dr Putri Maulina

dr Alvin K
 Rawat Inap Rawat Jalan Total
Surgery 1 2 3
Non Surgery - 2 2
Ob-Gyn 3 - 3
Pediatric - 2 2
Total 4 6 10
No Name Age Diagnosis
1 G (F) 12 Acute Tonsilopharyngitis
2 S S (F) 28 Urinary Tract Infection + Renal Colic
Suggestive of Urolithiasis (PAPS)
3 A A (M) 38 Multiple Vulnus Excoriatum
4 M (F) 32 Susp. Pneumonia dd/ TB (PAPS)
5 D P A (M) 21 Vulnus Laceratum 0,2 x 0,3 x 1 cm on
the regio Femoral Dextra
6 A P (F) 11 Fever day 4th due to Urinary Tract
Infection
No Nama Usia Diagnosa
1 A (M) 15 Closed Comminutive Fracture of Right Iliac
Wing + Closed Linear Fracture of Right
Femur
2 M (F) 38 G5P4A0 + Gravida 38-39 weeks + in
Labour Stage I latent Phase + Single Fetus,
Head Precentation, Alive + Preeclampsia
dd/ Hypertension in Pregnancy
3 T S (F) 29 G1P0A0 + Gravida 38 weeks + in Labour
Stage I latent Phase + Single Fetus, Head
Precentation, Alive With Progressive High
Myopia (-6.5 D)
4 R E (F) 25 G4P2A1 + Gravida 32 weeks + Intra
Uterine Fetal Death (Confirmed with USG
by Sp.OG) + Oblique Precentation
Closed Comminutive Fracture of Right
Iliac Wing + Closed Linear Fracture of
Right Femur
Chief Complain Referal from RSUD Karimun with History of
Traffic Accident (13 days) , Closed Fx of right
iliac wing and right Femur
History History of Traffic Accident 13 days before
admittance to ER. Patient was riding a
mototrcycle in average speed and crashed into
a slow moving pick-up truck from the side.
Patient’s right iliac and feet collided to the
front bumper of the pick-up truck. patient
was not using helmet, seizure (-), vomiting (-
), Loss of consciousness (-), amnesia (-).
Patient was then admitted to RSUD karimun
for 5 days and then moved to bakti timah
hosmpital for 3 days before readmitted to
RSUD karimun for 5 days. Complete blood
Count, X-ray of pelcic, right femur, and thorax
was present.
History of Disease:-
History of Medication: Ceftriaxone, Ketorolac, Ranitidine. Skin
Traction of Right femur with 10 kg traction weight
Sensorium: Compos BP 100/70 mmhg Temp 36,7 C
Mentis HR 72 x/minute RR 20 x/minute
VAS: 2 SpO2 98%
Head Conjunctiva: Anemic -/-, sclera: icteric -/-
Light Refex +/+, Pupil Size isocor 2/2 mm
Neck Trachea: Medial, No other Abnormalities
found
Thorax I: Fusiform-Simetric, Wound (-), Breathing
simetric
P: Pain (-), Crepitation (-)
P: Sonor on both hemithorax, Pain (-)
A: Breathing Sound: vesiculer Right= Left
Additional Sound: -/-
Heart Sound: S1S2 (+) N Reg, Gallop(-),
Murmur (-)
Abdomen Falt, Simetric, Peristaltic (+) N , timpanic,
Pain (-), Flexible, Muscular Rigidity (-)
Extremities Acral : Warm, CRT < 2 s, Edema (-)
 Pelvic Area:
 L: Deformity (-), Wound (-)
 F: Pain (-), Neurovascular Distal: Normal
 M: Reduced ROM, Pain with Movement

 Lower Right Extremity:

 L: Deformity (+) in Femoral, Shortening, Medial
Angulation 10’
 F: Pain (+), Axis Tapping Pain (+), Axis Traction
Pain (+), Neurovascular Distal: Normal
 M: Reduced Rom, Pain with Movement
 Complete Blood Count (20/4/2016 RSUD
Karimun)
 Hb: 11.0 mg/dl
 Ht: 33 g%
 Leukosit: 8.610/ uL
 Trombosit: 214.000/ uL
 Closed Comminutive Fracture of Right Iliac
Wing + Closed Linear Fracture of Right Femur
 Re-Splinting of Right Lower Extremities
 Complete Blood Count, Blood Glucose ad
Random
 Co. dr. Jorianto, SpOT
 Ketorolac 30 mg IV drips in 100 cc NaCl
0,9%/ 8 hours
 G4P2A1 + Gravida 32 weeks + Intra
Uterine Fetal Death (Confirmed with
USG by Sp.OG) + Oblique Precentation
 S: Referral from dr. Dino, SpOG with G4P2A1 +
Gravida 32 weeks + Intra Uterine Fetal Death
(Confirmed with USG, Weight 1,9 kg via USG) +
Breech Presentation. Last fetal movement felt 1 day
before, contraction (-), bloody show (-), amniotic
fluid (-), history of fever (-), bleeding (-), trauma (-),
High Blood pressure (-). Routine ANC with Sp.OG,
Last ANC this morning with dr. Dino, SpOG.
 Obstetric History: 1st Pregnancy Abortus, 2nd
Pregnancy ,Female, Death on delivery, 3rd Pregnancy ,
Female, 3 y o, Healthy, Vaginal Birth

 History of Disease: -
 History of Medication: -
O: sens: CM BP: 120/70 mmhg HR: 84x/m
RR: 20x/m T: 37 C
Obstetric Examination
Leopold: TFU 27 cm, HIS(-), FHR:-, Oblique
Presentation (head on maternal left side), Fetal
Movement (-)
 G4P2A1 + Gravida 32 weeks + Intra Uterine
Fetal Death (Confirmed with USG by Sp.OG) +
Oblique Precentation
 Co. dr. Wahyudi, SpOG
 Check CBC, Blood Type, Blood Glucose
 Admittance to VK
 Reconfirmation via USG result: Positive IUFD
 Prepared for Labour via Induction
 G1P0A0 + Gravida 38 weeks + in Labour
Stage I latent Phase + Single Fetus, Head
Precentation, Alive With Progressive High
Myopia (-6.5 D)
 S: Contraction since 3 hours before admittance to
ER, Bloody Show (+), Amnion fluid (-), First day
of last menstruation: 4-8-2015, history of
Hypertension in and before pregnancy (-),
G1P0A0, ANC with dr. Wahyudi, SpOG. Last ANC
in the same day of Admittance, Planned for
elective SC 30/4/2016 because of risk of Ablatio
Retina due to High Progressive Myopia (-6,5 D).
Fever (-).
 History of Disease: -
 History of Medication: -
 O: sens: CM BP: 110/70 mmhg HR: 80x/m
RR: 20x/m T: 37 C
Obstetric Examination
Leopold: TFU 32 cm, HIS (+) >2x/10 minutes,
Back on Right Side, FHR: 136x/m, Head
Presentation, Descent into Pelvic (+), Well-
Flexed (+).
VT: Portio thinning (+), d: 2 cm, bloody show
(+), amniontic sac (+), head: Hodge I
 G1P0A0 + Gravida 38 weeks + in Labour
Stage I latent Phase + Single Fetus, Head
Precentation, Alive With Progressive High
Myopia (-6.5 D)
 Co. dr. Wahyudi, SpOG
 Check CBC, Blood Type, Blood Glucose, HIV
Rapid Test, HbsAg, CT/BT
 Admittance to VK
 Ketoprofen 200 mg Suppository
 Scheduled for SC 28/4/2016
G5P4A0 + Gravida 38-39 weeks + in Labour
Stage I latent Phase + Single Fetus, Head
Precentation, Alive + Preeclampsia dd/
Hypertension in Pregnancy
 S: Contraction since 2 hours before admittance to
ER, Bloody Show (+), Amnion fluid (-), First day
of last menstruation: 10-8-2015, History of High
Blood Pressure (140/90 mmhg) in this
pregnancy, history of Hypertension before
pregnancy (-), G5P4A0, 1st Female, 23 y.o. Birth
Weight (Patient Forget), Healthy. 2nd Female, 11
y.o, 3400 gr, Healthy. 3rd Female, 10 y.o., 3300
gr, Healthy, 4th Male, 1,5 y.o., 3200 gr, Healthy.
All childs are of Vaginal Birth. ANC with dr.
Amuransyah, SpOG. Refered to ER by
Midwife(RSBP). Fever (-).
 History of Disease: -
 History of Medication: -
 O: sens: CM BP: 130/80 mmhg HR: 90x/m
RR: 22x/m T: 37 C
Obstetric Examination
Leopold: TFU 36 cm, HIS (+) 1x/10 minutes,
Back on Right Side, FHR: 138x/m, Head
Presentation, Descent into Pelvic (+), Well-
Flexed (+).
VT: Portio thinning (+), d: 1 cm, bloody show
(+), amniontic sac (+), head: Hodge I
 G5P4A0 + Gravida 38-39 weeks + in Labour
Stage I latent Phase + Single Fetus, Head
Precentation, Alive + Preeclampsia dd/
Hypertension in Pregnancy
 Co. dr. Amuransyah, SpOG
 Check CBC, Urine, Blood Type, Blood Glucose
 Admittance to VK