Duty Report

Monday , June 12nd 2015

Supervisor on duty:
Dr. dr. Sarma N. Lumbanraja, M.Ked(OG),
SpOG.K
Duty Team: 1. Dr. Juhriani Malahayati
2. Dr. Irliansyah Putra
3. Dr. Isnayu
4. Dr. Irfan Hamidi
5. Dr. Ria Suci
6. Dr. Ryan Andrian
7. Dr. Dwi Fenny Amir
Obstetric dan Gynecology Department
Faculty of Medicine of USU/ RSUP HAM
2015

1.

Mrs. K, 29 years old, G4P3A0

Dx : IUFD + MG + IUP (28-30) gw + preeclampsia BERAT+
partial HELLP syndrome
Planning :
- Inj. MgSO4 20% 4 gram loading dose
- Inj. MgSO4 40% 12 gram maintenance dose
- Inj. Dexamethasone 10 10 5 5 gram (48 hours)

PATIENT 1

1. Mrs. K, 29 years old, G4P3A0, moslem , housewife wife of Mr.

E ,40 yo,, moslem,admitted at Adam Malik Hospital at August
30th 2015, 03.00 a.m. with :
CC
E

: Decreased of consciousness (alloanamnesis)

: Experienced by the patient since this morning, history

of fever (+) since 3 days ago. The characteristic of fever is

intermitten and get little better with antipyretic. history of
nausea and vomiting (-) history of blood from vagina (-).
History of abdominal pain (-) . History of water from vagina
(-), History of hypertension before pregnancy (-). History of
hypertension on the previous pregnancy (-). Headache (-),
blurred vision (-). Defecation and micturition normal.

Previous ilness: Diabetes (-), Hypertension (-), asthma (-)

Previous medical hist: HPHT : Unclear
TTP

: Unclear

ANC

: Midwife 5 x

Hystory of pregnancy :
1.

,aterm, 2500 gram, PSP, Midwife, clinic, 12 yo, healthy

2.

,aterm, 3500 gram, PSP, Midwife, clinic, 6 yo, healthy

3.

, aterm, ? gram, PSP, Midwife, clinic, 2 yo, healthy

4.

This pregnancy

Vital Sign
Cons
BP
Pulse
RR
Temp

: apatis
Anemic
: (-)
: 180/100 mmHg
Icteric
: (-)
: 94x/i
Cyanosis
: (-)
: 28 x/i
Dypsnoe
: (+)
: 36,2C
Edema
: ( -)
Proteinuria : +3
Localized State :
Head : Conj Palpebra inferior anemic ( -)/(-), icteric (-)/(-)
Neck

: in normal limit

Thorax : Respiratory sound

Additional sound

: Vesiculer
: Wheezing(-)/(-), Rhonki (-)/(-)

Obstetrical state
Abdomen
Fundal Height
Teregang
Terbawah
Movement
His
FHR
VT

:
:
:
:
:
:

assymetricaly enlarged
3 fingers above umbilical
right
head
::: Servix closed

Dx : IUFD + MG + IUP (28-30) gw + preeclampsia

BERAT+ partial HELLP syndrome

 Planning:
- Inj. MgSO4 20% 4 gram loading
dose
- Inj. MgSO4 40% 12 gram
maintenance dose
- Inj. Dexamethasone 10 10 5 5
gram (48 hours)
Report to supervisor Dr. dr. Sarma
N. Lumbanraja, M.Ked(OG), SpOG.K
Acc

LABORATORY FINDINGS on 30/08/2015

Hb
: 14.9 gr/dl N: 12-14/gr/dl
Leukocyte
: 34,23 /mm3N: 4000-11000/uL
Hematocrit
: 45,8 % N: 36,0-42,0/%
Platelet
: 52 /mm3N:150.000-400.000/u
Ad Random Glucose : 30 mg/dl N: < 200 mg/dl

APT
: 129,8
C= 33,5 S

PT
: 65,2
C= 14 S

TT
: 29,5
C = 17,8 S

Ureum
: 14,87
N : 10-50 mg/dl

Creatinin
: 1,3
N : 0,6-1,2 mg/dl

Natrium
: 128 mg/dl N : 135-155 mg/dl

Kalium
: 6,9 mg/dl N : 3,6- 5,5 mg/dl

Klorida
: 85 mg/dl N : 96-106 mg/dl

 USG belum ada

USG TAS
Single fetus, head presentation
FM (-), FHR (-)
BPD 7,69 cm
FL 5,31 cm
AC 25, 69 cm
HC 28,22 cm
Placenta corpus anterior
Amnion fluid : MVP = 4
Kesan : IUFD + IUP (29-30) gw + Head
presentation

THANK YOU