJP EDP Hb 12
P2A0 dr.Edi Patmini, OBSGIN with assistant dr. Sugma and dr. Tiara had HCT 37.6
LMP 20/5/17 performed TVH, colporaphy anterior, and colporaphy posterior o/I PLT 374
Uterine Prolapse Grade IV, Cystocele Gr III, Rectocele Gr II with PPT 12.9/13.9
cervix elongation APTT 31.2/30.7
BP 120/65 mmHg HbSAg Not Reactive
N 87 bpm SGOT 70
R 20 bpm Dx pre op : Uterine Prolapse Grade IV, Cystocele Gr III, SGPT 31
T 36.5 C Rectocele Gr II with cervix elongation BUN 5.10
Dx post op: Uterine Prolapse Grade IV, Cystocele Gr III, Creat 0.64
ECG Rectocele Gr II with cervix elongation Alb 3.54
SR, HR 100 bpm Blood Type B
Durante op: RBG 148
- Routine operation procedure, patient litothomy position in narcose Na 145
20
Thorax rontgen stage K 4.10
Cor and pulmo - In narcose stage performed asepsis of operation field Cl 107
within normal limit - Performed insertion of permanent catheter
- Performed installation of sims anterior and posterior
- Performed infiltration NaCl 0,9% + epinephrine 1:200.000 on
POP-Q
vaginal mucosa around cervix
+2 +5 +7 - Performed incision around cervix
4 2 9 - Anterior vaginal mucosa opened, performed incision of anterior
-2 0 -4 fornix until peritoneum seen
- Seen cervix elongated/ elongation + 8 cm
- Ligamentum sacrouterina right/left c/c/s
- A/V uterina c/c/s
- Ligamentum cardinale c/c/s
- Performed opening of uterus by hemisection
- Uterus size 5x4x4 cm with myoma uteri on fundus size 3 cm
- Complex ligamentum rotundum and fallopian tube right/left c/c/s
- Performed suture tabac pac on outer wall of vesica urinaria
- Inner part of anterior vaginal wall sutured one by one
- Anterior vaginal wall closed by continous suture control bleeding
(-)
- Inner part of posterior vaginal wall closed by sutured one by one
- Performed colporaphy posterior
- Operation done
- Performed plug of vaginal compact cotton

- amount of bleeding 500 cc

21
USG
VU filled enough,
seen uterus size
10.7 x 4.3 cm, seen
serviks enlarged
with opening 6.05
cm, endometrial
line (+) 4,07 cm

22
 Conditon this morning
Vital Sign: Fluid balance: Hb Post Op
BP: mmHg IF ml
P: bpm OF ml
RR bpm IWL ml
T 0C FB ml
UO ml/h
C. MINOR GYNECOLOGIC (0)
III. OPERATION PLAN
A. MAJOR OBSTETRIC
Bugenville 2 1.Mrs.Dina Ikasari, G3P1A1, 33 yo Lab 6/7/2017
6/7/17 MR. 01.57.42.49 WBC 10,09
JKN Non PBI RBC 3,45
DPJP dr.AAT Dx : G3P1A1 pregnant 37 weeks , not in labor, mother with Hb 9,6
history of brain stem glioma, history of oral chemotherapy 15 HCT 29,9
G3P1A1 series, chemoradiation 7 times PLT 238
LMP 20/10/2016 Tx : Elective C-Section PPT 13,6/13,9
EDC 27/7/2017 Place / time : 4.04/13.00 APTT 27,2/29,1
GA 37 weeks Team : INT/ATA/RES/dr.AAT INR 0,98
Blood type A
BP:150/80 mmHg Alb 3,59
P: 88 bpm BUN 4
R: 20 bpm Cr 0,5
T: 36.6 C SGOT 16
SGPT 14
BH 157 cm RBG 109
BW 56 kg Na 137
BMI 22,7 kg/m2 K 3,80
Cl 103
ECG : STC 103 HbsAg (non
bpm reactive)

MRI(2016) : seen
damaged tissue in
brain stem area

23
USG
Singletone baby
Longitudinal
Cephalic
presentation,FHR(
+),fetal movement
(+). Placenta at
fundus, AF enough

BPD9,7 cm ~
39+6 wks
AC 32,8 cm~
36+5 wks
FL9,7 cm ~ 39+6
wks
EFW 3408 gr

24
NST
FHR baseline 130
bpm
Variability >5
Acceleration (+)
Deceleration (-)
Movement (+)
NST category I

25
Bugenville 2 2.Mrs.Nuryati, G1P0A0, 29 yo Lab 6/7/2017
6/7/17 MR. 01.80.95.26 WBC 8,02
General RBC 4,33
DPJP dr.HRS Dx : Breech, Primigravida, 38 weeks 3 days pregnancy, not in Hb 12,5
parturition HCT 36,9
G1P0A0 Tx : Elective C-Section PLT 187
LMP 7/10/2017 Place / time : 1.02/10.00 PPT 12,3/13,9
EDC 14/7/2017 Team : ARA/ICA/LAN/dr.HRS APTT 27,2/29,1
GA 38 weeks 3 INR 0,87
days Blood type B
Alb 3,51
BUN 8
BP: 120/70mmHg Cr 0,53
P: 84 bpm SGOT 33
R: 20 pm SGPT 22
T: 36.6 C RBG 71
Na 137
BH 150 K 4,21
BW 61 Cl 105
BMI HbsAg (non
reactive)
ECG
NSR, 95 bpm

USG
Singletone baby
Longitudinal
Breech
presentation
FHR (+), fetal
movement (+).
Placenta at corpus
posterior extended
downward not
close oui

BPD 9,19 cm ~ 38
wks 3 days
AC 29,73 cm ~
33wks 5 days
FL 5,70 cm~ 29
wks 6 days
EFW 2765 gr

26
NST
FHR baseline 140
bpm
Variabilitas >5
Acceleration (+)
Deceleration (-)
Movement (+)
NST Category 1

27
 B. MAJOR GYNECOLOGIC
Bugenville 2 1.Mrs.Indriani, P2A0, 32yo Lab 4/7/2017
6/7/17 MR. 01.80.98.81 WBC 9,93
JKN RBC 5,24
DPJP dr.H Dx : Ovarian cancer Post Cystectomy 3 months ago Hb 14,8
Tx : Relaparotomy POA HCT 46,2
P2A0 Place / time : 4.04/08.00 PLT 281
LMP 17/6/2017 Team : dr.H/VIL/DAR PPT 14,7/14,3
The youngest child APTT 36,6/29,5
6 yo Alb 4,54
BUN 5,90
Cr 0,88
BP: 128/84 mmHg SGOT 14
P: 92bpm SGPT 11
R: 18 pm RBG 89
T: 36.6 C Na 140
K 3,91
BH 155 cm Cl 103
BW 60 kg HbsAg (non
BMI 25 kg/m2 reactive)
CEA 0,65
ECG CA 125 14,20
SR, 88 bpm

MRI
3x1x14.2 = 42.6
USG Staff:
VU slightly filled,
seen uterus size
6,9x3,8 cm, not
seen mass in
adnexa

C. MINOR GYNECOLOGIC
D. STERILIZATION
NONE
IV. PATIENTS ADMITTED TO HOSPITAL

28
 V. WARDS SITUATION
BOG 2 BOG 1
OBS ONK
GIN GIN
MFM ER
IMP Other wards
OBS ONC
MFM OBS
GIN
ER
MFM
ICU
VI. PATIENTS IN OTHER WARDS
Amarta 1 1. Mrs.Rahman Latifah,G1P1A0, 22yo, gestational age 10 Lab 5/7/2017
6/7/2017 weeks(SHI) Hb 12,4
JKN Non PBI MR. 01.36.90.75 WBC 12,94
PLT 314
G1P0A0 Dx : Abortus Imminens Hct 39,5
LMP 27/4/2017 Tx : RBG 149
EDC 3/2/2018 - Uterogestan 200mg/12 hours/po HBsAg Non reactive
GA 10 weeks

BP 120/80 mmHg
P 80 bpm
R 20 pm
T 36,5C

Cendana 1 2. Mrs.Sujarmi, GPA, yo Lab 2/7/2017

6/7/2017 MR. 01.79.89.08 Hb 10,2
JKN Non PBI WBC 16,5
DPJP Dx : Breech presentation, secundigravida 31+5 weeks, not in PLT 477
labor, with carcinoma mammae and cancer pain on Hct 30,3
G2P1A chemotherapy PPT 13,4/14,7
LMP 3/11/2016 Tx : APTT 28,9/28,9
EDC 1/9/2017 - Observation of His and FHR Alb 3,02
GA 31+5 weeks - Plan for termination GA 34 weeks SGOT 26
- Other therapy Surgery department SGPT 8
BP: 110/70 mmHg BUN 4,90
P: 84 bpm Cre 0,52
R: 20 bpm RBG 100
T: 36,7 C HBsAg Non reactive
Na 139
K 4,02
BW 46kg Cl 103
BH 152cm
BW 5 kg

29
IMT 19,9 kg/m2

His (-)
FHR 142 bpm
Dahlia 4 3. Mrs. Nur Endah, G2P1A0, 33yo Hb 5,2
6/7/2017 MR. 01.81.59.15 WBC 28,2
RBC 2,48
Dx : Secundigravida, pregnant 31 weeks 4 days, not in PLT 219
G2P1A0 parturition with mother anemia and TB Pulmo
LMP 2/12/16 Tx : MDT : suspect
EDC 9/9/17 - SF 1 tab/24 hours/po severe infection DD
GA 31 weeks 4 - Calcium Lactate 1 tab/24 hours/po haemolytic process
days
Fecal exam :
BP: 104/66 mmHg Egg worm (-)
P: 92 bpm Fungi (+)
R: 26 bpm Paracyte (-)
T: 36,7 C
Urinalysis :
Blood (-)
BW 44kg Nitrit (-)
BH 150cm Leu est (+3)
BW 4 kg Leu 30
IMT 19,5 kg/m2 Bact 156.9
Prot -
Keton -

Cendana 5 4.Mrs. Nanik Indrawati, G3P2A0, 32yo Lab

6/7/17 MR. 01815503 WBC 8.64
18.00 RBC 3.56
JKN Non PBI Dx : Multigravida, 28+6 wks pregnancy, with femoral fracture Hb 9.9
DPJP AAT 1/3 distal sinistra, Post ORIF HCT 30.2
Tx : PLT 143
G3P2A0 Obs his and FHR PPT
LMP 16/12/16 Others therapy Orthopaedic Department APTT
EDD 22/9 Blood type
GA 28+6 wks Alb 2.38
BUN 5
BP: 110/70 mmHg Cr 0.4
P: 88 bpm RBG 82
R: 20bpm Na 138
T: 36.6 C K 4.22
Cl 105
HbsAg (non
BH 155 cm reactive)
BW 55 kg
BMI 22,9 kg/m2

HCU 5.Mrs. Albertina Banggenop , G8P6A1, 39 thn, 33 wks Lab

6/7/17 MR 01816054 WBC 17.28
JKN NON PBI RBC 5.09
30
DPJP AAT Hb 13.7
Dx : Post SC emergency a.i Fetal Distress, PEB, edema pulmo, HCT 39.6
G8P6A1 preterm, P7A1,H1 Plt 336
HPM ? PPT 12.0/13.1
HPL ? Tx : APTT 33.5/30.1
GA 31 mgg INR 0.85
SGOT 28
BP 162/97 mmHg SGPT 17
P 118 kpm BUN 30.4
R 36 kpm Creat 2.95
T 36.5 C Alb 2.34
HbsAg
TB 150 cm (non reaktif)
BB 85 kg RBG 116
BMI 37,7 kg/m2 Na 143
BB 12 kg K 2.76
Cl 105
LDH 658

Urinalisa
Leu 298
Leu Est -+
Bakt 334.4
Nitrit
Protein +3

ICU 5.Ny.Florida, P1A0, yo

6/7/2017 MR 01.81.48.83
JKN NON PBI Dx :
DPJP AAT Tx :

P1A0
HPM ?
HPL ?

BP 113/76 mmHg
P kpm
R 36 kpm
T 36.5 C

TB 150 cm
BB 85 kg
BMI 37,7 kg/m2
BB 12 k
ICU 6. Nn. Mariani Ninci Bea, P1A0, 22 yo
6/7/2017 MR 01.81.55.24

VII. REKAPITULATION PHC

JETIS TEGALREJO
Physiologic delivery - Physiologic
Patologic delivery - delivery -
IUD 0 Patologic delivery -
31
 IUD -
MERGANGSAN S
Physiologic delivery - E
Patologic delivery 0 W
IUD 0 O
N

P
h
y
s
i
o
l
o
g
i
c

d
e
l
i
v
e
r
y

-
P
a
t
o
l
o
g
i
c

d
e
l
i
v
e
r
y

-
I
U
D

32
 -
VIII. DELIVERY ROOM
IMP 1. Mrs, GPA, yo WBC
10/6/11 MR. RBC
Hb
GPA Dx : HCT
LMP Tx : PLT
EDD PPT
GA APTT
Blood type
BP: mmHg Alb
P: bpm BUN
R: bpm Cr
T: afebrile SGOT
SGPT
BH RBG
BW Na
BW K
Cl
HbsAg (non
reactive)

USG

OBSTETRICS HEMORRHAGE
TEGALREJO 0
JETIS 0
MERGANGSAN 0
SEWON 0
RS BANJAR NEGARA 0
RS WONOSOBO 0
RS WATES 0
RS PATI 0
RS CILACAP 0
RS KLATEN 0
RS MUNTILA 0
RS BANTUL 0
RS WONOSARI 0
RS SLEMAN 0
RS BANYUMAS UNIT 0
RS BANYUMAS UNIT 0
RS WONOSARI 0
RS PURWOREJO 0
RS SLEMAN 0
RS BANYUMAS UNIT 1 0
RS BANYUMAS UNIT 2 0

Corrector Jaga Tua

33
dr. dr.

Chief on Duty

dr.

34