FETOMATERNAL WARD REPORT

Thuesday, December 15th 2015

SUPERVISOR
dr. Fadjrir, M.Ked(OG), SpOG
dr. Jenius Lumban Tobing, M.Ked(OG), SpOG
dr. Riza H. Nasution, SpOG

Ward Residents : 1. dr. Novi Rindi

2. dr. Widya Nelvi P

Obstetric and Gynecology Department

Medical Faculty University of Sumatera Utara
dr. Pirngadi General Hospital
2015

Reported:
1. Post Laparatomy d/t Advanced Abdominal Pregnancy + PD6 +
Anemia

No
1

Income

Outcome

Mrs. M, 36 yo, P3A0

Therapy :
Th/ IVFD RL 20 gtt/i
Diagnose:
-Inj. Ceftriaxon 1 g/12 hr
Post Laparatomy d/t Advanced -Inj. Gentamycine 80 mg/8 hours
Abdominal Pregnancy + PD6 + -Drip Metronidazole 500 mg/8 hr
Anemia
-Inj. Ranitidine 50 mg/12 hr
-Inj. Ketorolac 30 mg/8 hr
Recent condition:
-Tab PCT 500 mg/ 8 hr
Fully alert, BP: 120/70 mmHg,
HR: 86 x/I, RR: 20 x/I, T: 36,8 C
Planning :
14/12/2015
Hb/Leu/Trom:
9.9/26.600/325.000
HCG at 12.30 pm : 36150,6
mIU/mL

Stabilization general condition

Metotrexate regimen

PATIENT 1

Mrs. M, 36 years old, P3A1, Muslim, Javanese, Junior High School,

Farmer, married to Mr. J, 37 years old, Muslim, Batak, Junior High
School, Farmer, came to Pringadi General Hospital with:
Chief Complain: Abdominal Pain
T: It has been experienced by the patient since 3 days ago post Csection. Initially, felt in th whole abdomen. History of vaginal
bleeding (-). Patient had fever since 2 days ago, the fever rise and
fall. Patient was reffered from other hospital with Dx : post
laparatpmy d/t Advanced Abdominal Pregnancy + PD3. Patient got
transfusion 2 bags of PRC in other hospital. Micturition and
defecation in normal limit.

History of Illness
: Asthma (-), DM (-), Hypertension
(-)
History of pregnancy:
Girl, aterm, 3000 gram, VSD, midwife, home, 12 years, healthy
Boy, aterm, 4200 gram, VSD, midwife, home, 4 years, healthy
Girl, aterm, 3000 gram, C-section, SpOG, hospital d/t advanced
abdominal pregnancy, 3 days, healthy

Status Presens
Sens
BP
HR
RR
Temp

: CM
: 110/70 mmHg
: 100 x/i
: 20 x/i
: 38,70C

Obstetrical state
Abdomen
FH
Vaginal Bleeding
Operation wound
Micturition
Defecation

Anemic
Icteric
Cyanotic
Dyspnoe
Oedem

:
:
:
:
:

(+)
(-)
(-)
(-)
(-)

: soepel, peristaltic (+) normal

: difficult to assess
: (-)
: covered by gauze, surgical wound moist
: (+) via cathether, uop 70 cc/ hour, yellowish
: (-)

Hasil Lab
Hb

: 5.5 gr/dl

Leukocyte

: 22.460/mm3

Hematocrit

N: 12-14/gr/dl
N:4000-11000/uL

: 16.8 %

N: 36,0-42,0/%

Trombocyte

: 193.000 /mm3

N: 150.000-400.000/Ul

aPTT

: 43.6

C= 33,0

PT

: 16.0

C= 13,7

INR

: 1,40

SGOT

: 10

N : 0 40 U/L

SGPT

: 10

N : 0 - 40 U/L

Ureum

: 11

N : < 50 mg/dl

Creatinine

: 0,66

N : 0.5-0.9 mg/dl

Random Blood Glucose

: 108

N :<140 mg/dL

Natrium

: 135

N : 135-155 mEq/L

Klorida

: 119

N : 96-106 mEq/L

Kalium

: 3,4

N : 3,6-5-5 mEq/L

USG TAS

USG TAS

Bladder filled
Placental in cavum abdominal
Free Fluid (-)

Diagnosis : Post Laparatomy d/t Advanced Abdominal

Pregnancy + PD6 + Anemia
Therapy:
-IVFD RL 20 gtt/i
-Inj. Ceftriaxone 1 gr/ 12 hours
-Inj. Gentamycin 80 mg/ 8 hours
-Drip Metronidazole 500 mg/ 8 hours
-Inj. Ranitidin 50 mg/ 12 hours
-Inj. Ketorolac 30 mg/ 8 hours
-Tab PCT 500 3x1
Plan:
- Improve general condition
-Transfusion PRC 4 bag
Report to supv dr. Riza H. Nasution, M.Ked(OG), SpOG Accepted

FOLLOW UP DEC 13th 2015

S

Abdominal pain

Presens state
Sens
: Compos Mentis
TD
: 110/70 mmHg
HR
: 86 x/i
RR
: 20 x/i
T
: 36,5C

Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 50 cc hours
Defecation : (-), flatus (+)

Post Laparatomy d/t Advanced Abdominal Pregnancy + PD4

Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1
Transfusion 4 bag PRC
HCG quantitative

FOLLOW UP DEC 14th 2015

S

Abdominal pain

Presens state
Sens
: Compos Mentis
TD
: 140/90 mmHg
HR
: 88 x/i
RR
: 24x/i
T
: 36,7C

Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 60 cc hours
Defecation : (-), flatus (+)

Post Laparatomy d/t Advanced Abdominal Pregnancy + PD5 + Anemia

Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1
- HCG quantitative (result : HCG : 36150,6)
-Post trasnfusion Hb 8,5 g/dL Report to spv. Dr. Riza H. Nst SpOG transfusion 2 bag PRC

Hasil Lab
Hb

: 9.9 gr/dl

Leukocyte

: 36.012/mm3

Hematocrit

N: 12-14/gr/dl

: 16.8 %

Trombocyte

: 325.000 /mm3

LED

: 50 mm/jam

N:4000-11000/uL
N: 36,0-42,0/%
N: 150.000-400.000/Ul

FOLLOW UP DEC 15th 2015

S

Abdominal pain

Presens state
Sens
: Compos Mentis
TD
: 110/70 mmHg
HR
: 86 x/i
RR
: 20 x/i
T
: 37,5C

Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 60 cc hours
Defecation : (-), flatus (+)

Post Laparatomy d/t Advanced Abdominal Pregnancy + PD6 + Anemia

Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1

THANK YOU