DUTY REPORT

Tuesday, November 7th 2017

Supervisor :
dr. Irliyan Saputra, M.Ked(OG), Sp.OG

Residents : 1. dr. Ahmad Syauki

2. dr. D. Levana Diandra
3. dr. Vivi Yovita
4. dr. Utari Purnama
5. dr. Frida Adhani E.S

Department of Obstetrics and Gynecology

Medical Faculty Universitas Sumatra Utara
Pirngadi General Hospital
2017
NEW PATIENT : 2 PATIENT
1. Mrs. M, 24 y.o, P2A0
Diagnose : PPH d/t perineal laceration
Plan : repair perineal laceration, transfusion PRC 4 bag

2. Mrs. R, 23 y.o, G1P0A0

Diagnose : Eclampsia + Preterm labor + PG + IUP (34-35) wga +
Head Presentation + alive fetus
Plan : emergency C-section
 New Patient: 2 Patient
NO Case Result
1. Mrs. M, 24 y.o, P2A0 Planning :
Diagnose : PPH d/t perineal laceration repair perineal
laceration,
transfusion PRC 4 bag

2. Mrs. R, 23 y.o, G1P0A0 Planning :

Diagnose : Eclampsia + Preterm labor + PG + emergency C-section
IUP (34-35) wga + Head Presentation +
alive fetus
PATIENT 1
Mrs. M, 24 y.o, P2A0,

CC : vaginal bleeding
Experienced by the patient since 7/11/2017 at 9 pm, stoolcell (+), reddish
(+). Previously the patient gave birth to the second child at the midwife
clinic at 11 am (7/11/2017), and placenta was complete. According to
patient, the perineal repair was done at the clinic. Micturition and
defecation within normal limit.

History of previous ilness : (-)

History of previous medication : (-)

History of Pregnancy
1. Boy, 3200 gr, aterm, midwife, clinic, SVD, 1 yo, healthy
2. Boy, 3900 gr, aterm, midwife, clinic, SVD, 0 day, healthy
Present State
Cons : Alert Anemic : (+)
BP : 130/90 mmHg Icteric : (-)
HR : 86 times/min Cyanotic : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36,7 C Oedem : (-)

Localized state
Head : Anemic palpebra Conjuctiva (+/+), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Abdomen : lax, peristaltic (+) normal limit, Fundal Height : 1 finger
above umbilical
Genitalia : suture of perineal repair (+), vaginal bleeding (+)
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Inspeculo : 2 pieces of gauze are removed laceration in the
portio at 6 o'clock blood did not flow
USG TAS
USG TAS
LABORATORY FINDINGS on November, 7th ,2017
Hb : 6,1 N: 12-14 gr/dl
Ht : 20,2 N: 36-42 gr/dl
Leukocyte : 18900 N:4000-11000/mm3
Platelet : 278.000 N:150000-400000/mm3
MCV : 76,5 N :80-97fL
MCH : 23,1 N :27-33.7pg
MCHC : 30,3 N :31.5-35g/dL
adRandom glucose : 148 N : < 200
Ureum : 10 N : > 50 mg/dl
Creatinin : 0,57 N : 0,6-1,2 mg/dl
Natrium : 144 N :135-155
Kalium : 4,5 N : 3.6-5.5
Cloride : 114 N : 96-106
Diagnosis:
PPH d/t perineal laceration

Therapy :
- O2 Nasal Canule 4 l/minute
- Double line : IVFD RL + oxytocine 20 IU 20 dpm,
IVFD NaCl 0,9% 20 dpm
- Inj. Methergine 1 amp/IM
- Inj. Oxytocine 10 IU/ IV

Plan:
- Repair the perineal laceration
- Transfusion PRC 4 bag

Reported to Supervisor on duty dr. Irliyan Saputra, SpOG Approved

THANK YOU
PATIENT 2
Mrs. R, 23 y.o, G1P0A0, Bataknese, Christian, Elementary School,
housewife, married to Mr.P, 50 y.o, Bataknese, Christian, ppedicab driver.

CC : seizure
Experienced by the patient since 30 minutes ago. Headache (+), nausea
and vomiting (+), blurred vision (+). Bloody show (-), amniotic fluid
leakage (-), labor contraction (+) since 7/11/2017 at 11 am. Micturition
and defecation within normal limit.

History of previous ilness : (-)

History of previous medication : (-)
LMD :?
EDD :?
ANC : 5x Midwife

History of Pregnancy
1. Current Pregnancy
Present State
Cons : Alert Anemic : (-)
BP : 170/120 mmHg Icteric : (-)
HR : 90 times/min Cyanotic : (-)
RR : 26 times/min Dispnoe : (-)
Temp : 36,4 C Oedem : (-)

Localized state
Head : Anemic palpebra Conjuctiva (-/-), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Genitalia : no abnormality
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Obtetrical State

Abdomen : Symmetrically enlargement

Fundal Height : 4 fingers below processus xyphoideus
Tension part : Left
Lower part : Head
Fetal Movement : (+)
Uterine contraction :
Fetal Heart Rate : 152 bpm, regular

Vaginal exam : Cervix : 4 cm, axial, eff 100%, Hodge II, amniotic
membranes (+), minor fontanella ???
Gloves : bloody slime (-), amniotic fluid (-)
USG TAS
 USG TAS
Singleton Pregnancy, Head presentation, alive fetus
FHR (+) 152 bpm, FM (+)
BPD : 85,6 mm
FL : 64,9 mm
AC : 30,41 mm
EFW : 2410 gram
Amniotic fluid was sufficient
Placenta posterior grade II

Conclusion:
IUP (34-35) wga + head presentation + alive fetus
LABORATORY FINDINGS on November, 8th ,2017
Hb : 12,4 N: 12-14 gr/dl
Ht : 38,0 N: 36-42 gr/dl
Leukocyte : 19160 N:4000-11000/mm3
Platelet : 80.000 N:150000-400000/mm3
MCV : 75,8 N :80-97fL
MCH : 24,8 N :27-33.7pg
MCHC : 32,6 N :31.5-35g/dL
adRandom glucose : 87 N : < 200
Ureum : 13 N : > 50 mg/dl
Creatinin : 7,3 N : 0,6-1,2 mg/dl
Natrium : 141 N :135-155
Kalium : 3,7 N : 3.6-5.5
Cloride : 115 N : 96-106
Diagnosis:
Eclampsia + Preterm Labor + PG + IUP (34-35) wga + Head
Presentation + alive fetus
Therapy :
- IVFD RL + MgSO4 40% 30 cc 14 dpm
- Bolus MgSO4 20% 20 cc
- Nifedipine 2 tab
- Inj. Ceftriaxone 2 gr/IV profilaxis (skin test)

Plan:
- Emergency C-section

Reported to Supervisor on duty dr. Irliyan Saputra, SpOG Approved

THANK YOU