DUTY REPORT

Thursday, May 3rd 2018

Supervisors :
dr. Risman F. Kaban, M.Ked(OG), Sp.OG

Residents :
1. dr. T. Larry Arthit
2. dr. Fakhrurrazi
3. dr. Rina Sinta Dhanu
4. dr. Vivi Yovita
5. dr. Muhammad Iqsan
6. dr. Sofyan Andri
7. dr. Willy Kurnia Almon
`
Department of Obstetric and Gynecology
Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2018
NEW PATIENT : 2 PATIENTS
 1. Mrs. N, 38 y.o, G8P6A1
Diagnose : Severe Oligohydramnion + GMG + IUP (29-30) wga + Head
Presentation + Alive Fetus
Planning : Expectant management
Sonography confirmation
Report to Supervisor on Duty dr. Risman F. Kaban, M.Ked(OG), Sp. OG 
Approved

2. Mrs. K, 39 y.o, P4A0

Diagnosis : Ca Cervix IIIB + Anemia
Planning : Improvement General State
Report to Supervisor on Duty dr. Risman F. Kaban, M.Ked(OG), Sp. OG 
Approved
PATIENT 1
Mrs. N, 38 y.o, G8P6A1, Bataknese, Christian, Senior High
School, Housewife, wife of Mr. S, 40 y.o, Bataknese, Christian,
Senior High School, Employee. The patient was admitted to
Adam Malik General Hospital on May 3rd 2018 at 09.12 pm
with:

CC : Referral from other hospital

History of labor contraction (-), History of blood slime (-),
History of amniotic fluid leakage (-). History of leukorrhea (-).
History of fever in this pregnancy (-), History of sexual
intercourse (+), History of abdominal massage (+) ± 3 weeks
ago. Patient was reffered from Balimbingan Hospital with
diagnosis Oligohydramnion + GMG + IUP (32-34) wga + Head
presentation + Alive fetus. Micturition and defecation showed
no abnormalities.
History of Previous Illness :-
History of Medication :-
History of Surgery :-
LMP : ?/9/2017
EDD : ?/6/2018
ANC : Obstetrician 2x, Midwife 1x
• History of Pregnancy
1. Female, aterm, 5000 gr, SVD, Midwife, Clinic, 19 y.o, healthy
2. Female, aterm, 2500 gr, SVD, Midwife, Clinic, 15 y.o, healthy
3. Female, aterm, 3400 gr, SVD, Midwife, Clinic, 14 y.o, healthy
4. Female, aterm, 3500 gr, SVD, Midwife, Clinic, 12 y.o, healthy
5. Male, aterm, 3500 gr, SVD, Midwife, Clinic, 8 y.o, healthy
6. Abortus
7. Male, aterm, 3500 gr, SVD, Midwife, Clinic, 4 y.o, healthy
8. Current Pregnancy
Vital Signs
Cons : CM E4V5M6 Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
Pulse : 78 x/i Cyanosis: (-)
RR : 20 x/i Dypsnoe: (-)
Temp : 36,4°C Edema : (-)
General state : Moderate
Nutritional state : Normal
Illness State : Moderate
Generelized Status :
• Head : Inferior palpebra conj pale (-), icteric (-)
• Neck : No abnormalities
• Thorax: Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rhales (-)/(-)
• Abdomen: Hepar/Lien not palpable
Obstetrical state
Abdomen : Symmetrically enlarged
Fundal Height : 3 fingers above navel level/ 26 cm
Tension part : Right
Lower part : Head
Fetal Movement : (+)
Fetal Heart Rate : (+) 136 bpm, regular
Uterine contraction : (-)
Vaginal Examination
• Inspeculo : Portio erosion (+), F/A (+), blood (-)
• VT : Not performed
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Trans Abdominal Sonography
Report
Cardiotocography
Trans Abdominal Sonography Report
Singleton Pregnancy, Head presentation, Alive Fetus
FM (+), FHR 137 bpm regular
BPD : 7.38 cm (29w4d)
HC : 27.39 cm (29w6d)
AC : 24.26 cm (28w4d)
FL : 5.71 cm (30w0d)
EFW : 1350 gram
MVP : 1,12 cm
Placenta fundal grade I
Umb Artery S/D ratio : 3.23

Conclusion:
Severe Oligohydramnion + IUP (29 - 30 ) wga + Head
presentation + Alive fetus
 Laboratory Findings
May, 3rd 2018

• Hb : 10,3 N: 12-14 gr/dL

• Leukocyte : 11.710 N: 4.000-11.000/uL
• Hematocrite : 30 N: 36,0-42,0 %
• Platelet : 194.000 N: 150.000-400.000/uL
• Ureum :9 N: 10-50 mg/dL
• Creatinin : 0,59 N: 0.6-1.2 mg/dL
• KGD ad : 83 N: 0. 00-140 mg/dL
• Natrium : 135 N: 136-155 mmol/dL
• Kalium : 2.9 N: 3.5-5.5 mmol/dL
• Chlorida : 100 N: 95-103 mmol/dL
• HbsAg : Non Reactive N: Non Reactive
• AntiHIV : Non Reactive N: Non Reactive
Diagnosis :
Severe Oligohydramnion + GMG + IUP (29-30) wga + Head Presentation
+ Alive Fetus

Therapy :
- Bed Rest
- O2 2-4L/I via nasal canule
- IVFD RL 20 dpm
- Inj. Dexamethasone 15 mg IV

Plan :
- Expectant management
- Sonography confirmation tomorrow
- Monitoring vital sign and fetal well-being

Report to Supervisor on Duty dr. Risman F. Kaban, M.Ked(OG), Sp. OG 

Approved
THANK YOU
PATIENT 2
Mrs. K, 39 y.o, P4A0, Javanese, Moslem, Junior High School, Housewife
married once at age 22 y.o, youngest child 7 y.o. Married with Mr. S, 39
y.o, Javanese Moslem, Senior High School, Employee. Patient was
admitted to Adam Malik General Hospital on May 3rd 2018, at 10.29 pm
with:

CC : Abdominal pain
This has been experienced since 1 day before admitted to hospital. Pain
in the abdomen and waist. History of vaginal bleeding (-) and history of
palpable lumps in the abdomen (-). History of postcoital bleeding (-).
History of leukorrhea (+), itch (+), odor (+) since 1 year ago. History of
weight decreased (-). History of decreased appetite (-). Nausea and
vomiting (+). Micturition and defecation showed no abnormalities.
Previous illness :-
Previous medication :-
History of surgery :-
History of contraceptive use : -
History of menstruation : Menarche at 12 y.o, regular cycle,
duration 6-7 days, volume 2-3 times changing pads/day,
menstrual pain (-), last menstruation April 8th 2018

General Condition : Moderate

Nutritional State : Normal
Illness condition : Moderate
Present State

Sensorium : Alert Anemic : (-)

Blood Pressure : 120/70 mmHg Icteric : (-)
Pulse : 80 bpm Cyanosis : (-)
Breath : 20 times/min Dyspnea : (-)
Temperature : 36,7 °C Oedem : (-)

Localized State

Head : Pale palpebra conjuctiva (-), icteric sclera (-)

Neck : Lymph node enlargement (-)
Cor : S1 > S2 (+)
Thorax : Respiratory sound : Vesicular (+/+)
Additional sound : Rales (-/-), Wheezing (-/-)
Superior Ext : No Abnormalities
Inferior Ext : Pretibial oedem : (-/-)
Gynecological State

• Abdomen : Laxed, peristaltic (+) N, tender (+)

• Vaginal Bleeding: (-)

Inspeculo :
Looks exophytic mass size 5 x 4 cm. fragile, bleed easily, cleaned not
active.

Rectal Examination :
Exophytic mass palpable size 5 x 4 cm. Both Adnexa no mass palpated.
Both parametrium laxed. Douglas cavity not protruded. Anal Sphincter
was tight. Ampula of recti fill with feces.
 Laboratory Findings
May, 3rd 2018

• Hb : 8,5 N: 12-14 gr/dL

• Leukocyte : 13.120 N: 4.000-11.000/uL
• Hematocrite : 27 N: 36,0-42,0 %
• Platelet : 423.000 N: 150.000-400.000/uL
• Ureum : 13 N: 10-50 mg/dL
• Creatinin : 0,74 N: 0.6-1.2 mg/dL
• KGD ad : 78 N: 0. 00-140 mg/dL
• Natrium : 138 N: 136-155 mmol/dL
• Kalium : 3,6 N: 3.5-5.5 mmol/dL
• Chlorida : 105 N: 95-103 mmol/dL
• Albumin : 3,2 N: 3.5-5.0 g/dL
Diagnosis :
Ca Cervix IIIB + Anemia

Therapy :
• IVFD NaCl 0,9%  20 dpm
• Inj. Ketorolac 30 mg/8 hours IV

Planning :
General Improvement Care

Report to Supervisor on Duty dr. Risman F. Kaban, M.Ked(OG), Sp. OG

 Approved
THANK YOU