II OBSTETRIC INPATIENT REPORT

Friday, Jun 29th 2018 – Thursday, Jul 5th 2018

Chief on Duty :
Dr. Abdul Bari

Supervisor:
Dr. H. Nuswil Bernolian. OBGYN (C). MARS

RECAPITULATION OF OBSTETRIC PATIENTS

Physiological Patients :2 Patients

Pathological patients : 28 Patients
Total : 30 Patients
Patient was discharge : 13 Patients
Patient was stable inward : 17 Patients

PROCEDURAL AMOUNT %
Vaginal delivery Spontaneous Delivery Aterm 2 7,1
Preterm 4 14,3
Breech 1 3,6
Assited Vaginal Delivery Forcipal Extraction - -
Vacuum Extraction
Partial Extraction
Abdominal Delivery 9 32,1
Conservative Management 6 21,4
Expectative Management 3 10,7
Medicinalis - -
Curettage - -
Manual Placenta 1 3,6
Brandt Andrew Manuever 2 7,1
TOTAL 28 100
 Day/ Date Old patients New patients Discharged patients Total Patients
Friday/ 33 16 13 29
June 29th, 2018
Saturday/ 29 2 0 31
June 30th, 2018
Sunday/ 31 7 4 34
July 1st, 2018
Monday/ 34 7 7 34
July 2nd, 2018
Tuesday/ 34 16 19 31
July 3rd , 2018
Wednesday/ 31 12 16 27
July 4th, 2018

Obstetrical Patients Friday, June 29th 2018

N Identity Diagnosis ICD Previous ICD Last Recen Phsy
o. 10 Procedure 9 Diagnosi t
s Proce
dure
1 Mrs SUA P1A0 post O30. • Wound care Z91. P1A0 post Stable GER
/22yo/UA LSCS o.i 039 • Antibiotics 19 LSCS o.i in ABR
breech O32. • Culture breech ward AM
presentatio 2 presentati
n+ on +
condyloma condylo
accuminata ma
13th days accumina
with wound ta 20th
dehiscence days with
wound
dehiscenc
e
2 Mrs.RUK/3 G4P2A1 24 O60. • Vaginal 650 P3A1 Had DAV
2yo/RA weeks 0 Delivery post been ABR
gestational spontaen discha FU
age inlabor ous rged
1st stage preterm
latent phase delivery
SLF
intrauterine
3 Mrs.REN/31 G2P1A0 30 O14. • Stabilization 650 P2A0 Had WDS
yo/RA weeks 13 • anti post been ABR
gestational O42. hypertention spontane discha FU
age inlabor 10 • Antibiotics ous rged
1st stage • Anti preterm
latent phase convulsions delivery
with severe • Vaginal + severe
preeclampsi Delivery preeclam
a+ psia
PPROM 12
hours SLF
cephalic
presentatio
n
4 Mrs. G5P3A1 34 O14. • Stabilization 659. G5P3A1 Had WDS
EVI/42yo/R weeks 13 • Expectative 8 34 weeks been ABR
A gestational O32. management gestation discha FU
age not 1 • Anti al age not rged
inlabor with hypertention inlabor
severe • Anti with
preeclampsi convulsions severe
a SLF • Lung preeclam
breech maturation psia SLF
presentatio • P/ US breech
n confirmation presentati
on

Obstetrical Patients Saturday June 30th 2018

No Identity Diagnosis ICD Previous ICD 9 Last Recen Resid
. 10 Procedure Diagnosi t ent/
s Proce Consu
dure ltant
1. Mrs. LIL P3A0 post O75.8 • Blood 99.0 Post Had EZA
34/UA spontaneo 2 Transfusion 75.4 manual been ABR
us delivery 72.1 • Manual plasenta discha HE
outside (7 O73.0 placenta oi rged
hours) D64.9 removal placenta
with early adhesiva
post
partum
hemorrhag
e c.b
retained
placenta +
severe
 anemia

2. Mrs. CAN P3A0 post O34.2 • Medicinalis 99.2 P3A0 Stable ABR
33/UA LSCS (oi 1 • wound care 93.57 post in FU
severe L08.9 • wound 879.8 LSCS (oi ward
preclampsi E11.9 culture severe
a not in D64.9 • consult to preclamp
labor + internal sia not in
PROM 5 department labor +
hours + PROM 5
prior CS hours +
1x) 10 prior CS
days with 1x) 10
wound days
infection + with
Type 2 wound
diabetes infection
melitus + + Type 2
Hypoalbu diabetes
mia + mild melitus +
anemia Hypoalb
umia +
mild
anemia

Obstetrical Patients Sunday, July 1st 2018

N Identity Diagnosis ICD Previous ICD 9 Last Recen Resid
o. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
1 Mrs. PUT G2P1A0 31 Z34.2 • Conservative 644.0 G2P1A0 Had ABR
28/UA weeks of O60.0 management 3 31 weeks been NS
gestational 0 • US 88.7 of discha
age with confirmation gestation rged
threatened al age
preterm with
labor SLF threatene
cephalic d
presentatio preterm
n labor
 SLF
cephalic
presentat
ion

2 Mrs LEN G4P3A0 38 O32.1 Bracht 65.0 P4A0 Had HUD

/34/UA weeks manuver post been ABR
gestational P/ IUD bracht discha AW
age insertion manuver rged
inlabor + Post
second IUD
stage SLF insertion
breech
presentatio
n
3 Mrs. FIT G3P2A0 31 Z34.2 • Expectative 644.0 G3P2A0 Had HUD
30/UA weeks of O60.0 management 3 31 weeks been ABR
gestational 0 • US 88.7 of discha AW
age with confirmation gestation rged
APH cb al age
total with
placenta APH cb
previa total
SLF placenta
cephalic previa
presentatio SLF
n cephalic
presentat
ion
4 Mrs. NOR/ G1P0A0 40 Z34.3 • Stabilization 65.0 P1A0 Had ABR
26/UA weeks O14.1 • P/ vaginal post been AW
gestational 3 delivery spontane discha
age in ous rged
labor firts delivery
stage
latent
phase with
severe
preeclamp
sia SLF
cephalic
presentatio
n+
Olygohidr
amnios
5 Mrs. PUT/ G1P0A0 33 Z34.3 • vaginal 65.0 P1A0 Had EZA
15/UA weeks 060. delivery post been ABR
gestational spontane discha AW
age in ous rged
labor first delivery
stage
latent
phase with
cephalic
presentatio
n

Obstetrical Patients Monday, July 2nd 2018

N Identity Diagnosis ICD Previous ICD 9 Last Recen Resid
o. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
1. Mrs SIL/33 G1P0A0 25 O60.1 • Vaginal 65.0 P1A0 Had ABR
yo/ UA weeks 0 Delivery post been AA
gestational spontane discha
age ous rged
inlabor preterm
first stage delivery
active + UTI
phase with
UTI, SLF
intrauterin
e
2. Mrs. ANI / G7P3A3 32 O15.9 Stabilization 401 P4A3 Stable RIW
42 y.o / weeks R55 Anti 669.7 post in ABR
RA gestational I67.9 Hypertension V52 LSCS oi ward IS
age not MgSO4 40% ~ antepartu
inlabor Protocol m
with LSCS eclampsi
antepartu Pomeroy a+
m Tubectomy decrease
eclampsia of
+ decrease consciou
of sness +
conscious history
ness + of
history of CVD+Tu
CVD SLF bectomy
cephalic pomeroy
 presentatio
n

3. Mrs. MEY / G2P1A0 33 O42.3 Antibiotics 99.21 P2A0 Stable GER

28 y.o / weeks Tocolitics 644.0 post in ABR
UA gestational Lung 3 LSCS oi ward PB
age not Maturation 659.8 anhydra
inlabor Plan for US 655.8 mnios
with confirmation 0
history of Plan for
preterm termination after
premature lung maturation
rupture of
membran
1 day SLF
cephalik
presentatio
n+
oligohydra
mnios
4. Mrs. ASR / G1PoA0 37 O42.3 Antibiotic 99.21 P1A0 Had DAV
23 y.o / weeks Plan for Vaginal 650 post been ABR
RA gestational Delivery spontane discha IS
age us rged
inlabor delivery
first stage with
laten history
phase with of
premature rupture
rupture of of
membrane membran
3 days e+
SLF moderate
cephalic anemia
presentatio
n

No Identity Diagnosis ICD Previous ICD 9 Last Recen Resid

. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
5. Mrs. DIA / G1P0A0 36 O14.9 Stabilization 401 P1A0 Stable GER
29 y.o / weeks 0 Anti 669.7 post in ABR
RA gestational O30.0 Hypertension LSCS o.i ward IS
age not 03 MgSO4 40% ~ Impendin
inlabor Protocol g
with LSCS Eclampsi
impending a+
eclampsia Gemelly
TLF
breech
presentatio
n – breech
presentatio
n.
6. Mrs. PUT / G1P0A0 33 O60.0 Conservative 664.0 G1P0A0 Stable EZA
29 y.o / weeks 3 management 3 33 weeks in ABR
UA gestational Tocolytics 659.8 gestation ward IS
age with Lung 655.8 al age
threatened Maturation 0 with
preterm Plan for US threatene
labor + confirmation d
history of preterm
vulnus labor +
laceration history
in of vulnus
abdominal laceratio
regio SLF n in
cephalic abdomin
presentatio al regio
n. SLF
cephalic
presentat
ion
7. Mrs. PUT / G1P0A0 30 O15.9 Stabilization 401 P1A0 Stable GER
25 y.o / weeks R55 Anti 669.7 post in ABR
UA gestational I67.9 Hypertension LSCS oi ward AF
age not MgSO4 40% ~ antepartu
inlabor Protocol m
with Abdominal eclampsi
antepartu Termination a
m after
eclampsia stabilization.
SLF
cephalic
presentatio
n
8. Mrs. AGU / G2P1A0 34 O14.1 Stabilization 401 P2A0 Stable GER
28 y.o / weeks 3 Anti post in ABR
UA gestational Hypertension LSCS oi ward IS
age not MgSO4 40% ~ fetal
inlabor Protocol distress
with LSCS
severe
preeclamp
sia + prior
cs 1x SLF
cephalic
presentatio
n

Obstetrical Patients Tuesday, July 3rd 2018

N Identity Diagnosis ICD Previous ICD 9 Last Recen Resid
o. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
1 Mrs. MAH/ G3P2A0 38 O75.9 LSCS 99. 60 P3A0 Stable GER
31yo/ weeks 075.8 IUD Insertion 669 post in ABR
UA/AW gestational 9 LSCS oi ward AW
age fetal
inlabor 1st distress
stage
active with
PROM 12
days +
intrapartu
m
infection
SLF
cephalic
presentatio
n + fetal
distress
2 Mrs. NUR/ G1P0A0 644.0 Concervative 338 G1P0A0 Stable ABR
26 yo/ 24 weeks 3 Management 23 weeks in AW
UA/AW gestational US gestation ward
age with Confirmation al age
threatened with
preterm threatene
labor with d
history of preterm
exploratio labor
 n with
laparatom history
y SLF of
Intrauterin explorati
e on
laparato
my SLF
Intrauteri
ne
3 Mrs. RUS / G4P3A0 29 O14.9 Stabilization 401 G4P3A0 Stable ABR
36 y.o /UA/ weeks 0 Anti 26 in HE
HE gestational O30.0 Hypertension weeks ward
age not 03 MgSO4 40% ~ gestation
inlabor Protocol al age
with Expectative not
severe management inlabor
preeclamp US with
sia TLF Confirmation severe
cephalic preeclam
presentatio psia TLF
n – breech cephalic
presentatio presentat
n. ion –
breech
presentat
ion.
4 Mrs. ARJ/ G3P2A0 O47.0 Conservative 644.0 P3A0 Stable ABR
36 yo/ UA/ 35 weeks O82 management Post in GER
AW gestational Tocolytics LSCS oi ward AW
age with Lung maturation Cervical
threatened Plan for US length
preterm confirmation 0,71 cm
labor with + LUS
prior CS thickness
1x SLF 0,2 cm
cephalic
presentatio
n

N Identity Diagnosis ICD Previous ICD 9 Last Recen Resid

o. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
5 Mrs. TUM/ G4P2A1 Stabilization 669 P3A1 Stable GER
36 yo/ 37 weeks Anti post in ABR
RA/AW gestationa Hypertension LSCS oi ward AW
l age not MgSO4 40% ~ preeclam
in labor Protocol psia +
with LSCS prior CS
severe 1x
preeclamp
sia + prior
CS 1x +
PROM 16
hours SLF
cephalic
presentati
on +
oligohydr
amnios
6 Mrs. P2A0 post Brandt Andrew P2A0 Stable ABR
EMI/33/RA/ spontaneo manuevre post in AW
AW us brand ward
delivery 6 andrew
hours manuevr
(outside) e oi
with early incarsera
post te
partum placenta
hemmorh
age cb
retain of
placenta
cb
incarserat
e placenta
7 Mrs. YUL/ G5P3A1 28 Z. • Post Z53.0 G5P3A1 Stable GER
35 weeks of 35.2 laparoto 28 weeks in ABR
yo/UA/AA gestationa N 83.5 my of ward AA
l age not explorati gestation
inlabor on al age
with acute • Stab not
abdomen wound inlabor
pain cb drain post
torsion of laparoto
ovarium my
cyst was explorati
suspected on ai
SLF Abces
 cephalic peritoneu
presentati m + post
on Stab
wound
drain

Obstetrical Patients Wednesday, July 4th 2018

N Identity Diagnosis ICD Previous ICD 9 Last Recen Resid

o. 10 Procedure Diagnosi t ent/
s Proce Cons
dure ultan
t
1 Mrs. G4P3A0 34 O.60. - Conservative G4P3A0 Stable ABR
YUW/33/U weeks 0 Management 34 weeks in AF
A gestational - Lung gestation ward
age with Maturation al age
threatened - PRC with
preterm Transfusion threatene
labor + d
moderate preterm
anemia labor
SLF +modera
cephalic te
presentatio anemia
n SLF
cephalic
presentat
ion
2 Mrs. P2A0 post O72.1 - Brandt 666 P2A0 Stable ABR
UMI/27 /RA spontaneo andrew post in HI
us delivery manuevre brandt ward
out side 3 andrew
hours manuevr
With early e
PPH c.b
incarserata
placentae