Final Weekly Report IV

8/18/2019 Final Weekly Report IV

1/113


2/113

WEEKLY REPORT

SUPERVISOR:

DR. SIGIT PRADONO DIPTOADI, Sp.OG

PRESENTED BY:

Aisyah Novita D.P. 2014-061-035

Stephaie !"#ita 2014-061-041$essie 2014-061-046

%i&he''e (e'i&ia ). 2015-061-050

*oi+asi"s 2015-061-052

R.R. Gaie'a ).T. 2015-061-054

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MEDICAL FACULTY OF ATMA JAYA CATHOLIC UNIVERSITY

2016

2


3/113

OBSTETRICS

3


4/113

No Ad!""!o#

D$%&

Id%!%' Wo()!#*

D!$*#o"!"

F!#$+

D!$*#o"!"

D!$*#o"!" o,

%-& .$.'1 (e"ay 2/th

2016

%s. A G2P1A0, 41 yeas

o', avi 3-3

ee#s a&&oi

to SG, ot i

'ao, ith a

histoy o+ oe

tie 7aesaea

Se&tio, ith

&hoi&

hypetesio, ith

si'e 'ivi +et"s

ita"teie, hea

pesetatio.

P2A0, 41 yeas

o', post pat"s

at""s y

7aesaea

Se&tio

ii&ate y

patiet ae a

post i'atea'

t"e&toy

ii&ate y

patiet

pe+ee&e

Te %a'e

Neoate, 3-

3/ ee#s o+

estatioa' ae

a&&oi to

Ne *a''a

S&oe, ith

eiht 250

as, 45 &,

APGAR s&oe

/8/. Diaose

as hea'thy

eoate

2 (e"ay 2/th

2016

%s. A G1P0A0, 25 yeas

o', avi 3-3/

ee#s a&&oi

to SG, i +ist

stae 'ao, 'atet

phase, ith

&epha'ope'vi&

ispopotio,

ith si'e 'ivi

+et"s ita"teie,hea pesetatio

P1A0, 25 years

old, post partus

maturus by

caesarean

section with

indication

cephalopelvic

disproportion

Ate a'e

eoate, ith

eiht 3220

, ith 'eth

4 &,

APGAR s&oe

/8/, iaose

as hea'thy

eoate

3 (e"ay 2/th

2016

%s. SA G2P1A0, 34 yeas

o', avi 40-41

ee#s a&&oi

to +ist ay o+ 'ast

peio, po'oe

a&tive phase, ith

P2A0, 34 9eas

o', post pat"s

at""s y

vaia' e'ivey

ith va&""

e:ta&tio

Te (ea'e

Neoate, 40-

41 ee#s o+

estatioa' ae

a&&oi to

Ne *a''a

4


5/113

si'e 'ivi +et"s

ita"teie, hea

pesetatio

ii&ate y

+eta' istess

S&oe, ith

eiht 300

as, 4/ &,

APGAR s&oe

385. Diaose

as hea'thy

eoate

4 %a&h 1st

2016

%s. ; G2P0A1 32 yeas

o', avi 3-3/

ee#s o+ estatio

a&&oi to SG,

ot i 'ao, ith

si'e 'ive +et"s

ita"teie, hea

pesetatio, ith

7PD

P1A1, 32 yeas

o', post pat"s

at"es y

&aesaia

se&tio ii&ate

y 7PD


6/113

8/9, diagnosed

as healty

neonate

6 %a&h 3

2016

%s. S G2P1A0, 30 yeas

o', avi 3-3/

ee#s a&&oi

to SG, ot i

'ao, ith

peat"e "pt"e

o+ the eae,

ith si'e +et"s

'ive ita"teie,

hea pesetatio

P2A0, 30 yeas

o', post pat"s

peat""s y

spotaeo"s

vaia' e'ivey

a post he&ti

ii&ate y

peiea' "pt"e

ae I.

Ate a'e

eoate,

appopiate

+o estatioa'

ae, 3-3/

ee#s

a&&oi to

Ne *a''a

S&oe, ith

eiht 260

, 4 &,

APGAR s&oe

/8/ ith e''

ay

. %a&h 3

2016

%s. ; G5P4A0, 3 yeas

o', avi 3/-40

ee#s a&&oi

to SG, ith

peat"e "pt"e

o+ eae,

si'e 'ivi +et"s

ita"teie, hea

pesetatio.

P5A0, 3 yeas

o', post pat"s

at""s y

&aesaea

se&tio ii&ate

y

o'iohyaio

s a +eta'

istess, post

t"e&toy ith

ii&atio o+

patiet

pe+ee&es.

Te a'e

eoate, 3/-40

ee#s o+

estatioa' ae

a&&oi to

Ne *a''a

S&oe, ith

eiht 350

, ith 'eth

4/ &,

APGAR s&oe

8/. Diaose

as hea'thy

eoate

. %a&h 3 %s. S) G3P2A0, 35 years P3A0, 35 years Term female

6


7/113

2016 old, gravid 39-40

weeks according

to first day of last

menstrual cyclewith prolonged

labour stage II,

with single living

fetus intrauterine,

breech

presentation

old, post partus

matures by

caesarian

section indicatedby breech

presentation

with prolonged

labour stage II

neonate,

appropriate for

gestational

age, 39-40minggu

according to

New Ballard

Score, birth

weight 2930

gram, birth

length 47 cm,

APGAR Score

6/9

/. %a&h 4th

2016

%s. S G3P2A0 2/ yeas

o', avi 3-3/

ee#s a&&oi

to SG, ipat",

stae oe o+ 'ao,

ith ee''i 'ive

+et"s ita"teie,

hea pesetatio.

P3A0, 2/ yeas

o', post pat"s

at"es y

&aesaia

se&tio ii&ate

y patiet

pe+ee&e

Te a'e

eoate,

appopiate +o

estatioa'

ae, 3-3/

ee#s

a&&oi to

Ne *a''a

S&oe, ith

eiht 2/00

, ith 'eth

4 &,

APGAR s&oe

/8/

Te a'e

eoate,

appopiate +o

estatioa'

7


8/113

ae, 3-3/

ee#s

a&&oi to

Ne *a''a

S&oe, ith

eiht 230

, ith 'eth

4 &,

APGAR s&oe

8/

CASE 1

8


9/113

G2P1A0/ 1 '&$(" o+d/ *($!d 345 &&)" $77o(d!#* %o USG/ #o% !# +$.o(/ !%- $ -!"%o('

o, o#& %!& CS/ !%- 7-(o#!7 -'8&(%"!o#/ !%- "!#*+& +!!#* ,&%9" !#%($9%&(!#&/ -&$d

8(&"%$%!o#

Id%!%'

Nae ? %s. A

Ae ? 41 yeas o'

>thi&ity ? $avaese

Re'iio ? %os'e

O&&"patio ? ;o"sei+e

>"&atio ? $"io ;ih S&hoo'

Date o+ aissio ? (e"ay 2/th 2016

A#$#&"!"

C-!&, 7o8+$!#%" :

Patiet &ae to the hospita' to have ateata' &ae e:aiatio.

H!"%o(' o, 8(&"% !++#&"" :

Patiet as aitte to osteti&s a ye&o'oy a +o Ata $aya &'ii& to have

ateata' &ae e:aiatio. Patiet@s e:pe&te 'ao is 4th %a&h 2016. Patiet i@t +ee' ay

aoia' is&o+ot a i@t have ay vaia' is&hae. D"i the pea&y, patiet

has a hih 'oo pess"e a i@t have othe &op'aits.

H!"%o(' o, 8$"% !++#&"" :

o ;istoy o+ hypetesio ? Patiet has histoy o+ &hoi&

hypetesio

o ;istoy o+ iaetes e''it"s ? Deie.

o ;istoy o+ a''ey ? Deie.

o ;istoy o+ epi'epsy ? Deie.

o ;istoy o+ heato'oi& isease ? Deie.

o ;istoy o+ "iay ta&t8#iey isease ? Deie.

o ;istoy o+ ta"a ? Deie.

9


10/113

o ;istoy o+ s"ey ? Patiet has a histoy o+ 7-Se&tio

+o he 1st pea&y seat

'a s"ey

H!"%o(' o, M"%(9$+ C'7+&

o %ea&he ? Appo:iate'y 13 yeas o'

o %est"a' 7y&'e ? ie"'a est"a' &y&'e, ith evey peio 'asti +o

ays a soeties ith yseohea.

o (ist ay o+ 'ast peio ? $"e, 6th 2015

M$(!%$+ H!"%o(':

Patiet has aie o&e, has 'aste 20 yeas ith &"et h"sa.

O."%&%(!7 -!"%o('?

No Date Gestatioa

' Ae

!ao

;istoy

Gee *ith

)eiht

*east

+eei

histoy

1 2011 / oths 7S

ii&ate y

o' ae

%a'e 2600

as

*east+e

15 ays

2 2016


11/113

4 Respiatoy ate ? 20 ties a i"te

4 ;eat ate ? 6 *P%

• )eiht


12/113

P'ate'ets ? 230008'

*'oo Type ? *8Rh


13/113

(""s? 1 +ie

e'o "i'i&"s

!o#ia "a 30 &&

Goo &ota&tio

%oi'iEatio? Ti't to

the 'e+t a iht

(""s? 1 +ie

e'o "i'i&"s

!o#ia "a 30 &&,

oo &ota&tio

%oi'iEatio? A&tive

(""s? 3 +ie

e'o "i'i&"s

!o#ia "a 20 &&

Goo &ota&tio

%oi'iEatio? A&tive

A P2A0, 41 yeas o',

post pat"s at""s

y 7S ii&ate y

patiet ae a post

i'atea' t"e&toy

ii&ate y patiet

pe+ee&e


14/113

o ("to'it 500 && O:yto&i 10


15/113

o ;istoy o+ hypetesio ? eie

o ;istoy o+ iaetes e''it"s ? eie

o ;itoy o+ a''ey ? eie

o ;istoy o+ epi'epsy ? eie

o ;istoy o+ heato'oi& isease ? eie

o ;istoy o+ ta"a ? eie

o ;istoy o+ s"ey ? eie

• ;istoy o+ %est"a' 7y&'e

o %ea&he ? 12 yeas o'

o %est"a' &y&'e ? 23 ays, e"'a'y, ith "atio o+

ays, &hae 2-3 pas a ay,

yseohea


16/113

G&($+ E;$!#$%!o#

• >yes ? aei& &oB"&tiva -8-, i&tei& s&'ea -8-

• %o"th ? et oa' "&osa eae

• Thoa:

o ;eat ? e"'a 1st a 2 heat so"s, "" -, a''op -o !" ? vesi&"'a eath so"s 8, o&hi -8-, heeEi -8-

o %aae ? aeo'a hypepietatio 8, ipp'e eta&tio -8-, east

i'# -8-

• Aoe

o Ispe&tio ? &ove:, 'iea ia ea -8-, 7RT K2 se&os

Physio'oi& e+'e: 888, patho'oi& e+'e:es


17/113

U+%($"o#o*($8-' >USG?

• >stiate (eta' )eiht ? 3500 as

• GA ? 3-3/ ee#s

CTG

*ase'ie ? 150 p

Caia'e ? Noa'

A&&e'eatio ? -

De&e'eatio ?

(eta' %oveet ?

;is ? -

Res"'t ? NST s"spi&io"s

Wo()!#* D!$*#o"!"

G1P0A0, 25 yeas o', avi 3-3/ ee#s a&&oi to SG, i +ist stae 'ao, 'atet

phase, ith &epha'ope'vi& ispopotio, ith si'e 'ivi +et"s ita"teie, hea

pesetatio

P+$##!#*

• Po 7aesaea Se&tio

•7e+ota:i 28IC

17


18/113

F!#$+ D!$*#o"!"

P1A0, 25 years old, post partus maturus by caesarean section with indication

cephalopelvic disproportion

• Ate a'e eoate, ith eiht 3220 , ith 'eth 4 &, APGAR s&oe /8/,

iaose as hea'thy eoate

Po"% O8&($%!o# T(&$%%

- Oseve vita' sis +o evey 15 i"tes8+ist oe ho", evey 30 i"tes8se&o ho",

a o&e i the thi ho". I+ sta'e, oseve vita' sis evey 4 ho"s.

- Noa' iet

- I+"se?

o R! 500&& Syto&io 2 ap"'e +o ho"s

o R! 500&& Syto&io 1 ap"'e Oaseto +o ho"so R! 500&& Syto&io 1 ap"'e >:ta&e 1 ap"'e +o ho"s

- 7e+ota:ie 18IC812 ho"s

- 7he heo'oi 2 ho"s post-opeatio

- 7he "ie a'a&e evey 6 ho"s

Fo++o 98

D$' 1"% M$(7- 2016 2#d M$(7- 2016 (d M$(7- 2016

S Pain post-operation

(VAS 4-5), urination

(+), defecation (-),

flatus (-), breastfeeding

(+)

Pain post-operation

(VAS 2), urination (+),

defecation (-), flatus

(+), breastfeeding (+)

Pain post-operation

(VAS 1), urination (+),

defecation (+), flatus

(+), breastfeeding (+)

O • General condition:

appeared calm

• Level of

consciousness: CM• Vital signs:

o BP:110/80 mmHg

o HR:108x/minutes

o RR: 20x/minutes

o Temp : 35,6°C

• Abdomen :

o I: convex

o

A: bowel sounds(+), 15x/minute

• General condition:

well

• Level of consciousness:

CM• Vital signs:

o BP : 100/70 mmHg

o HR :64x/minutes

o RR : 20 x/minutes

o Temp : 35,3°C

• Abdomen :

o I: convex

o

A: bowel sounds(+), 8x/minute

• General condition:

well

• Level of consciousness:

CM• Vital signs:

o BP : 100/70 mmHg

o HR :80x/minutes

o RR : 18 x/minutes

o Temp : 35,3°C

• Abdomen :

o I: convex

o

A: bowelsounds (+),

18


19/113

o P : supple, pain on

palpation (+)

• Obstetric

o Fundal height : as

high as umbilicus

o Contraction:

strong

o Mobilization : tilt

to left and right

o Lochia: rubra 60

cc

o P : supple, pain

on palpation (-)

• Obstetric

o Fundal height : 2

fingers below

the umbilicus

o Contraction:

moderate

o Mobilization :

active

o Lochia: rubra,

20 cc

8x/minute

o P : supple, pain

on palpation (-)

•Obstetric

o Fundal height :

3 fingers below

the umbilicus

o Contraction:

moderate

o Mobilization :

active

o Lochia:

spotting

A P1A0, 26 years old,

post partus maturus by

caesarean section e.c.

cephalopelvic

disproportion, POD-1

P1A0, 26 years old, post

partus maturus by


cephalopelvic



partus maturus by


cephalopelvic


P • Oxytocin 10 IU/ IV

drip

• Ondansetron

1ampule/IV

• Cefotaxim 2x1g IV

• Cefadroxil 3x500 gr

• Pospargin 3x0,125

mg

• Mefenamic acid

3x500 mg

• Ketroz 2x100 mg

• Molocco B12 3x1

• Kalk 1x1



mg

• Mefenamic acid

3x500 mg

• Ketroz 2x100mg• Moloco B12 3x1

• Kalk 1x1

Dulcolax

aff cathether

aff IVFD

Patient can go back

home with the

medications:



mg

• Mefenamic acid

3x500 mg

• Moloco B12 3x1

• Kalk 1x1

19


20/113

20


21/113

CASE

G2P1A0/ '&$(" o+d/ *($!d 041 &&)" $77o(d!#* %o ,!("% d$' o, +$"% 8&(!od/ !# ,!("%

"%$*& o, +$.o(/ $7%!& 8-$"&/ !%- "!#*+& +!!#* ,&%9" !#%($9%&(!#&/ -&$d 8(&"%$%!o#

Id%!%'

• Nae ? %s. SA

• Ae ? 34 yeas o'

• >thi&ity ? $avaese

• Re'iio ? %os'e

• O&&"patio ? ;o"sei+e

• >"&atio ? $"io hih s&hoo'

• Date o+ Aissio ? (e"ay 2/th 2016

A#$#&"!"

• 7hie+ 7op'ait

Patiet as havi aoia' &aps si&e 16 ho"s e+oe aissio to the hospita'.

• ;istoy o+ Peset I''ess

Patiet &op'aie ao"t havi aoia' &aps si&e oi a patiet sti''

+ee' the +eta' oveet.

• ;istoy o+ Past I''ess



o ;istoy o+ a''ey ? eie





• ;istoy o+ %est"a' 7y&'eo %ea&he ? 11 yeas o'



yseohea


22/113

No Date Gestatioa'

Ae

!ao"

;istoy

Se: *ith

)eiht

*east

(eei

1. 200 / oths Psp

o:yto&i

i"&e

*oy 3100

2. 2015 This

pea&y

• 7ota&eptio ;istoy

-

• ;istoy o+ Ateata' 7ae

Thee ties at piay hea'th &ae.

P-'"!7$+ E;$!#$%!o#

• Geea' 7oitio ? appeae oeate'y i''

• !eve' o+ 7o&io"sess ? &opos etis

• Cita' Sis

o *'oo pess"e ? 12080 ;

o ;eat ate ? 0 :8i"tes

o Respiatoy ate ? 32 :8i"tes

o *oy Tepeat"e ? 3,3˚7

• )eiht ? - #• )eiht e+oe peat ? 41 #

• ;eiht ? 141 &

• *%I ? 20, #82

G&($+ E;$!#$%!o#

• >yes ? aei& &oB"&tiva -8-, i&tei& s&'ea -8-


•Thoa:

o ;eat ? e"'a 1st a 2 heat so"s, "" -, a''op -

o !" ? vesi&"'a eath so"s 8, o&hi -8-, heeEi -8-


i'# -8-

• Aoe

o Ispe&tio ? &ove:, 'iea ia


23/113

O."%&%(!7 E;$!#$%!o#

• >stiate "e ate ? (e"ay 16th 2016

• ("a' heiht ? 31 &

• (eta' eiht estiatio ? 2./0 as

• teie &ota&tio ? 4 ties810 i"tes, "atio 40-45 se&os

• (eta' heat ate ? 15 :8i

• !eopo' ae"ve

o !eopo' I ? "ttos

o !eopo' II ? a o the iht sie

o !eopo' III ? hea

o !eopo' IC ? iveet, 485

• Ispe&"'o ? ot pe+oe

• Caia' To"&he ? &evi&a' i'atatio / &, &evi&a'

e++a&eet /0F, aio is ita&t, ;oe II

L$.o($%o(' E;$!#$%!o#

• ; ? 13,/ 8!

• ;t ? 3/ F

• !e"&o&yte ? 24.000 8"!

• P'ate'ets ? 23.000 8"!

• *'oo Type ? * 8Rh


24/113

• *ase'ie ? 15 p

L Caia'e ? Noa'

L A&&e'eatio ?

L De&e'eatio ?


25/113

P+$##!#*

• O:ytosi 1 ap8ip

• !io&aie 2 ap

• Do the e'ivey ith va&"" e:ta&tio

T(&$%%

• Osevatio o+ patiet@s &oitio a+te e'ive


26/113

%oi'iEatio? Ti't to the 'e+t a

iht

Goo &ota&tio

%oi'iEatio? A&tive

A P2A0, 34 yeas o', post pat"s

at""s y vaia' e'ivey

ith va&"" e:ta&tio

ii&ate y +eta' istess


27/113

CASE

G2P0A1 2 '&$(" o+d/ *($!d 54@ &&)" o, *&"%$%!o# $77o(d!#* %o USG/ #o% !# +$.o(/

!%- "!#*+& +!!#* ,&%9" !#%($9%&(!#&/ -&$d 8(&"%$%!o#/ !%- CPD

Id%!%'

Nae ? %s. ;

Ae ? 32 yeas o'

>thi&ity ? $avaese

Re'iio ? %os'e

O&&"patio ? ;o"sei+e

>"&atio ? ;ih s&hoo'

Date o+ aissio ? %a&h 1st 2016

H!"%o('

C-!&, 7o8+$!#%" :

Patiet &ae +o he /th Ate Nata' 7ae.

H!"%o(' o, 8(&"% !++#&"" :

Patiet as aitte to osteti&s a ye&o'oy a. Patiet ha o vaia' is&hae

i&'"i 'oo o "&"s. A&t"a''y, patiet@s e:pe&te 'ao is (e"ay 12 2016 a&&oi

to +ist ay o+ 'ast est"atio.

H!"%o(' o, 8$"% !++#&"" :

o ;istoy o+ hypetesio ? Deie.

o ;istoy o+ iaetes e''it"s ? Deie.

o ;istoy o+ a''ey ? Deie.





o ;istoy o+ s"ey ? 7"ettae o 2014 e&a"se o+

aotio

F$!+' H!"%o('

27


28/113

• ;istoy o+ hypetesio ? eie

• ;istoy o+ pe'vi& oa po'apse ? eie

• ;istoy o+ iaetes e''it"s ? eie

• ;istoy o+ a''ey ? eie

H!"%o(' o, M"%(9$+ C'7+&


o %est"a' 7y&'e ? 20 ays ith e"'a est"a' &y&'e, ith evey

peio 'asti +o ays a o yseohea.

o (ist ay o+ 'ast peio ? %ay, 5th 2015

M$(!%$+ H!"%o(':

Patiet has aie o&e, has 'aste 2 yeas ith &"et h"sa.

O."%&%(!7 -!"%o('?

No Date Gestati

oa'

Ae

!ao ;istoy Gee *ith

)eiht

*east

+eei

histoy

1 2014 3

oths

Aotio -

7"ettae

- - -

2 2016 3-3/

ee#s

- - - -

Co#%($7&8%!o# H!"%o('

Patiet eve "se &ota&eptive pi''

H!"%o(' o, $#%$%$+ 7$(&:

Patiet has a o"tie ateata' &ae at ii+e.

P-'"!7$+ E;$!#$%!o#

Geea' 7oitio ? )e''

7os&io"sess !eve' ? 7opos %etis

Cita' Sis

*'oo Pess"e ? 12080 ;

Tepeat"e ? 36,2o7

Respiatoy ate ? 0 ties a i"te

;eat ate ? 20 *P%

)eiht e+oe pea&y ? 30 #

)eiht ? 3 #

28


29/113

;eiht ? 145 &

*%I ? 14,26 #82

G&($+ E;$!#$%!o#

>yes ? Aei& &oB"&tiva -8-, I&tei& s&'ea -8-

%o"th ? )et oa' "&osa

Thoa: ?

;eat ? Re"'a 1st a 2 heat so"s, "" -, a''op -

!"s ? vesi&"'a eath so"s 8, ho&hi -, heeEi -

%aae ? Aeo'a hypepietatio 8, Nipp'e eta&tio -8-,

east i'# -8-

Aoe ?

Ispe&tio ? 7ove:, Stiae Gavia" ea i ay e:teities, physio'oi& e+'e: 8

8


30/113

• ;*sA ? Neative

USG

Gestatioa' Ae ? 3-3/ ee#s

>stiate (eta' )eiht ? 3200 a

Wo()!#* d!$*#o"!"

G2P0A1, 32 yeas o', 3-3/ ee#s o+ estatio a&&oi SG, ot i 'ao, ith si'e

'ivi ita"teie +et"s, hea pesetatio, ith 7PD

P+$##!#*

•

Po 7aesaia se&tio• 7e+i:ie 1 itaveo"s

• (asti

F!#$+ D!$*#o"!"

%othe?

P1A1, 32 yeas o', post pat"s at"es y &aesaia se&tio ii&ate y 7PD


31/113

;aeo'oi &he a+te 6 ho"s post opeatio

Ga"a' iet

Fo++o 98

M$(7- 1"%

2016 M$(7- 2#d

2016S? Patiet &ae +o he /th Ate Nata' 7ae.

Thee@s o vaia' is&hae i&'"i 'oo

o "&"s

O? Geea' &oitio ? e''

7os&io"sess ? &opos etis

*'oo pess"e ? 12080 ;

P"'se ? 0 p

Respiatoy Rate ? 20 p

Tepeat"e ? 36,2o 7

>ye ? pa'pea' eea -8-, aei& &oB"&tiva

-8-, i&tei& s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

7o ? A"s&"'tatio? e"'a 1st a 2

heat so", Ga''op


32/113

o A"s&"'tatio ? oe' so" ,

:8i"tes

>:teities? )a

o >ea? !oe e:teities -8-

o Physio'oi&a' e+'e:? 888o Patho'oi&a' e+'e: ? --8--

)o#"p?

;eo'oi ? 12,2 8'

;eato&it ? 3/F

!e"&o&yte ? /008'

P'ate'ets ? 300008'

*'oo Type ? *8Rh


33/113

ho"s

• 7e+ota:ie IC 3 : 1

• a'to+e S"pp 3:1

• Raitiie Ap 1:1

• ;aeo'oi &he a+te 6 ho"s post

opeatio

33

M$(7- #d 2016

S? ('at"s


34/113

CASE

G3P1A1, 29 years old, Gestational age 40-41 weeks based on USG with Feto-Pelvic

Disproportion and single living fetus intrauterine, head presentation

Identity

Name : Mrs. E

Age : 29 years old

Ethnicity : Javanese

Religion : Moslem

Occupation : Housewife

Education : High School

Date of admission : March 1st 2016

History

Chief Complaints

Patient had no signs of labor eventhough its already her estimated time of delivery

History of present illness

Patient came to obstetrics and gynecology outpatient clinic and was referred from Tritunggal

clinic because it was about her due date but there’s no signs of labor yet. Patient’s expected

labor was March 01st 2016

History of past illness

o History of hypertension : Denied

o History of diabetes mellitus : Denied

o History of allergy : Denied

o History of epilepsy : Denied

o History of hematologic disease : Denied

o History of urinary tract/kidney disease : Denied

o History of trauma : Denied

o History of surgery : Denied

34


35/113

History of Menstrual Cycle

o Menarche : Approximately 14 years old

o Menstrual Cycle : 30-35 days with irregular menstrual cycle, with every

period lasting for 7-8 days and no dysmenorrhea.

o First day of last period : May, 18th

2015

Marital History:

Patient has married once, has lasted 7 years with current husband

Obstetric history:

No Date Gestationa

l Age

Labor

History

Gender Birth

Weight

Breast feeding

history

1 2009 4 months Abortus

2 September

15th 2010

9 months Spontaneo

us

Vaginal

delivery

Male 3600 gr 1 year

3 2016 (This

Pregnancy

)

Contraception History

Patient has used injection contraceptive, last time using in 2015.

History of antenatal care:

Patient has a routine antenatal care at Tritunggal clinic during this pregnancy.

Physical Examination

General Condition : Mildly ill

Consciousness Level : Compos Mentis

Vital Signs

o Blood Pressure : 120/80 mmHg

o Temperature : 36,7oC

o Respiratory rate : 20 times a minute

o Heart rate : 100 bpm

Weight : 65 kg

Height : 158 cm

35


36/113

BMI : 26,0 kg/m2

General Examination

Eyes : Anemic conjunctiva -/-, Icteric sclera -/-

Mouth : Wet oral mucosa

Thorax :

4 Heart : Regular 1st and 2nd heart sounds, murmur -, gallop -

4 Lungs : vesicular breath sounds +/+, rhonchi -, wheezing -

4 Mammae : Areola hyperpigmentation +/+, Nipple retraction -/-,

breast milk -/-

Abdomen :

4 Inspection : Convex, Striae Gravidarum (-), Linea nigra(+)

4 Auscultation : Bowel sounds (+)

Extremities : No Edema in any extremities, physiologic reflex +/+/

+/+, pathological reflex -/-

Obstetric examination

Estimated due date : March, 01st 2016

Fundal Height : 36 cm

Fetal Weight Examination : 3565 gr

Uterine Contraction : -

Fetal Heart Rate : 158 bpm

Leopold maneuver

Leopold I : Buttocks

Leopold II : Back on right side

Leopold III : Head

Leopold IV : convergent 5/5

Vaginal toucher : not performed

Inspeculo : not performed

Rectal Toucher : not performed

Cardiotocography

Not performed

Laboratory Examination

Hemoglobin : 12.3 g/dl

Hematocrit : 36%

36


37/113

Leucocyte : 9400/ µ l

Platelets : 245000/ µ l

Blood Type : 0/Rh (+)

HBsAg : Negative

HIV : Negative

USG

• BPD : 10,34 cm

• HC : 34,99 cm

• FHR : 158 bpm

• AC : 34,76 cm

• FL : 7,81 cm

• EFW : 3791 gr

• EDD : March 1st 2016

• GA : 40w0d

Working Diagnosis

G3P1A1, 29 years old, Gestational age 40-41 weeks according to USG with Feto Pelvic

Disproportion and single living fetus intrauterine, head presentation

Planning

Pro caesarian section

Ceftriaxone 1gr IV

Consult anesthesiologist

Final DiagnosisMother

P2A1, 29 years old, post partus maturus by caesarian section indicated by Feto Pelvic

Disproportion

Baby

Term female neonate, appropriate for gestational age, 40-41 weeks according to New Ballard

Score, birth weight 3580 gr, 48 cm, APGAR score 8/9, diagnosed as healthy neonate

37


38/113

Post-partum instruction

• Observed vital signs every 15 minutes for the first one hour, every 30 minutes for the

second hour and every hour until 4 hour

• IVFD : Futrolite + oxcytocyn 20u for 8 hours

Futrolite + oxcytocyn 10u for 8 hours Futrolite + oxcytocyn 10u for 8 hours

Cefotaxime 3x1g IV

Ranitidine 1x50mg IV after 8 hours

• Kaltrofen 3x1 supp

Follow-up

March 01st 2016 March 2nd 2016

S: felt contraction

O: General condition : mildly ill

Consciousness : compos mentis

Blood pressure : 120/80 mmHg

Pulse : 100 bpm

Respiratory Rate : 20 bpm

Temperature : 36,7o C

Eye : palpebral edema -/-, anemic conjunctiva

-/-,icteric sclera -/-.

Oral : Wet oral mucous

Thorax:

Cor : Auscultation: irregular 1st and 2nd

heart sound, Gallop (-), Murmur (-)

Pulmo :

• Inspection : symmetrical in both static and

dynamic breathing

• Percussion :sonor on both lungs• Auscultation : vesicular breath sound +/+,

S: post-op pain vas 2-3




Pulse : 80 bpm


Temperature : 36.5o C

Eye : palpebral edema -/-, anemic

conjunctiva -/-,ictericsclera -/-.


Thorax:

Cor : Auscultation: irregular 1st and

2nd heart sound, Gallop (-), Murmur (-)

Pulmo :

• Inspection : symmetrical in both static

and dynamic breathing

• Percussion :sonor on both lungs• Auscultation : vesicular breath sound

38


39/113

wheezing -/-, crackles -/-

• Mammae : hyperpigmentation of areola +/

+, nippleretraction -/-

Abdomen

• Inspection : convex, striae gravidarum -,

linea nigra (+),

• Palpation : supple in all abdominal region,

tenderness -

• Percussion: tympanic sound in all

abdominal region

• Auscultation : bowel sound (+)

Extremities: Warm

• Edema:Lower extremities -/-

• Physiological reflex: ++/++/++/++

•

Pathological reflex : --/--• Sensory examination +/+

Workup:

• Laboratory:

• Hemoglobin : 12.3 g/dl

• Hematocrit : 36%

• Leucocyte : 9400/ µ l

• Platelets : 245000/ µ l

• Blood Type : 0/Rh (+)

• HBsAg : Negative

• HIV : Negative

A: G3P1A1, 29 years old, Gestational age 40-41

weeks according to USG with Feto Pelvic

Disproportion and single living fetus intrauterine,

+/+, wheezing -/-, crackles -/-

Mammae : hyperpigmentation of

areola +/+, nippleretraction -/-,

breastmilk +/+

Abdomen :

o Inspection : convex, striae gravidarum

-, lineanigra (+),

o Palpation : supple in all abdominal

region, tenderness -

o Percussion: tympanic sound in all

abdominal region

o Auscultation : bowel sound +, 7

x/minutes

Extremities: Warm

o Edema:Lower extremities -/-

o Physiological reflex: ++/++/++/++

o Pathological reflex : --/--

o Sensory examination +/+

Puerperium Status :

• Fundal height : 1 fingers above the

umbilical

• Contraction : strong

• Lochia : approximately 20 cc

• Mobilitation : shift to the left and right

A: P2A1, 29 years old, post partus maturus

by caesarian section indicated by Feto Pelvic

Disproportion

P: Medication

39


40/113

head presentation

P:

•Pro caesarian section

• Ceftriaxone 1gr IV

• Consult anesthesiologist

Post operation

A :

Mother :

P2A1, 29 years old, post partus maturus by

caesarian section indicated by Feto Pelvic

Disproportion

Baby :

Term female neonate, appropriate for gestational

age, 40-41 weeks according to New Ballard

Score, birth weight 3580 gr, 48 cm, APGAR score

8/9, diagnosed as healty neonate

Post Operation Instruction :

• Observed vital signs every 15 minutes for

the first one hour, every 30 minutes for the


• IVFD :

• Futrolite + oxcytocyn 20u for 8 hours• Futrolite + oxcytocyn 10u for 8 hours

• Futrolite + oxcytocyn 10u for 8 hours

• Cefotaxime 3x1g IV

• Ranitidine 1x50mg IV after 8 hours

• Kaltrofen 3x1 supp

o Cefadroxil 3x500mg

o Methergin 3x0,125mg

o Mefinal 3x500mg

Aff catheter in 1x24 hours

40

M$(7- (d 2016

S? post-op pai vas 1

O? Geea' &oitio ? i''y i''


*'oo pess"e ? 11080 ;

P"'se ? 4 p


Tepeat"e ? 36.0o 7

>ye ? pa'pea' eea -8-, aei&

&oB"&tiva -8-,i&tei&s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

7o ? A"s&"'tatio? ie"'a 1st a

2 heat so", Ga''op


41/113

CASE 6

G2P1A0/ 0 '&$(" o+d/ *($!d 54@ &&)" $77o(d!#* %o USG/ #o% !# +$.o(/ !%-

8(&$%9(& (98%9(& o, %-& &.($#&/ !%- "!#*+& ,&%9" +!!#* !#%($9%&(!#&/ -&$d

8(&"%$%!o#

Id%!%'

• Nae ? %s. S

• Ae ? 30 yeas o'


• Re'iio ? 7histia

• O&&"patio ? >p'oyee

• >"&atio ? Dip'oa 3

• Date o+ Aissio ? %a&h 3 2016

A#$#&"!"

• 7hie+ 7op'ait

!i"i is&hae +o the vaia si&e ho"s e+oe hospita' aissio


Patiet &ae to eee&y "it ith &op'aie ao"t havi &'ea 'i"i is&hae

+o vaia si&e ho"s e+oe hospita' aissio. Patiet sai that the tota' ao"to+ 'i"i is&hae as appo:iate'y 50 &&. The 'i"i iJt a&&opaie y 'oo

o "&"s a the patiet a'so iJt +ee' ay &ota&tio. Patiet sai that she ha

hite vaia' is&hae si&e 1 ee# ao a the &o'o t"e ito o si&e 2 ays

ao. Patiet iJt +ee' ay pai.




o ;itoy o+ a''ey ? eieo ;istoy o+ epi'epsy ? eie






o %est"a' &y&'e ? 2 ays, e"'a'y, ith "atio o+ -

ays, &hae 4 pas a ay,yseohea


42/113

o (ist ay o+ 'ast est"a' &y&'e ? %ay 23 2015

• %aita' ;istoy

%aie o&e, a'eay 6 yeas ith the 'ast h"sa

• Osteti& ;istoy

No Date Gestatioa'

Ae

!ao"

;istoy

Se: 7op'i&atio *ith

)eiht

*east

(eei

1. 2012 3/ ee#s Spotaeo"

s pe

vaia

+ea

'e

- 2.00

2

oths

2 This

pea&y

40 ee#s


Patiet "se ita "teie evi&e &ota&eptio +o 2012-2015


>iht ties at piay hea'th &ae.

P-'"!7$+ E;$!#$%!o#



• Cita' Sis

o *'oo pess"e ? 12080 ;

o ;eat ate ? 0 :8i"tes



• )eiht ? 55 #


43/113

o A"s&"'tatio ? oe' so"s, 4-5 :8i

o Pa'patio ? s"pe', teeess :teities ? >ea -8-, 7RT K2 se&os



44/113

Spe&i+i& avity test ? K1005

O&&"'t 'oo ? pithe' ?


45/113


46/113

- Repeat Caia' To"&he i 3 ho"s

1.00 Caia To"&he e:aiatio? i'atio 10 &, e++a&eet 100F, potio thi

a so+t, his 4: i 10 i"tes ith "atio 40 se&os.

!ea the se&o stae 'ao"

1.26 %a'e ay o, ith ith eiht 260 a, +eta' 'eth 4 &, 3-3/ ee#s

a&&oi to N*S, APGAR s&oe /8/, ith e'' ay

1.30 P'a&eta as o, ith tota' 'eei 0 &&

P'a&eta e:aiatio

SiEe ? 20 : 1 :1,5 &

)eiht ? 550

46


47/113

7oty'eo ? &op'ete

%eae? &op'ete

7a'&i+i&atio ? -

;eatoa ? -

Sto'&e' ?

i'i&a' &o ? 60 &

Isetio ? aia'is

T(&$%%

• Post pat"s ist"&tio?

o Osevatio +o vita' sis, &ota&tio, a 'eei 2 ho"s a+te 'ao"

o Noa' iet

o I+"se R! 10 I o:yto&i 8 ho"s

I+"se R! 10 I o:yto&i 8 ho"s

o 7e+ao:i' ta 3 : 500

o %e+eai& a&i ta 3 : 500

o %ethei ta 3 : 0,125

o %o'o&&o *12 3:1

o Oseve "iatio i 6 ho"s post pat"

F!#$+ D!$*#o"!"

• P2A0, 30 yeas o', post pat"s peat""s y spotaeo"s vaia' e'ivey a post

he&ti ii&ate y peiea' "pt"e ae I.

• Ate a'e eoate, appopiate +o estatioa' ae, 3-3/ ee#s a&&oi to Ne

*a''a S&oe, ith eiht 260 , 4 &, APGAR s&oe /8/ ith e'' ay

Fo++o 98

D$%& S9.&7%!

&

O.&7%!& A""&"% P+$##!#*

%a&h

, 5th

2016

Pai post-

he&ti

aea


48/113

>


49/113

umbilical

o Contraction : strong

o Lochia: ±7 cc

• Mobilization : active

49


50/113

CASE 3

GPA0/ 3 '&$(" o+d/ *($!d @40 &&)" $77o(d!#* %o USG/ !%- 8(&$%9(& (98%9(& o,

&.($#&/ "!#*+& +!!#* ,&%9" !#%($9%&(!#&/ -&$d 8(&"%$%!o#

Id%!%'

• Nae ? %s. ;

• Ae ? 3 yeas o'


• Re'iio ? %os'e


• >"&atio ? >'eetay s&hoo'


A#$#&"!"

• 7hie+ 7op'ait

Caia' is&hae si&e 6 ho"s e+oe hospita' aissio


Patiet &ae to the hospita' e&a"se she ha &'ea vaia' is&hae ith tota' ao"t

appo:iate'y 200 && si&e 6 ho"s e+oe hospita' aissio. The patiet a'so

&op'aie ao"t havi aoia' &aps a pai. Patiet sti'' +e't the +eta'

oveet.







o

;istoy o+ ta"a ? eieo ;istoy o+ s"ey ? eie





yseohea


51/113

%aie o&e, a'eay 16 yea ith this h"sa

• Osteti& ;istoy

No Date Gestatioa'

Ae

!ao"

;istoy

Se: *ith

)eiht

*east

(eei1. 2000 / oths Psp *oy 4000

2. 2003 / oths Psp *oy 3000

3. 2005 6 oths Psp - I(D - -

4. 2013 / oths Psp Gi' 3000 -

5. 2015 This

pea&y


Patiet eve "se iBe&t, ip'at, pi'' &ota&eptio. !ast "se i 2 yeas ao.


Thee ties at *ha#ti ;ospita'

P-'"!7$+ E;$!#$%!o#



• Cita' Sis

o

*'oo pess"e ? 13080 ;o ;eat ate ? 4 :8i"tes



• )eiht ? 65 #

• )eiht e+oe peat ? 52 #

• ;eiht ? 156 &

• *%I ? 21.36 #82

G&($+ E;$!#$%!o#• >yes ? aei& &oB"&tiva -8-, i&tei& s&'ea -8-


• Thoa:




i'# -8-

• Aoe

o Ispe&tio ? &ove:, 'iea ia


52/113

• >:teities ? >ea -8-, 7RT K2 se&os

Physio'oi& e+'e: 888, patho'oi& e+'e:es USG?• !ivi +et"s ita"teie, +eta' heat ate? 10 p, I7A? 2 &.

C$(d!o%o7o*($8-' >CTG?

52


53/113

• *ase'ie ? 160 p

L Caia'e ? Noa'

L A&&e'eatio ? -

L De&e'eatio ?

L (eta' %oveet ?

L ;is ?

L Res"'t ? 7ST o eass"i

Wo()!#* D!$*#o"!"

G5P4A0, 3 yeas o', avi 3/-40 ee#s a&&oi to SG, ith peat"e "pt"e o+

eae, si'e 'ivi +et"s ita"teie, hea pesetatio.

P+$##!#*

• Pe Op?

o O2 via asa' &a"'e 4!8i

o IC(D R! 100 && i 20 ops8i

o 7e+ota:ie 2 IC

• Po 7aesaea Se&tio

53


54/113

T(&$%%

• Osevatio o+ patiet@s &oitio a+te e'ivey


55/113

(""s? 2 +ie aove

"i'i&"s

!o#ia "a 30 &&

Goo &ota&tio

%oi'iEatio? -

O? 1,1 &&8#8ho"

(""s? 1 +ie e'o

"i'i&"s

!o#ia "a 15 &&

Goo &ota&tio

%oi'iEatio? Ti't to the

'e+t a iht

(""s? 2 +ie e'o

"i'i&"s

!o#ia "a 10 &&

Goo &ota&tio

%oi'iEatio? A&tive

A %othe? P5A0, 3 yeas

o', post pat"s at""s

y &aesaea se&tio

ii&ate y

o'iohyaios a

+eta' istess, post

t"e&toy ith

ii&atio o+ patiet

pe+ee&es.


56/113

CASE 5

G3P2A0, 35 years, gravid 39-40 weeks according to first day of last menstrual cycle with

single living fetus intrauterine, breech presentation

Identity

Name : Mrs. SW

Age : 35 years old


Religion : Moslem


Education : Junior High School

Date of admission : 3rd March 2016

History

Chief complaints :

Patient was referred from primary health care because she already had dilation 9 cm and her

baby was breech presentation

History of present illness :

Patient was admitted to obstetrics and gynecology ward from the emergency room. Patient

experiences an abdominal discomfort since 2nd of March and she came to the primary health

care. She was then referred to Atmajaya Hospital and she already had dilation 9 cm and her

baby was in breech presentation. Patient’s expected labor is March, 3rd 2016

56


57/113

History of past illness :

o History of hypertension : Denied.

o History of diabetes mellitus : Denied.

o History of allergy : Denied.

o History of epilepsy : Denied.

o History of hematologic disease : Denied.

o History of urinary tract/kidney disease : Denied.

o History of trauma : Denied.

o History of surgery : Denied.



o Menstrual Cycle : 30-40 days with irregular menstrual cycle, with every

period lasting for 7 days and no dysmenorrhea.

o First day of last period : May, 25th 2015

Marital History:

Patient has married once, has lasted 12 years with current husband.

Obstetric history:

No Date Gestationa

l Age

Labor History Gender Birth

Weight

Breast

feeding

history

1 2004 9 months Spontaneous

Vaginal

Delivery

Female 3000

grams

Breastfed 6

months

2 2005 9 months Spontaneous

Vaginal

Delivery

Female 2800

grams

Breastfed 1

year

2 2016

(this

pregna

ncy)

57


58/113


Patient has used injection contraceptive, last time using in 2015


Patient has a routine antenatal care with 9 visits at Atmajaya clinic during this pregnancy.


General Condition : Mildly ill


Vital Signs

Blood Pressure : 120/80 mmHg

Temperature : 36,9oC

Respiratory rate : 16 times a minute

Heart rate : 96 BPM

Weight : 72 kg

Height : 149 cm

BMI : 32,4 kg/m2

General Examination



Thorax :

Heart : Regular 1st and 2nd heart sounds, murmur -, gallop -

Lungs : vesicular breath sounds +/+, rhonchi -, wheezing -

Mammae : Areola hyperpigmentation -/-, Nipple retraction -/-,

breast milk -/-

Abdomen :

Inspection : Convex, Striae Gravidarum (-), Linea Alba(+)

Auscultation : Bowel sounds (+) 6 times/minute



Obstetric examination

Estimated due date : March, 3rd 2016

58


59/113

Fundal Height : 31 cm

Fetal Weight Examination : 3100 gr

Uterine Contraction : -

Fetal Heart Rate : 140 bpm

Leopold maneuver

Leopold I : Head

Leopold II : Back on left side

Leopold III : Buttocks

Leopold IV : divergent 2/5

Vaginal toucher : vulva in normal limit, vagina wall in normal

limit, portio thin and soft, cervical dilation 9cm, rupture membrane rupture,

Hodge II

Inspeculo : not performed

Rectal Toucher : not performed

Cardiotocography

*ase'ie ? 140 p

Caia'e ? oa'

A&&e'eatio ?

De&e'eatio ?

(eta' oveet ?

59


60/113

;is ? (e"e&y ?4:810 i"te, D"atio ? 10 se&os8;is, Poe ? 40-0

;

Res"'t ? 7ST eass"i

Laboratory examination

• Hemoglobin : 12.9 g/dL

• Hematocrit : 38%

• Leucocyte : 8,900/ µ L

• Platelets : 171,000/ µ L

• Blood type : B/Rh(+)

• Blood glucose : 96 mg/dL

• HbsAg (-)

Working diagnosis

G3P2A0, 35 years old, gravid 39-40 weeks according to first day of last menstrual cycle with

prolonged labour stage II, with single living fetus intrauterine, breech presentation

Planning

• Pro caesarian section• Cefixime 1gr intravenous

• Primperan 10mg intravenous

• Consult anesthesiologist

o Acc for anesthesia

o IV line performed

Final Diagnosis

Mother :

P3A0, 35 years old, post partus matures by caesarian section indicated by breech presentation

with prolonged labour stage II

Baby :

Term female neonate, appropriate for gestational age, 39-40 minggu according to New

Ballard Score, birth weight 2930 gram, birth length 47 cm, APGAR Score 6/9

60


61/113




• 2 hours post-operation Haemoglobin test

• observed vaginal bleeding and uterine contraction

• measure urine output and fluid balance every 6 hours

• regular diet

• phases mobilitation

• IVFD :

o RL 500cc + 1amp Syntocinon + 1 amp Tramal for 8 hours

o RL 500cc + 1amp Syntocinon + 1 amp Omeprazole for 8 hours

o RL 500cc + 1amp Syntocinon + 1 amp Extrace for 8 hours

• Oral :


o Pospargin 3x0,125mg

o Mefenamic acid 3x500mg

o Molocco B12 3x1

o Kaltrofen 2x1 supp

Follow Up :

M$(7- (d 2016 M$(7- %- 2016

S? aoia' is&o+ost si&e 1 ay e+oe

aissio



*'oo pess"e ? 12080 ;

P"'se ? /6 p

Respiatoy Rate ? 16p

Tepeat"e ? 36,/o 7


-8-,i&tei&s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

S? post-op pai vas 3-4, +'at"s , e+e&atio -



*'oo pess"e ? /0860 ;

P"'se ? p


Tepeat"e ? 36o 7



Oa' ? )et oa' "&o"s

Thoa:?


61


62/113

7o ? A"s&"'tatio? ie"'a 1st a 2

heat so", Ga''op


63/113

• ;sA


64/113

evey 6 ho"s

• e"'a iet

• phases oi'itatio

• IC(D ?

o R! 500&& 1ap Syto&io 1

ap Taa' +o ho"s


ap OepaEo'e +o ho"s


ap >:ta&e +o ho"s

• Oa' ?

o 7e+ao:i' 3:500

o Pospai 3:0,125

o

%e+eai& a&i 3:500o %o'o&&o *12 3:1

o a'to+e 2:1 s"pp

M$(7- 6%- 2016 M$(7- 3%- 2016

S? post-op pai vas 2, +'at"s , e+e&atio M

"iatio



*'oo pess"e ? 100860 ;

P"'se ? 2 p


Tepeat"e ? 36,5o 7



Oa' ? )et oa' "&o"s

Thoa:?


2 heat so", Ga''op ye ? pa'pea' eea -8-, aei&


Oa' ? )et oa' "&o"s

Thoa:?


2 heat so", Ga''op


65/113

P"'o ?

• Ispe&tio ? syeti&a' i oth stati&

a yai& eathi• Pe&"ssio ?soo o oth '"s

• A"s&"'tatio ? vesi&"'a eath so"

8, heeEi -8-, &a'es -8-

%aae ? hypepietatio o+

aeo'a 8, ipp'eeta&tio -8-,

easti'# 8

Aoe ?

o Ispe&tio ? &ove:, stiae

avia" -, 'ieaia :teities? )a

o >ea?!oe e:teities -8-

o Physio'oi&a' e+'e:? 88

8

o Patho'oi&a' e+'e: ? --8--

o Sesoy e:aiatio 8

P"epei" Stat"s ?

• ("a' heiht ? 2 +ies "e the

"i'i&a'

• 7ota&tio ? sto

• !o&hia ? appo:iate'y 30 &&

• %oi'itatio ? shi+t to the 'e+t a

P"'o ?

• Ispe&tio ? syeti&a' i oth stati&

a yai& eathi• Pe&"ssio ?soo o oth '"s


8, heeEi -8-, &a'es -8-

%aae ? hypepietatio o+

aeo'a 8, ipp'eeta&tio -8-,

easti'# 8

Aoe ?


avia" -, 'ieaia :teities? )a

o >ea?!oe e:teities -8-


8


o Sesoy e:aiatio 8

P"epei" Stat"s ?

• ("a' heiht ? 2 +ies "e the

"i'i&a'

• 7ota&tio ? sto

• !o&hia ? appo:iate'y 15 &&

• %oi'itatio ? shi+t to the 'e+t a

65


66/113

iht

A? G3P2A0, 35 yeas o', avi 3/-40

ee#s a&&oi to +ist ay o+ 'ast est"a'

&y&'e ith po'oe 'ao" stae II, ith

si'e 'ivi +et"s ita"teie, ee&h

pesetatio

P? %ei&atio

o 7e+ao:i' 3:500

o Pospai 3:0,125o %e+eai& a&i 3:500

o %o'o&&o *12 3:1

o a'to+e 2:1 s"pp

iht

A? G3P2A0, 35 yeas o', avi 3/-40

ee#s a&&oi to +ist ay o+ 'ast est"a'

&y&'e ith po'oe 'ao" stae II, ith

si'e 'ivi +et"s ita"teie, ee&h

pesetatio

P? %ei&atio

o 7e+ao:i' 3:500

o Pospai 3:0,125o %e+eai& a&i 3:500

o %o'o&&o *12 3:1

o a'to+e 2:1 s"pp

66


67/113


68/113

• ;istoy o+ hypetesio ? ;e +athe has hypetesio

• ;istoy o+ pe'vi& oa po'apse ? eie

• ;istoy o+ iaetes e''it"s ? eie

• ;istoy o+ a''ey ? A'' +oos ae o+ es.

H!"%o(' o, M"%(9$+ C'7+&


o %est"a' 7y&'e ? 2 ays ith e"'a est"a' &y&'e, ith evey

peio 'asti +o ays a o yseohea.

o (ist ay o+ 'ast peio ? %ay, 15th 2015

M$(!%$+ H!"%o(':

Patiet has aie o&e, has 'aste / yeas ith &"et h"sa.

O."%&%(!7 -!"%o('?

No Date Gestatio

a' Ae

!ao ;istoy Gee *ith

)eiht

*east

+eei

histoy

Othe

i+oatios

1 2010 / oths De'ivey pe

vaia

A i' 2/00 1 yea -

2 2014 / oths De'ivey pe

vaia

A oy 3200 1 yea Gestatioa'

hypetesio

3 2016 3-3/

ee#s

Co#%($7&8%!o# H!"%o('

Patiet "se &ota&eptive pi' "ti' 2015

H!"%o(' o, $#%$%$+ 7$(&:Patiet has a o"tie ateata' &ae at ii+e.

P-'"!7$+ E;$!#$%!o#

Geea' 7oitio ? )e''

7os&io"sess !eve' ? 7opos %etis

Cita' Sis

*'oo Pess"e ? 12080 ;

Tepeat"e ? 36,1o7

Respiatoy ate ? 22 ties a i"te

;eat ate ? *P%

)eiht ? 101 #

68


69/113

)eiht e+oe pea&y ? 5 #

• Gai eiht ? 26 #

;eiht ? 155 &

*%I ? 31,21#82 yes ? Aei& &oB"&tiva -8-, I&tei& s&'ea -8-

%o"th ? )et oa' "&osa

Thoa: ?

;eat ? Re"'a 1st a 2 heat so"s, "" -, a''op -

!"s ? vesi&"'a eath so"s 8, ho&hi -, heeEi -

%aae ? Aeo'a hypepietatio 8, Nipp'e eta&tio -8-,

east i'# -8-

Aoe ?

Ispe&tio ? 7ove:, Stiae Gavia"


70/113

!eopo' IC ? ivee, 385

Caia' to"&he ? at 1?30 i'atio &evi: / &, e++a&eet


71/113

L$.o($%o(' E;$!#$%!o#

;eo'oi ? 10, 8'

;eato&it ? 35F

!e"&o&yte ? 104008'

P'ate'ets ? 3600008'

*'oo Type ? *8Rh


72/113

IC(D R! ? Na7' 2 ? 1

O:yto&i 3:1 ap IC

7e+ota:ie IC 2 : 1

Taao' 3 : 100 ip

Raitiie 2 : 1 ap

a'to+e S"pp 3: II

Tae:aat a&i 3 : 250 IC

Fo++o 98

M$(7- %- 2016 M$(7- %- 2016

S? Patiet e:peie&e vaia is&hae

i&'"i "&"s a 'oo. It happee 15 ho"s

e+oe &oi to hospita'.

O? Geea' &oitio ? e''


*'oo pess"e ? 12080 ;

P"'se ? p


Tepeat"e ? 36,1o 7


-8-, i&tei& s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

7o ? A"s&"'tatio? e"'a 1st a 2

heat so", Ga''op ye ? pa'pea' eea -8-, aei&

&oB"&tiva 8, i&tei& s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

7o ? A"s&"'tatio? e"'a 1st a

2 heat so", Ga''op


73/113

avia" , 'iea ia -,

o Pa'patio ? s"pp'e i a''

aoia' eio

o

Pe&"ssio? typai& so" i a''aoia' eio


:8i"tes

>:teities? )a

o >ea? !oe e:teities 8



)o#"p?

o ;eo'oi ? 10, 8'

o ;eato&it ? 35F

o !e"&o&yte ? 104008'

o P'ate'ets ? 3600008'

o *'oo Type ? *8Rh


74/113

P?

• IC(D R! ? Na7' 2 ? 1

• O:yto&i 3:1 ap IC


• Taao' 3:100 ip

• Raitiie 2:1 ap

• a'to+e S"pp 3: II

• Tae:aat a&i 3:250 IC

• IC(D R! ? Na7' 2 ? 1

• O:yto&i 3:1 ap IC


• Taao' 3:100 ip

•

Raitiie 2:1 ap• a'to+e S"pp 3: II

• Tae:aat a&i 3:250 IC

A+te 24 ho" post op?

• 7e+ao:i' 3 : 500

• Taao' 3 : 50

• %e+eaat a&i 3 : 500

• %o'o&&o 3 : 1

• Raitiie 3 : 1

M$(7- 6%- 2016 M$(7- 3%- 2016

S? ('at"s ye ? pa'pea' eea -8-, aei&

&oB"&tiva 8, i&tei& s&'ea -8-.

Oa' ? )et oa' "&o"s

Thoa:?

7o ? A"s&"'tatio? e"'a 1st a

2 heat so", Ga''op


75/113

• Pe&"ssio ? soo o oth '"s


8, heeEi -8-, &a'es -8-

• %aae ? hypepietatio o+

aeo'a 8, ipp'e eta&tio -8-,

easti'# 8

Aoe


avia" , 'iea ia-,


aoia' eio, %d&(#&""

< $(o9#d o8&($%!o# o9#d

o Pe&"ssio? typai& so" i

a'' aoia' eio


:8i"tes

P"ep"i" e:aiatio

- F9#d$+ -&!*-%: o#& ,!#*&(" 988&(

9.!+!79"

2 7

- Lo7-!$: 0 77 (9.($

- Co#%($7%!o#: od&($%&

- Mo.!+!$%!o#: $7%!&

>:teities? )a

o >ea? !oe e:teities -8-o Physio'oi&a' e+'e:? 88

8


)o#"p?

o ;eo'oi ? /,/8'

A? P3A0, 2/ yeas o', post pat"s at"es

• Pe&"ssio ? soo o oth '"s


8, heeEi -8-, &a'es -8-

• %aae ? hypepietatio o+

aeo'a 8, ipp'e eta&tio -8-,

easti'# 8

Aoe


avia" , 'iea ia-,


aoia' eio, %d&(#&""

< $(o9#d o8&($%!o# o9#d

o Pe&"ssio? typai& so" i

a'' aoia' eio


:8i"tes

P"ep"i" e:aiatio

- F9#d$+ -&!*-%: o#& ,!#*&(" 988&(

9.!+!79"

2 7

- Lo7-!$: 0 77 (9.($

- Co#%($7%!o#: od&($%&

- Mo.!+!$%!o#: $7%!&

>:teities? )a

o >ea? !oe e:teities -8-o Physio'oi&a' e+'e:? 88

8


)o#"p?

o ;eo'oi ? /,/8'

A? P3A0, 2/ yeas o', post pat"s at"es

75


76/113

y &aesaia se&tio ii&ate y patiet

pe+ee&e, POD-2

P?

• 7e+ao:i' 3 : 500

• Taao' 3 : 50

• %e+eaat a&i 3 : 500

• %o'o&&o 3 : 1

• Raitiie 3 : 1

• A++ &athete

y &aesaia se&tio ii&ate y patiet

pe+ee&e, POD-3

P?

• 7e+ao:i' 3 : 500

• Taao' 3 : 50

• %e+eaat a&i 3 : 500

• %o'o&&o 3 : 1

• Raitiie 3 : 1

GYNECOLOGY

76


77/113

No Ad!""!o

# D$%&

Id%!%' Wo()!#* D!$*#o"!" F!#$+ D!$*#o"!"

10 %a&h 2,

2016

%s. 7 P3A1, 41 yeas o', ith

septa' vaia

P3A1, 41 yeas o', post

vaia' sept" e:&i&io

ii&ate y septa' vaia

11 %a&h 2

2016

%s. S G4P3A0, 40 yeas o',

avi 15-16 ee#s

a&&oi to SG ith

isse aotio a

&hoi& hypetetio

P3A1, 40 yeas o', post

&"etae ith ii&atio

&hoi& hypetesio a

isse aotio

12. %a&h 3

2016

%s. N9 G1P0A0, 21 yeas o',

avi 1/-20 ee#s

a&&oi to SG,

ith isse aotio

P0A1, 21 yeas o', ith post

pat"s iat""s y

spotaeo"s vaia' e'ivey,

ith isse aotio

13. %a&h 4th

2016

%s. S; G2P0A1, 35 years old,

gravid 16-17 weeks

according to first day of

last menstrual cycle, with

ectopic pregnancy


Salphingectomy indicated by

ectopic pregnacy at right

fallopian tube

14. %a&h 5

2016

%s. ! G1P0A0, 1/ yeas o',

avi - ee#s

a&&oi to SG, ith

aot"s i&op'ete

P0A1, 1/ yeas o', post

&"etae ith ii&atio

aot"s i&op'ete

15. %a&h 6th

2016

%s.9 G2P1A0, 1/ yeas o',

avi 1-1 ee#s

a&&oi to SG, ith

aot"s i&op'ete

P1A1, 1/ yeas o', post

&"etae ith ii&atio

aot"s i&op'ete

CASE 10

PA1/ 1 '&$(" o+d/ !%- "&8%$+ $*!#$

77


78/113

Id%!%'

• Nae ? %s. 7

• Ae ? 41 yeas o'


• Re'iio ? %os'e

• O&&"patio ? ep'oyee

• >"&atio ? e'eetay s&hoo'


A#$#&"!"

• 7hie+ 7op'ait

!"p i he vaia si&e 1 yea ao


Patiet &ae to Ata $aya hospita' &op'aii ao"t '"p i he vaia si&e 1 yea

ao. The patiet sai that she +e't oe is&o+ot these ays e&a"se o+ that. She a'so

sai that she iJt +e't pai o the '"p.




o ;itoy o+ a''ey ? eie









yseohea


79/113

e'ivey

2. 1//5 ea -8-, 7RT K2 se&os

79


80/113


81/113

P+$##!#*

• 7e+ao:i' 3:500

• %e+ia' 3:500

• Po e:&isio septa' vaia

Fo++o 98

Day 3 %a&h 2016

S No pai, "iate


82/113

CASE 11

G4P3A0, 40 yeas o', avi 15-16 ee#s a&&oi to SG ith isse aotio a

&hoi& hypetetio

Id%!%'

• Nae ? %s. S

• Ae ? 40 yeas o'• >thi&ity ? $avaese

• Re'iio ? %os'e


• >"&atio ? >'eetay s&hoo'

• Aess ? !"a *ata

• Date o+ Aissio ? %a&h 2, 2016

A#$#&"!"

• 7hie+ 7op'ait

!i"i a 'oo is&hae +o the vaia 3 ays e+oe aissio.


Patiet &op'aie ao"t havi sa'' ao"t o+ &'ea 'i"i a 'oo is&hae

+o vaia si&e 3 ays e+oe hospita' aissio. Aoia' pai a aoia'

&ap as eie.


82


83/113

o ;istoy o+ hypetesio ? si&e +ist pea&y, "&oto''e,

&os"e &aptopi' 2:25



o

;istoy o+ epi'epsy ? eieo ;istoy o+ heato'oi& isease ? eie





o %est"a' &y&'e ? 30 ays, e"'a'y, ith "atio o+ 5

ays, &hae 4-5 pas a ay, yseohea


84/113

o ;eat ate ? :8i"tes



• )eiht ? 53 #

• ;eiht ? 145 &

• *%I ? 25.2 #82

G&($+ E;$!#$%!o#

• >yes ? aei& &oB"&tiva 8, i&tei& s&'ea -8-


• Thoa:




i'# -8-

• Aoe

o Ispe&tio ? &ove:, 'iea ia ea -8-, 7RT K2 se&os



85/113

U+%($"o#o*($8-' >USG?

0=12=1 ? G4P3A0, avi 15-16 ee#s s"sp. +eta' as&ites

*PD ? 3,02 &

(! ? 12,11 &

02=0=16 ? G4P3A0 avi 24-25 ee#s, ith I(D

*PD ? 2,5 &

GA ? 15 1

(;R ? -

Wo()!#* D!$*#o"!"

G4P3A0, 40 yeas o', avi 15-16 ee#s a&&oi to SG ith isse aotio a

&hoi& hypetesio

P+$##!#*

• %isoposto' 100 H84 ho"s, pe vaia "ti' the +et"s as e'ivee

• 7aptopi' 1 : 25 PO

• Po &"etae

F!#$+ D!$*#o"!"

P3A1, 40 yeas o', post &"etae ith ii&atio &hoi& hypetesio a isse aotio

T(&$%%

• Osevatio o+ patiet@s &oitio a+te e'ivey


86/113


87/113

Extremities: Warm

o Edema:Lower extremities -/-

o Physiological reflex: ++/++/++/++

o Pathological reflex : --/--

o Sensory examination +/+

Workup:

o Laboratory:

Hemoglobin : 10,1 g/ dL

Hematocrit : 30%

Leucocyte : 14,900/ L

Platelets : 418,000 / L

Blood group : O/ Rh+

HbSAg : -

Urine:

Protein : -

Ultrasonography (USG)

30/12/15 : G4P3A0, gravid 15-16 weeks susp.

Fetal ascites

BPD : 3,02 cm

FL : 12,11 cm

02/03/16 : G4P3A0 gravid 24-25 weeks, with

IUFD

BPD : 2,85 cm

GA : 15w 1d

FHR : -

A: G4P3A0, 40 yeas o', avi 15-16 ee#s

a&&oi to SG ith isse aotio a

&hoi& hypetetio

9x/minutes

Extremities: Warm



• Pathological reflex : --/--

• Sensory examination +/+

Delivery on March 3th, 2016 on 3 am

- Fetal weight : 90 g

- Fetal lenght : 11 cm- Minimal bleeding (+- 200 cc)

Post partus and curretage

A : G4P3A0, 40 yeas o', avi 15-16

ee#s a&&oi to SG ith isse

aotio a &hoi& hypetetio

P:

• Observe vital sign, if stable, patient was

permitted to discharge

87


88/113

P:

Deliver the baby

•Misoprostol 100 g/4 hours, per vaginam

until the fetus was delivered

• Captopril 1 x 25 mg PO

• Pro curretage

• Observe the vital signs after procedure

88


89/113

CASE 12

G1P0A0/ 21 '&$(" o+d/ *($!d 1@420 &&)" $77o(d!#* %o USG/

!%- !""&d $.o(%!o#

Id%!%':

• Nae ? %s. N9

• Ae ? 21 yeas o'


• Re'iio ? %os'e


• >"&atio ? Seio hih s&hoo'

• Aess ? !"a *ata

•

Date o+ aissio ? %a&h 3

, 2016

H!"%o('

C-!&, 7o8+$!#%

Patiet &ae to the hospita' e&a"se she as e+ee +o 'o&a' piay hea'th &ae a as

iaose ith I(D. Patiet +e't o +eta' oveet si&e 4 ays pio to aissio.

H!"%o(' o, 8(&"% !++#&""Patiet &ae to the hospita' e&a"se she +e't o +eta' oveet +o 4 ays pio to

aissio. Aoia' pai +e't o s"pap"i& aea. *'oo is&hae +o vaia as eie.

2 ee#s e+oe, patiet &ae to 'o&a' piay hea'th &ae a she sai thee as +eta'

oveet the.

H!"%o(' o, 8$"% !++#&"":

o ;istoy o+ hypetesio ? Deie.

o ;istoy o+ iaetes e''it"s ? Deie.o ;istoy o+ a''ey ? Deie.





o ;istoy o+ s"ey ? Deie.

• ;istoy o+ est"a' &y&'e?


89


90/113

o %est"a' &y&'e ? 30 ays,

ie"'a'y, ith "atio o+ 5- ays,

&hae 2-3 pas yes ? Aei& &oB"&tiva -8-, i&tei& s&'ea -8-

• %o"th ? )et oa' "&osa eae

• Thoa:

o ;eat ? Re"'a 1st a 2 heat so"s, "" -, a''op -

o !" ? Cesi&"'a eath so"s 8, ho&hi -8-, heeEi -8-

90


91/113

o %aae ? Aeo'a hypepietatio 8, ipp'e eta&tio -8-, east

i'#-8-

• Aoe

o Ispe&tio ? 7ove:, stiae avia" :teities ? !e eea -8-, 7RTK 2 se&os



92/113

P+$##!#*

• De'ive the ay

• IC(D R! 500 && OepaEo'e 1 ap *"s&opa 1 ap

• %isoposto' 50 &84 ho"s

• Oseve the vita' sis a+te po&e"e

Wo()!#* d!$*#o"!" $,%&( d&+!&( %-& .$.'

P0A1, 21 yeas o', ith post pat"s iat""s y spotaeo"s vaia' e'ivey, ith isse

aotio

P+$##!#*

• Po SG

%a&h 4th, 2016 at / a ? o 'e+t tiss"e.

F!#$+ D!$*#o"!":

P0A1, 21 yeas o', ith post pat"s iat""s y spotaeo"s vaia' e'ivey, ith isse

aotio

Treatment

Take home medicine

• Cefadroxyl 3 x 500 mg PO

• Pospargin 3 x 1 tab PO

• Mefenamic acid 3 x 500 mg PO

If the condition is stable and no further complication occurs, patient is permitted for

discharge

March 3rd 2016 March 4th 2016

S: Patient felt no fetal movement

O: General condition : well



S: Suprapubic pain VAS 4-5, defecate (+),

urinate (+), appetite (+)

O: General condition : well


92


93/113

Pulse : 96 bpm




-/-, icteric sclera -/-.


Thorax:



Pulmo :



• Percussion :sonor on both lungs

• Auscultation : vesicular breath sound

+/+, wheezing -/-, crackles -/-• Mammae : hyperpigmentation of

areola +/+, nippleretraction -/-

Abdomen

• Inspection : convex, striae gravidarum

-, lineanigra (+),

• Palpation : supple in all abdominal

region, tenderness +


abdominal region

• Auscultation : bowel sound +, 6

x/minutes


Pulse : 80 bpm

Respiratory Rate : 16bpm

Temperature : 37,1o

C


conjunctiva -/-, icterics clera -/-.


Thorax:

Cor : Auscultation: irregular 1st

and 2nd heart sound, Gallop (-), Murmur

(-)

Pulmo :

• Inspection : symmetrical in both

static and dynamic breathing

• Percussion :sonor on both lungs• Auscultation : vesicular breath sound


• Mammae : hyperpigmentation of

areola +/+, nippleretraction -/-,

breastmilk -/-

Abdomen :

• Inspection : convex, striae

gravidarum -, lineanigra (+),




abdominal region

93


94/113

Extremities: Warm





Workup:

• Laboratory:

- Hemoglobin : 12,8 g/ dL

- Hematocrit : 39%

-

Leucocyte : 8,700/ L- Platelets : 218,000 / L

- Blood group : O/ Rh+

- HbSAg : -

Urine:

- Glucose : -

- Protein : -

- Ketones : ++

- Leucocyte : +++

A? P0A1, 21 yeas o', ith post pat"s

iat""s y spotaeo"s vaia' e'ivey, ith

isse aotio

P:

Deliver the baby

• IVFD RL 500 cc + Omeprazole 1 amp +

Buscopan 1 amp

• Misoprostol 50 mcg/4 hours

• Observe the vital signs after procedure

• Auscultation : bowel sound +,

9x/minutes

Extremities: Warm

• Edema: Lower extremities -/-




Delivery on March 4th, 2016

- Fetal weight : 320 g- Fetal lenght : 18 cm

- Minimal bleeding (+- 150 cc)

Post partus

A : P0A1, 21 yeas o', ith post pat"s

iat""s y spotaeo"s vaia' e'ivey,

ith isse aotio

P:

• Observe vital sign

• Pro USG

USG on 9 am : no tissue was left

Patient permitted to discharge with

• Cefadroxyl 3 x 500 mg PO

• Pospargin 3 x 1 tab PO

• Mefenamic acid 3 x 500 mg PO

94


95/113

CASE 1

G2P0A1, 35 years old, gravid 16-17 weeks according to first day of last menstrual cycle,

with ectopic pregnancy

Identity

Name : Mrs. SH

Age : 35 years old


Religion : Moslem


Education : Junior High School

Date of admission : 4th March 2016

History

Chief complaint

Patient felt pain at her left lower abdomen since 5 hours before hospital admission

95


96/113

History of present illness

Patient came to the emergency room with lower abdominal pain at 2 a.m. the patient said that

since december, her menstrual cycle came irregularly and she took the pregnant test and it

was said positive. The abdominal pain felt like she was being stabbed and squeezed, it got

worse since one month ago. The patient also said that sometimes she felt dizzy after the

pregnancy test was positive.

History of past illness :

o History of hypertension : Denied.

o History of diabetes mellitus : Denied.

o History of allergy : Denied.

o History of epilepsy : Denied.

o History of hematologic disease : Denied.

o History of urinary tract/kidney disease : Denied.

o History of trauma : Denied.

o

History of surgery : appendectomy (2004)



o Menstrual Cycle : 18 days with regular menstrual cycle, with every

period lasting for 7 days and no dysmenorrhea.

o First day of last period : December, --th 2015

Marital History:

Patient has married twice, has lasted 2 years with current husband.

Obstetric history:

No Date Gestational

Age

Labour

History

Sex Complication Birth

Weight

Breast

Feeding1. 2002 2 months Abortus

96


97/113

2 2016 (this

pregnancy)

±3 months Abortus


No contraception history


Patient didn’t have a routine antenatal care


General Condition : Moderate ill


Vital Signs

Blood Pressure : 120/80 mmHg

Temperature : 36,7oC

Respiratory rate : 32 times a minute

Heart rate : 96 BPM

Weight : 65 kg

Height : 165 cm

BMI : 23,8 kg/m2

General Examination



Thorax :

Heart : Regular 1st and 2nd heart sounds, murmur -, gallop -

Lungs : vesicular breath sounds +/+, rhonchi -, wheezing -

Mammae : Areola hyperpigmentation -/-, Nipple retraction -/-,

breast milk -/-

Abdomen :

Inspection : Convex, Striae Gravidarum (-), Linea Alba (-)

Auscultation : Bowel sounds (decreased)



97


98/113

Gynecologic examination

• First day of the last menstrual period: December --th 2015

• Pelvic examination

o

Vagina toucher : Cervix dilation (-)o Rectovaginal toucher : not performed

o Inspekulo : Vulva: no abnormality

Vagina: no abnormality

Porsio: erosion (-)

Slinger pain (+)

Fluksus (+)

Corpus uteri: no abnormality

Douglassi cavum: no abnormality

Laboratory examination

• Hemoglobin : 11,6 g/dl

• Hematocrit : 35 %

• Leucocyte : 15600/ µ l

• Platelets : 312.000/ µ l

• Blood type : O/+

• HbsAg : -

• Pregnancy test : (+)

Working diagnosis

G2P0A1, 35 years old, gravid 16-17 weeks according to first day of last menstrual cycle, with

ectopic pregnancy

Planning

• Pro Laparotomy Salphingectomy

• Consul anesthesia for preoperative preparation

Final diagnosis

P0A2, 35 years old, post Salphingectomy indicated by ectopic pregnacy at right fallopian

tube


98


99/113




• observed vaginal bleeding and uterine contraction

• measure urine output and fluid balance every 6 hours• if flatus (+), give mushy diet


• IVFD :

o RL 500cc + 1amp Ondancentron + 1 amp Tramal for 8 hours

o RL 500cc + 1amp Alinamin F + 1 amp Omeprazole for 8 hours

o RL 500cc + 1 amp Extrace for 8 hours

• Oral :


o Doxycyclin 2x100mg

o Tranexamic acid 3x500mgo Mefenamic acid 3x500mg

o Kaltrofen rectal 2x1 supp

Follow-up :

March 4th 2016 March 5th 2016

S: pain at the lower abdominal, felt like stabbed

and squeezed

O: General condition : moderate ill



Pulse : 96 bpm

Respiratory Rate : 32bpm



-/-,ictericsclera -/-.


Thorax:

S: post-op pain vas 3-4, flatus + , defecation -




Pulse : 80 bpm






Thorax:


99


100/113



Pulmo :

• Inspection : symmetrical in both static and

dynamic breathing


• Auscultation : vesicular breath sound +/+,

wheezing -/-, crackles -/-

• Mammae : hyperpigmentation of areola

-/-, nippleretraction -/-

Abdomen

• Inspection : convex, striae gravidarum -,

lineanigra (-),

• Palpation : supple in all abdominal region,

tenderness at lower region


abdominal region

• Auscultation : bowel sound decreased

Extremities: Warm





Inspeculo :

• Vulva: no abnormality

• Vagina: no abnormality

• Porsio: erosion (-)

• Slinger pain (+)

• Fluksus (+)

• Corpus uteri: no abnormality


Pulmo :




• Auscultation : vesicular breath sound


• Mammae : hyperpigmentation of

areola -/-, nippleretraction -/-,

breastmilk -/-

Abdomen :

• Inspection : convex, striae gravidarum

-, lineanigra (-),




abdominal region

• Auscultation : bowel sound +, 6

x/minutes

Extremities: Warm• Edema:Lower extremities -/-




A: P0A2, 35 years old, post Salphingectomy

indicated by ectopic pregnacy at right

fallopian tube

100


101/113

• Douglassi cavum: no abnormality

Workup:

• Laboratory:

• Hemoglobin: 11,6 g/dl

• Hematocrit: 35 %

• Leucocyte: 15600/ µ l

• Platelets: 312.000/ µ l

• Blood type : O/+

• HbsAg: -

• Pregnancy test: (+)

A: G2P0A1, 35 years old, gravid 16-17 weeks

according to first day of last menstrual cycle, with

ectopic pregnancy

P:

Pro Laparatomy Salphingectomy

Consul anesthesia for preoperative preparation

Post operation

A : P0A2, 35 years old, post Salphingectomy

indicated by ectopic pregnacy at right fallopian

tube


• Observed vital signs every 15 minutes for

the first one hour, every 30 minutes for the



• observed vaginal bleeding and uterine

contraction

• measure urine output and fluid balance

every 6 hours

P:

Aff catheter in 1x24 hours

Medication

Cefadroxil 3x500mg

Doxycyclin 2x100mg

Tranexamic acid 3x500mg

Mefenaic acid 3x500mg

Kaltrofen supp 2x1

Sangobion 2x1

Ranitidine 2x150mg

101


102/113

• if flatus (+), give mushy diet


• IVFD :

o RL 500cc + 1amp Ondancentron + 1

amp Tramal for 8 hourso RL 500cc + 1amp Alinamin F + 1

amp Omeprazole for 8 hours

o RL 500cc + 1 amp Extrace for 8 hours

• Oral :


o Doxycyclin 2x100mg

o Tranexamic acid 3x500mg

o Mefenamic acid 3x500mg

o Kaltrofen rectal 2x1 supp

March 6th 2016 March 7th 2016

S: post-op pain vas 6, flatus + ,

defecation+/watery stool, urination +




Pulse : 80 bpm






Thorax:



S: post-op pain vas 1-2, flatus + ,

defecation+, urination +


Consciousness

Date post:	07-Jul-2018
Category:	Documents
Upload:	errie-mer-lim
View:	217 times
Download:	0 times

Final Weekly Report IV

Documents