DUTY REPORT

Friday, July 20th 2018 at 04.00 PM – Saturday, July 21th 2018 at 07.00 AM
Consultant on Duty: Dr. Awan Nurtjahyo, OBGYN(C)

Resident on Duty :
Dr. Singgih Prasetyo Nugroho (Obstetrical Chief)
Dr. Fella H. Pratami (Gynecological Chief)
Dr. R. A. Kesuma Andini
Dr. Ita Chandra Wasih
Dr. Gerry Irawan
Dr. Uci Elisa
Dr. Fitria Koeshardani
Dr. Dian Aviani
Dr. Octaria Saputra
Dr. Wadhit Taubah

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 DUTY REPORT
Friday, July 20th 2018 at 04.00 PM – Saturday, July 21th 2018 at 07.00 AM
Consultant on Duty: Dr. Awan Nurtjahyo, OBGYN(C)

• Physiologic obstetrical patient : 0 cases

• Pathologic obstetrical patient : 5 cases
• Gynecological patient : 2 cases
• Passed Away : 0 cases
Total patients : 7 cases

• Obstetric ward patients : 28 patients

• Gynecology and Oncology ward patients : 65 patients
• ICU patient : 2 patients
Total patients : 95 patients

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 Obstetrical Patients
NO Identity Diagnosis ICD 10 Procedure ICD 9
1. Mrs. OKT / G1P0A0 37 weeks gestational age not O14.13 • Stabilization 650
34 y.o. / UA inlabor with severe preeclampsia • MgSO4 40% ~ protocol
/ FU SLF cephalic presentation • Anti Hypertension
• Vaginal delivery
2. Mrs. SUS / G3P2A0 38 weeks gestational age O14.13 • Stabilization 650
31 y.o. / RA inlabor first stage active phase with • MgSO4 40% ~ protocol
/ AW severe preeclampsia SLF cephalic • Anti Hypertension
presentation • Vaginal delivery
3. Mrs. MIR / G2P0A1 34 weeks gestational age O32.1 • Informed Consent 650
25 y.o. / UA inlabor second stage SLF breech • Bracht Manuevre
/ AW presentation
4. Mrs. DES / G2P1A0 34 weeks gestational age O60.03 • Conservative Management 655
24 y.o. / UA with threatened preterm labor SLF • Lung Maturation
/ AW cephalic presentation • Tocolytics
• P/ US Confirmation
5. Mrs. EMA / G5P4A0 37 weeks gestational age O14.13 • Stabilization 650
36 y.o. / RA inlabor first stage active phase with • MgSO4 40% ~ protocol
/ AW severe preeclampsia SLF cephalic • Anti Hypertension
presentation • Vaginal delivery

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 Gynecologycal Patients
NO Identity Diagnosis ICD 10 Procedure ICD 9
1. Mrs. LET / Incomplete Abortion + Malignancy of O03.4 • Curretage 69.02
41 y.o. / left Breast Tumor was suspected + N63.0 • Assess Surgeon, Interne and
UA / AW suspect of Metastases to coxae bone Anestesia Department
+ moderate anemia
2. Mrs. TRI / Endometrial Cancer was suspected + C54.1 • Blood Transfusion V58.2
62 y.o. / Severe Anemia + Haematuria D64.9 • Assess Surgeon, Interne 54.1
RA / AT Department
• P/ Surgical Staging

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 Mrs. OKT / 34 y.o. / UA / FU
July 20th 2018 at 01.00 AM
Chief complain Aterm pregnancy with high blood pressure
Uterine contraction (+) H/ of amniotic leakage (-). H/ of bloody show (-). H/ of high
blood pressure before pregnancy (-). H/ of blurred sight (-). H/ of vomiting (-). H/ of
History epigastric pain (-). She went to Puskesmas Indralaya, was referred to Ogan Ilir Hospital
then to Moh. Hoesin Hospital. She admitted her pregnancy was full term and fetal
movement (+)
Marital status 1x, 10 months.
Reproduction Menarche since 13 yo, regular 28-day cycle, lasts 7 days, LMP: 1-11-2017
Obstetric history 1. Current pregnancy
General Exam BP: 150/80 mmHg, HR: 94 x/m, T: 36.4oC, RR: 20 x/m, BW: 73kg, BH: 156 cm
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), longitudinal lie,
Obstetrical
cephalic presentation, U 5/5, uterine contraction (-), FHR: 142 x/minute, EFW: 2790 g
Examination
VT: portio soft, posterior, effacement 50%, dilatation (-), cephalic presentation, H I,
IG 4, BS 3
amniotic membrane and denominator could not be evaluated
HB: 11.9, WBC: 10.800, PLT: 403.000, OT/PT: 19/9, Alb: 3.4, LDH: 214, Ur: 9, Cr: 0.51,
Laboratorium Exam
UA: 4.4, Prot (++)
 - SLF cephalic presentation
- BPD: 8.68 cm. HC: 31.06 cm. AC: 32.07 cm. FL: 7.07 cm. EFW: 2881 g
USG ER - Placenta on posterior uterine corpus
- Amnionic fluid sufficient, SDP: 5 cm
C/ 37 weeks gestational age SLF cephalic presentation
G1P0A1 37 weeks gestational age not in labor + severe preeclampsia SLF cephalic
Diagnosis
presentation
Stabilization 3 hours
Observation of vital signs, FHR, contraction, signs of labor
IVFD RL xx drops/minute
Dwelling catheter
Therapy Nifedipine 10 mg/8 hours PO
MgSO4 40% ~ Protocol IM
Evaluation with gestosis index
Plan for cervical ripening after stabilization
Consult Internal Medicne Department and Ophthalmology Department
A/Gestational hypertention
Interne Department
P/Methyldopa 250mg/8 hours
Ophtalmology A/No sign of choroidopathy and retinopathy hypetension
Department P/ Re-counsul if decrease of vision

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 Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 5/5, uterine contraction (-), FHR: 142 x/minute.
VT: portio soft, posterior, effacement 50%, dilatation (-), cephalic presentation, H I, amniotic
Follow UP
membrane and denominator could not be evaluated
July 20th
A: G1P0A1 37 weeks gestational age not in labor + severe preeclampsia SLF cephalic
2018 at
presentation
04.00 AM
P:
• Cervical ripening with Misoprostol 25mcq / 6 hours
• Plan for Vaginal Delivery
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 1x/10’/15’’, FHR: 146 x/minute.
VT: portio soft, medial, effacement 75%, dilatation (-), cephalic presentation, H II, amniotic
Follow UP
membrane and denominator could not be evaluated
July 20th
A: G1P0A1 37 weeks gestational age not in labor + severe preeclampsia SLF cephalic
2018 at
presentation
10.00 AM
P:
• Cervical ripening with Misoprostol 25mcq / 6 hours
• Plan for Vaginal Delivery
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 2x/10’/25’’, FHR: 139 x/minute.
VT: portio soft, medial, effacement 100%, dilatation 1 cm, cephalic presentation, H II,
Follow UP
amniotic membrane (+) denominator could not be evaluated
July 20th
A: G1P0A1 37 weeks gestational age inlabor first stage laten phase + severe preeclampsia SLF
2018 at
cephalic presentation
12.00 PM
P:
• Augmentation with Oxytocin drips 9
• Plan for Vaginal Delivery
 Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 2x/10’/25’’, FHR: 152 x/minute.
VT: portio soft, anterior, effacement 100%, dilatation 2 cm, cephalic presentation, H II,
Follow UP
amniotic membrane (+) denominator transverse saggital suture
July 20th
A: G1P0A1 37 weeks gestational age inlabor first stage laten phase + severe preeclampsia SLF
2018 at
cephalic presentation
02.00 PM
P:
• Augmentation with Oxytocin drips
• Plan for Vaginal Delivery
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 2x/10’/30’’, FHR: 142 x/minute.
VT: portio soft, anterior, effacement 100%, dilatation 3 cm, cephalic presentation, H II-III,
Follow UP
amniotic membrane (+) denominator right occiput
July 20th
A: G1P0A1 37 weeks gestational age inlabor first stage laten phase + severe preeclampsia SLF
2018 at
cephalic presentation
04.00 PM
P:
• Augmentation with Oxytocin drips
• Plan for Vaginal Delivery
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 3x/10’/30’’, FHR: 142 x/minute.
VT: portio soft, anterior, effacement 100%, dilatation 4 cm, cephalic presentation, H II-III,
Follow UP
amniotic membrane (+) denominator right anterior occiput
July 20th
A: G1P0A1 37 weeks gestational age inlabor first stage active phase + severe preeclampsia SLF
2018 at
cephalic presentation
06.00 PM
P:
• Augmentation with Oxytocin drips 10
• Plan for Vaginal Delivery
 Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 3x/10’/30’’, FHR: 142 x/minute.
VT: portio soft, anterior, effacement 100%, dilatation 5 cm, cephalic presentation, H II-III,
Follow UP
amniotic membrane (-),clear, odorless, denominator right anterior occiput
July 20th
A: G1P0A1 37 weeks gestational age inlabor first stage active phase with severe preeclampsia
2018 at
SLF cephalic presentation
08.00 PM
P:
• Augmentation with Oxytocin drips
• Plan for Vaginal Delivery
Palpation: Uterine fundus 3 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 3x/10’/35’’, FHR: 142 x/minute.
Follow UP VT: unpalpable portio, full dilatation, amniotic membrane (-) denominator anterior occiput
July 20th A: G1P0A1 37 weeks gestational age inlabor second stage with severe preeclampsia SLF
2018 at cephalic presentation
10.30 PM P:
• Episiotomy mediolateral
• Conduct the labor
Labor 23.00 PM Female life baby was born, BW 2750g, BL 47 cm, A/S 8/9 FTAGA
Report 23.10 PM Placenta delivered completely, PW: 450 gram, UCL 45 cm, Ø 17x18 cm
Juli 20th
2018 Dx: P1A0 post spontaneous delivery with severe preeclampsia
Follow Up Patient was stable in ward

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 Mrs. SUS / 31 y.o. / RA / AW
July 20th 2018 at 09.00 PM
Chief complain Aterm pregnancy with high blood pressure
Since 4 hours before admitted RSMH hospitals, patient told uterine contraction (+)
regularly, H/ of amniotic leakage (-). H/ of bloody show (+). H/ of high blood pressure
History before pregnancy (-). H/ of blurred sight (-). H/ of vomiting (-). H/ of epigastric pain (-).
She went to midwife and referred to Moh. Hoesin Hospital. She admitted her
pregnancy was full term and fetal movement (+)
Marital status 1x, 9 years.
Reproduction Menarche since 13 yo, regular 28-day cycle, lasts 5 days, LMP: 10-10-2017
1. 2011, male, aterm, 3500g, spontaneous delivery, midwife, healthy.
Obstetric history 2. 2014, female, aterm, 2900g, spontaneous delivery, midwife, healthy.
3. Current pregnancy
General Exam BP: 140/90 mmHg, HR: 97 x/m, T: 36.4oC, RR: 20 x/m, BW: 87kg, BH: 158cm
Palpation: Uterine fundus 2 fingers below xyphoid process (35 cm), right longitudinal
Obstetrical lie, cephalic presentation, U 3/5, uterine contraction 4x/10’/40’’, FHR: 146 x/minute,
Examination EFW: 3720g
IG 4 VT: portio soft, anterior, effacement 100%, dilatation 9 cm, cephalic presentation, H
III, amniotic membrane (+), denominator right anterior occiput
HB: 11.9, WBC: 10.800, PLT: 403.000, OT/PT: 19/9, Alb: 3.4, LDH: 214, Ur: 9, Cr: 0.51,
Laboratorium Exam
UA: 4.4, Prot (++)
 G3P2A0 38 weeks gestational age inlabor first stage active phase with severe
Diagnosis
preeclampsia SLF cephalic presentation
Stabilization
Observation of vital signs, FHR, contraction, signs of labor
IVFD RL xx drops/minute
Dwelling catheter
Therapy Nifedipine 10 mg/8 hours PO
MgSO4 40% ~ Protocol IM
Evaluation with gestosis index
Consult Internal Medicne Department and Ophthalmology Department
P/ Vaginal Delivery
A/Gestational hypertention
Interne Department
P/Methyldopa 250mg/8 hours
Ophtalmology A/No sign of choroidopathy and retinopathy hypetension
Department P/ Re-counsul if decrease of vision
23.00 PM Female life baby was born, BW 3700g, BL 48 cm, A/S 8/9 FTAGA
Labor Report 23.10 PM Placenta delivered completely, PW: 650 gram, UCL 50 cm, Ø 19 x 20 cm
Juli 20th 2018
Dx: P1A0 post spontaneous delivery with severe preeclampsia
Follow Up Patient was stable in ward

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 Mrs. MIR / 25 y.o. / UA / AW
July 21th 2018 at 02.40 AM
Chief complain Preterm pregnancy inlabor with breech presentation
Since 5 hours before admitted to the hospital, patient told of contraction (+), bloody
show (+), amniotic leakage (-), leukhorea (-), trauma (-), massage on abdomen (-),
History
post coital (-), toothache (-), fever (-). Patient go to midwife and referred to RSMH.
Patient realized that she has preterm gestational and fetal movement (+).
Marital status 1x, 1 years
Reproduction Menarche since 12 yo, regular cycle 28 days, 5 days, LMP forget
1. 2017, abortion, not curretage
Obstetric history
2. This pregnancy
General Exam BP: 120/80 mmHg, P: 88x/min, T: 36.5C, RR: 20 x/min, Weight 150 kg, Height 53 cm
Inspection: Fundal height ½ umbilical - proc. xypoideus (27 cm), longitudinal, right
Obstetrical
back, breech w, contraction 4x/10’/40’’, FHR 158 x/m, EFW 2495g
Examination
VT: portio was unpalpable, Ø full dilatation, amniotic membran (-), clear, odorless,
breech at lower spina ichiadica, denominator right sacrum.
Diagnosis G2P0A1 34 weeks gestational age inlabor second stage SLF breech presentation
 • Vital sign observation, contraction, FHR
• IVFD RL xx/ minute
Therapy
• Empty the bladder
• Conduct the labor
02.50 AM Female life baby was born, BW 2200g, BL 48 cm, A/S 8/9 PTAGA
02.55 AM Placenta delivered completely, PW: 380 gram, UCL 45 cm, Ø 17x18 cm
Labor Report
Dx: P1A1 post Bracht Manuevre
Follow Up Patient was stable in ward

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 Mrs. DES / 24 y.o. / UA / AW
July 21th 2018 at 04.00 AM
Chief complain preterm pregnancy with abdominal contraction
Since 3 hours before admitted to the hospital, patient told that the abdominal was
contraction (+) irregular, bloody show (-), amnionic leakage (-), fluor albus (+), trauma
History (-), massage on abdomen (-), post coital (-), tooth or skin infection (-), fever (-),
consuming medications or potions(-). She came to ER RSMH hospital. Patient realized
that she has preterm gestational of age and fetal movement (+).
Marital status 1x, 2,5 years
Reproduction Menarche since 13 yo, regular cycle 28 days, 3-5 days, LMP December 2017
1. 2016, Male, 2000g, preterm, spontaneous delivery, midwife, healthy
Obstetric history
2. This pregnancy
General Exam BP: 120/70mmHg, P: 82x/min, T: 36.5C, RR: 18x/min, Weight 55kg, Height 156cm
Inspection: Fundal height 4 fingers bellow proc. xypoideus (24cm), longitudinal, left
Obstetrical
back, U 5/5 contraction 2x/10’/10’’, FHR 143 x/m, EFW 1860g
Examination
Inspeculo: portio livide, oue closed, fluor (+), fluxus (-), e/l/p (-)
IT 1
VT: portio soft, posterior, eff 0%, Ø closed, amniotic membran and denominator cant
be assed yet.
Laboratorium Exam Hb 11,2 g/ dL, WBC 18800, PLT :458.000
 - Single life fetus cephalic presentation
- Fetal Biometry: BPD 8.78 cm AC 29.20 cm EFW 2342 g
HC 30.71 cm FL 6.37 cm
USG ER (KAI)
- Placenta at corpus anterior of uterine
- Amniotic fluid was enough, SDP: 2.89 cm
C/ 34 weeks of gestational age, SLF cephalic presentation.
Diagnosis G2P1A0 34 weeks gestational age with threatened preterm labor SLF cephalic presentation
• Vital sign observation, contraction, FHR
• IVFD RL xx/ minute
• Conservative management
• Lab examination
Therapy
• Inj. Dexametashone 6mg / 12 hours IV
• Nipedipin 10mg / 6 hours PO
• Plan Vaginal Swab
• Plan for US confirmation
Follow Up Patient was stable in delivery room

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 Mrs. EMA / 36 y.o. / RA / AW
July 21th 2018 at 12.00 AM
Chief complain Aterm pregnancy with high blood pressure
Since 4 hours before admitted RSMH hospitals, patient told uterine contraction (+)
regularly, H/ of amniotic leakage (+). H/ of bloody show (+). H/ of high blood pressure
History before pregnancy (-). H/ of blurred sight (-). H/ of vomiting (-). H/ of epigastric pain (-).
She went to midwife and referred to Moh. Hoesin Hospital. She admitted her
pregnancy was full term and fetal movement (+)
Marital status 1x, 17 years.
Reproduction Menarche since 13 yo, regular 28-day cycle, lasts 5 days, LMP: 05-11-2017
1. 2002, male, aterm, 2700g, spontaneous delivery, midwife, pass away 3 day’s life
2. 2003, female, aterm, 2700g, spontaneous delivery, traditional birth attendant, healthy.
Obstetric history 3. 2008, female, aterm, 3000g, spontaneous delivery, traditional birth attendant, healthy.
4. 2012, female, aterm, 2700g, spontaneous delivery, traditional birth attendant, healthy.
5. Current pregnancy
General Exam BP: 150/90 mmHg, HR: 97 x/m, T: 36.4oC, RR: 20 x/m, BW: 54kg, BH: 150cm
Palpation: Uterine fundus 2 fingers below xyphoid process (31 cm), right longitudinal
Obstetrical lie, cephalic presentation, U 4/5, uterine contraction 3x/10’/40’’, FHR: 146 x/minute,
Examination EFW: 3720g
IG 5 VT: portio soft, anterior, effacement 100%, dilatation 4 cm, cephalic presentation, H
III, amniotic membrane (-), denominator right occiput
 HB: 11.9, WBC: 10.800, PLT: 403.000, OT/PT: 19/9, Alb: 3.4, LDH: 214, Ur: 9, Cr: 0.51,
Laboratorium Exam
UA: 4.4, Prot (++)
G5P4A0 37 weeks gestational age inlabor first stage active phase with severe
Diagnosis
preeclampsia SLF cephalic presentation
Stabilization 3 hours
Observation of vital signs, FHR, contraction, signs of labor
IVFD RL xx drops/minute
Dwelling catheter
Therapy Nifedipine 10 mg/8 hours PO
MgSO4 40% ~ Protocol IM
Evaluation with gestosis index
Consult Internal Medicne Department and Ophthalmology Department
P/ Vaginal Delivery
A/Gestational hypertention
Interne Department
P/Methyldopa 250mg/8 hours
Ophtalmology A/No sign of choroidopathy and retinopathy hypetension
Department P/ Re-counsul if decrease of vision

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 Palpation: Uterine fundus 2 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 4x/10’/45’’, FHR: 146 x/minute, EFW: 3720g
Follow UP VT: portio soft, anterior, effacement 100%, dilatation 7 cm, cephalic presentation, H III,
July 21th amniotic membrane (-), denominator right occiput
2018 at A: G5P4A0 37 weeks gestational age inlabor first stage active phase with severe preeclampsia
03.00 AM SLF cephalic presentation
P:
• Plan for Vaginal Delivery
Palpation: Uterine fundus 2 fingers below xyphoid process (31 cm), right longitudinal lie,
cephalic presentation, U 4/5, uterine contraction 4x/10’/45’’, FHR: 146 x/minute, EFW: 3720g
Follow UP VT: portio soft, anterior, effacement 100%, dilatation 7 cm, cephalic presentation, H III,
July 21th amniotic membrane (-), denominator right occiput
2018 at A: G5P4A0 37 weeks gestational age inlabor second stage with severe preeclampsia SLF
05.00 AM cephalic presentation
P:
• Conduct the labor
Labor 05.05 AM Female life baby was born, BW 2950g, BL 46 cm, A/S 8/9 FTAGA
Report 05.10 AM Placenta delivered completely, PW: 450 gram, UCL 45 cm, Ø 17x18 cm
Juli 21th
2018 Dx: P5A0 post spontaneous delivery with severe preeclampsia

Follow Up Patient was stable in ward

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 Mrs. LET / 41 y.o. / UA / AW
July 20th 2018 at 06.00 PM
Chief complain Early pregnancy with vaginal bleeding
Since 11 days ago patient complain about vaginal bleeding, 1x change pad, dark blood
(+), fish eye appearance (-), clotting (+), vomitting (+), trauma (-), massage on
History abdominal (-), traditional medicine (-), post coital (-), tense of breast (+), and patient
come to OBGYN and refers to RSMH. Patient go to history of late mentruation (+)
since 3 month ago.
Marital status 1x, 15 years
Past iIlness history Was diagnosed Bronchial Asthma since 35 y.o.
Reproduction Menarche, 13 yo, regular cycle 28 days, 7 days, LMP May 5th 2018
1. 2004, male, aterm, 2400g, spontaneous delivery, midwife, healthy
2. 2009, female, aterm, 2500g, spontaneous delivery, midwife, healthy
Obstetric history
3. 2016, abortion, 2 months, not curettage
4. This pregnancy
General Exam BP: 120/70 mmHg, P: 84 x/min, T: 36.5C, RR: 20 x/min, Weight 57 kg, Height 142 cm
Inspection: abdomen was flat, symmetrical, uterine fundal height was not palpable,
Gynecological
mass (-), free fluid sign (-), pain (-)
Examination
Speculum Examination: portio was livide, OUE was opened 1 cm, there is mass in
OUE, flour (-), fluxus (+), blood doesn’t active, E/L/P (-)
Laboratorium Exam Hb 8.3, WBC: 7.200, PLT: 396.000, HT: 26
 Incomplete Abortion + suspect of Malignancy Breast Tumor Sinistra + suspect of
Diagnosis
Metastases coxae bone + moderate anemia
• Vital sign observation, bleeding
• IVFD RL drops XX / minute
• Inj Ceftriaxshon 1gr / 12 hours IV
Therapy • Lab examination
• Informed consent
• Curettage
• Assess Surgeon, Anesthesia,
• Uterus AF 7 cm
Operation Report
• There is blood 50 cc. and mass 50 cc
Surgeon A/No sign of Breast Tumor
Department P/ US Breast
Follow Up Patient was Stable in Ward

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 Mrs. TRI / 62 y.o. / RA / AT
July 20th at 04.00 PM
Chief complain Vaginal bleeding
History Since 6 months ago, patient complained vaginal bleeding , brownish (+), 1x/day
changing napkins, leucorrhea (-) mass in abdominal (-). Since 1 months ago, patient
complained vaginal bleeding and worsening, mass (+), pain (+), exhausted (+). Since 4
days ago, condition patient become worsen, patient go to pertamina hospital and
referred to Prabumulih Hospital and was US by OBGYN, conclusion was malignancy in
cervix. And patient was referred to RSMH
Marital status 1x, 40 years
Reproduction P5A0
Obstetric history Menopausal periode since 3 months ago
Gynecological Inspection and Palpation: Abdomen Convex, symmetrical and non tense abdominal,
Examination mass (+) upper was umbilical, lower was pubic simpisis, right at midclavicula dextra, left
at midclavicula sinistra,free fluid sign (-).
BP: 110/60 mmHg Inspeculo: Portio was retracted, OUE was opened, fluor (-), fluxus (+) blood but didn’t
P: 80x/min active, E/L/P (-)
T: 36.5 C VT: Elastic portio, OUE was opened, right & left AP were tense, CUT ~ 20 weeks,
RR: 18 x/min Douglas cavity wasn’t protrusion
RT: TSA was good, slippery mucous, ampula recti was empty, MIL (-), Douglas cavity
wasn’t protrusion
US ER (KAI) C/ suspect of malignancy in uterine cavity + hydronefrosis dextra + minimum ascites
Laboratorium Hb: 3.5 WBC: 9500 Ht: 10 PLT: 333.000 OT/PT: 45/8 Ur: 143, Cr: 9.9 Ca 8 Na 114 K 8.7
Diagnose Suspect of Endometrial Cancer + Severe Anemia + Haematuria
Therapy Obs vital sign, bleeding
IVFD RL gtt xx/m
Lab exam (DR, KM, CM)
Inj. Ceftriaxone 1 g /12 hours IV
Inj. Ondansentron 8mg / 8 hours IV
Inj Tranexamat Acid 500mg / 8 hours IV
Plan for blood tranfusion
Plan for surgical stagging
Pronalgest Suppose
Assess Interne and Surgeon
Follow Up Patient was stable in ward