DUTY REPORT

Friday, January 4th 2019, 03.30 PM to

Saturday, January 5th 2019, 07.00 AM
Consultant on Duty :
Dr. H. Iskandar Zulqarnain, SpOG(K)

Resident on Duty :
Obstetrical chief : Dr. Rakhmad Hidayat
Gynecological chief : Dr. Arief Krisnadhi P
Dr. Fitrah Tindar Atthaariq
Dr. Dwi Antono Dahlan
Dr. Riyan Wira Pratama
Dr. Aprian Ilhami
Dr. Excellena
Dr. Fitria Koeshardani
Dr. Ines Wijaya
Dr. Wadhit Taubah
Dr. M. Atthaariq Prasetiyo
Dr. Sonia Prima Arisa Putri
1
 Duty Report
Friday, January 4th 2019, 03.30 PM to
Saturday, January 5th 2019, 07.00 AM

• Physiologic obstetrical patient : 1 case

• Pathologic obstetrical patient : 4 cases
• Gynecological patient : 2 cases
• Passed Away : - case
Total patients : 7 cases

• Obstetric ward patients : 27 patients

• Gynecology and Oncology ward patients : 43 patients
• ICU / HCU/ P1 patient : 2/-/- patients
Total patients : 71 patients

2
Obstetric Patients
No Identity Diagnosis ICD 10 Procedure ICD 9

G4P2A1 36 weeks gestational age not

Mrs. WAN/ O42.113 • Tocolytic
1 inlabor with APH cb. Total Placenta Previa + 74.1
36/RA/IZ O41.0 • US confirmation
prior CS 2x SLF transverse lie

• Stabilization
• Observed VS, FHR
• Consult to
Internal,
Ophtalmology
G2P1A0 42 weeks of gestational age in labor Department
Mrs. YUN / 27 1st stage active phase with severe • anticonvulsant
2 O14.13 650
yo/ RA/ IZ preeclampsia + moderate anemia SLF • Urine
cephalic presentation Catheterization
• antihypertension
• Evaluation ~
gestosis task
• vaginal delivery
No Identity Diagnosis ICD 10 Procedure ICD 9

• Obs. VS,
contraction, FHR
G4P1A2 37 weeks gestational age not • Tocolytic
Mrs. inlabor with prior CS 1x (oi APH ec TPP) • Plan for US
O44.1
3 RUM/38/RA/I + Total Placenta Previa dd/ tumor previa confirmation -
O34.1
Z ec myom uterine SLF cephalic • plan for
presentation abdominal
termination

• Stabilization
• Consult to
Internal,
G2P1A0 37 weeks of gestational age in Ophtalmology
Mrs. YUL/ 34 labor 1st stage active phase with Department
4 O13.3 650
yo/ UA/ IZ gestational hypertension SLF cephalic • anticonvulsant
presentation • Antihypertension
• Evaluation
gestosis task
• Vaginal delivery
Gynecology
Patients
No. Identity Diagnosis ICD 10 Procedure ICD 9
• Observed VS
• Surgery and
internal dept.
Cervical cancer stg IVA + bilateral
Mrs.WAN/56 assesment
1 hydronephrosis + post right C53.9 -
yo/RA • analgetic
nephrostomy
• Plan for
abdominal CT
scan
• Observed VS
• Leucogen inj.
Mrs.MUL/40 Cervical cancer stg IB2 post radical • Plan for TC
2 C53.9 99.2
yo/UA hysterectomy + leucophenia transfusion
• Plan for
chemotherapy
Obstetric Patients
Identity Mrs. WAN/36/RA/IZ JANUARY, 4TH 2019 6.30 PM
Chief complain Preterm pregnancy with vaginal bleeding

History 14 hours before admission, patient complain for vaginal bleeding(+) 2x change pads,
reddish color. abdominal contraction (+) irregularly. History of amniotic leakage (-)
History of trauma (-), history of leucorrhea (-), history of post coital (-), traditional
herbal drink (-), traditional massage at abdominal (+) 1 weeks ago, fever(-). Patient
went to Kayu Agung hospital and diagnosed with aterm pregnancy and total placenta
previa
Patient admitted that her pregnancy was preterm and fetal movement (+)
Marital status 1x, 11 years

Reproduction status Menarche since 14 yo, irregular cycle, LMP : forgot

Obstetric history 1. 2011. Abortion. 8 weeks. Curettage. Kayu Agung hospital
2. 2013. female. 3000 g. CS oi transverse lie. Kayu Agung hospital. Healthy
3. 2014. female. 3200 g. CS oi prior CS 1x + interdelivery. Kayu Agung hospital. Healthy
4. This pregnancy
Physical Examination BP : 110/70 mmHg, P : 80 x/min, T : 36.5 C, RR : 20 x/min

Obstetrical Palpation : Uterine fundal palpable 4 fingers below proc. Xypoideus (26 cm), transverse
examination lie, dorsoinferior, head on the left, 5/5 , contraction (1x/10’/10”), FHR 151x/m
Inspeculo : portio livide, OUE closed , Fluor (-), fluxus (+) not active bleeding, E/L/P (-)
VT: not performed

Lab Examination Hb: 11.5 g/dL, WBC: 11.100/mm3, PLT: 181.000/mm3 Ht 35% 9
4/1/2019
Identity
US ER -Single life fetus transverse lie
FTA - Fetal Biometry: BPD 8.56 cm AC 32.61 cm EFW : 2994 g
4/1/2019 HC 31.02cm FL 7.28 cm
- Placenta at posterior corpus, covered OUI
- Amnionic fluid sufficient, SDP 3.25 cm
-C/ 36 weeks gestational age with placenta covered OUI SLF transverse lie
Diagnosis G4P2A1 36 weeks gestational age not in labor with APH cb. Total Placenta Previa + prior CS
2x SLF transverse lie
Therapy Expectative
Obs. Vital sign, contraction, fetal heart rate, bleeding
IVFD RL xx drops/m
Nifedipine 10mg/ 6 hours PO
Proterin drip 2 amp in D5% 500cc xxv dpm
Anesthesiology assessment
Consult to oncology division
Plan for US confirmation
US Confirmation -Single life fetus transverse lie
PB - Fetal Biometry: BPD 8.50 cm AC 30.93 cm EFW : 2551 g
7/1/2019 HC 31.26 cm FL 6.87 cm
- Placenta at posterior corpus, covered OUI
- Amnionic fluid sufficient, SDP 4.7 cm
-Clear zone (+)
-C/ 35 weeks gestational age with placenta covered OUI SLF transverse lie
10
-No sign of placente acreta
 Identity Mrs. YUN / 27 yo/ RA/ IZ JANUARY, 4TH 2019 7.30 PM
Chief complaint in labor with high blood pressure
History ± 12 hour before admission, patient complained about History of abdominal contraction (+),
bloody show (+), amniotic leakage (-) History of hypertension this pregnancy (+), history of
hypertension before pregnancy (-), history of hypertension in prior pregnancy (-) history hypertension
on family (-), headache (-), vomit and nausea (-), blurry vision (-), epigastric pain (-). Patient went to
Banyuasin hospital and then referred to Moh Hoesin Hospital.
Patient admit that her pregnancy is fullterm and still feel the movement of the fetus.

Marital status 1x, 3 years

Reproduction status Menarche since 14 y.o, regular, LMP: 10-03-2018

Obstetric history 1. 2017, female, 2800 g, spontaneous delivery, midwife, healthy
2. This pregnancy
Physical examination BP : 160/100 mmHg, P : 88x/min, T : 36.5 C, RR : 20 x/min
Obstetrical Palpation : Fundal height was 2 fingers below proc. xyphoideus (34 cm), longitudinal lie, left back,
examination head, 3/5, uterine contraction (3x/10’/10”), FHR : 121x/m, EFW: 3410 g
GI : 6
VT: portio soft, anterior, eff 100%,∅ 7 cm, head, amniotic membrane (-) and denominator right
anterior occiput

Laboratory Hb: 7.7 g/dl WBC: 14.200 PLT: 455.000 Ht: 28% Total bilirubin 0.70 SGOT 16 SGPT 6 LDH 305 Ca
8.0 Mg 3.7 Na 143 K 3.9
 US (ER) • Single life fetus chepalic presentation
FTA • BPD: 9.1 cm HC: 32.62. cm AC: 34.81 cm FL: 7.36 cm EFW: 3481 grams
• Placenta at anterior corpus
• Amniotic volume sufficient, SDP 2.5 cm
37 weeks gestastional age cephalic presentation
Diagnosis G2P1A0 42 weeks of gestational age in labor 1st stage active phase with severe preeclampsia +
moderate anemia SLF cephalic presentation

Therapy • Stabilization 1-3 hours

• Observed vital sign, FHR
• IVFD RL xx dpm
• Active management
• Consult to Internal Department, Ophtalmology Department, Anesthesia Department
• O2 3L/m
• MgSO4 40% ~ protocol
• Urine Catheterization, fluid balance monitoring
• Nifedipine 10mg/ 6 hours per oral
• Evaluation ~ gestosis task
• Informed consent
• Plan for vaginal delivery
 Follow Up • BP : 140/90 mmHg, P : 88x/min, T : 36.5 C, RR : 20 x/min
10.30 PM • Palpation : Fundal height was 2 fingers below proc. xyphoideus (34 cm), longitudinal lie, left
Post Stabilization back, head, 3/5, uterine contraction (3x/10’/35”), FHR : 121x/m, EFW: 3410 gr
GI 4 • Internist Assesment : Hypertension in pregnancy
Advice : Metil Dopa 3 x 500 mg
• Ophtalmologist Assesment : No sign of retinopathy hypertension
Advice :
Delivery report 00.45 AM Male life baby was born BW 2900 g BL 49 cm AS 5/6 FTAGA
5/1/2019 00.50 AM Placenta was delivered completely PW 500 g UCL 45 cm Ø 19x18 cm
Identity Mrs. RUM/38/RA/IZ JANUARY, 5TH 2019 00.00 AM
Chief complain Fullterm pregnancy with prior CS 1x

History 6 hours before admission, patient complain about abdominal contraction (+) regularly.
History of amniotic leakage (-) bloody show (-), History of trauma (-), history of
leucorrhea (-), history of post coital (-) traditional massage in abdominal (-).
Patient admitted that her pregnancy was aterm and fetal movement (+)
Marital status 1x, 4 years

Reproduction status Menarche since 14 yo, regular cycle, 28 days, LMP : 10-04-2018
Obstetric history 1. 2016. Abortion. 8 weeks. Not Curettage.
2. 2017. abortion. 18 weeks. Curettage. Muhammadiyah Hospital
3. 2017. female. 2700gr. CS oi total placenta previa. Muhammadiyah hospital. Healthy
4. This pregnancy
Physical Examination BP : 120/80 mmHg, P : 88 x/min, T : 36.5 C, RR : 20 x/min

Obstetrical Palpation : Uterine fundal palpable 3 fingers below proc. Xypoideus (32 cm),
examination longitudinal lie, right back, 5/5 , contraction (1x/10’/10”), FHR 142x/m EFW 2945gr
Inspeculo : portio livide, OUE closed , Fluor (-), fluxus (-) E/L/P (-)
VT: not performed

Lab Examination Hb: 13.5 g/dL, WBC: 12400/mm3, PLT: 146.000/mm3 Ht 39%
4/1/2019

22
Identity
US ER -Single life fetus cephalic presentation
FTA - Fetal Biometry: BPD 8.68 cm AC 32.14 cm EFW : 2974 g
5/1/2019 HC 35.2cm FL 7.36 cm
- Placenta at posterior corpus, covered OUI
- Amniotic fluid sufficient
- there is a hypoechoic mass on low uterine segment with feeding artery (+), uterine myom
was suspected
-C/ 37 weeks gestational age with placenta covered OUI SLF cephalic presentation
Diagnosis G4P1A2 37 weeks gestational age not inlabor with prior CS 1x (oi APH ec TPP) + Total
Placenta Previa dd/ tumor previa ec myom uterine SLF cephalic presentation
Therapy Obs. Vital sign, contraction, fetal heart rate
IVFD RL xx drops/m
Nifedipine 10mg/ 6 hours PO
Plan for US confirmation
plan for abdominal termination
US confirmation -Single life fetus cephalic presentation
PB - Fetal Biometry: BPD 8.32 cm AC 30.77 cm EFW : 2675 g
7/1/2019 HC 29.8 cm FL 7.10 cm
- Placenta at anterior corpus, covered OUI
- Amniotic fluid sufficient SDP 4.55 cm
- there is a hypoechoic mass on posterior corpus with feeding artery (+), uterine myom was
suspected
-C/ 37 weeks gestational age with total placenta previa + uterine myom at posterior corpus
SLF cephalic presentation 23
Advice : caesarean section on obstetric indication
 Identity Mrs. YUL/ 34 yo/ UA/ IZ JANUARY, 5TH 2019 5.00 AM
Chief complain in labor with high blood pressure
History ± 3 hour before admission, patient complained about History of abdominal contraction (+), bloody
show (+), amniotic leakage (-) History of hypertension this pregnancy (-), history of hypertension
before pregnancy (-), history of hypertension in prior pregnancy (-) history hypertension on family (-),
headache (-), vomit and nausea (-), blurry vision (-), epigastric pain (-).
Patient admit that her pregnancy is fullterm and still feel the movement of the fetus.

Marital status 1x, 5 years

Reproduction status Menarche since 14 y.o, irregular cycle, LMP: forgot

Obstetric history 1. 2014, female, 3500, spontaneous delivery, Siti chodijah hospital, healthy
2. This pregnancy
Physical examination BP : 140/90 mmHg, P : 88x/min, T : 36.5 C, RR : 20 x/min BW 56 kg BH 150 cm
Obstetrical Palpation : Fundal height was 3 fingers below proc. xyphoideus (34 cm), longitudinal lie, right back,
examination head, 4/5, uterine contraction (3x/10’/30”), FHR : 128x/m, EFW: 3410 gr

VT: portio soft, anterior, eff 100%,∅ 5 cm, head, amniotic membrane (+), HII and denominator right
anterior occiput

Laboratory Hb: 12.2 g/dl WBC: 11.200 PLT: 347.000. Ht: 37% Total bilirubin 0.50
result
 US (ER) • Single life fetus chepalic presentation
FTA • BPD: 9.35 cm HC: 32.77 cm AC: 32.69 cm FL: 7.47 cm EFW: 3155 grams
• Placenta at anterior corpus
• Amniotic volume sufficient
C/ 37 weeks gestastional age cephalic presentation
Diagnosis G2P1A0 37 weeks of gestational age in labor 1st stage active phase with gestational hypertension SLF
cephalic presentation

Therapy • Stabilization
• Observed vital sign, FHR
• IVFD RL xx dpm
• Laboratory test
• Urine chateterization
• Nifedipine 10mg/ 6 hours per oral
• MgSO4~protocols
• Evaluation gestosis task
• Assesment of Internal and ophthalmology department
• Informed consent
• Plan for vaginal delivery
Delivery report 08.40 AM Male life baby was born BW 3500 g BL 53 cm AS 8/9 FTAGA
5/1/2019 08.50 AM Placentae was delivered completely PW 600 g UCL 45 cm Ø 19x18 cm
Gynecology
Patients
 Identity Mrs.WAN/56 yo/RA JANUARY, 4TH 2019 5.30 PM

Chief complain Abdominal enlargement

History 3 months before admission, patient complained about abdominal enlargement.

Abdominal pain (+), dyspareunia (-), post coital bleeding (+). History f vaginal
bleeding (+). Defecation within normal limit. Abnormal mixturition. Food and
drink consumption was decrease since 5 days ago. Patient went to belitang
hospital and then referred to moh. Hoesin hospital
Previous illness • Post biopsy (10/11/2018) PA result : 4802/A/2018/ C/ atypical cells on the
cervix
• Hospitalized in moh. Hoesin Hospital (21/11/2018) diagnosed with cervical
cancer std IV was suspected + post nephrostomy

Marital status 1x, 38 years

Obstetric P4A0
history

Physical E4M6V5, BP : 110/70 mmHg, P : 90 x/min, T : 36.5 C, RR : 20 x/min

examination
 Identity Mrs.WAN/56 yo/RA
Gynecology Inspection & Palpation : Abdominal convex, tense, symmetric, Fundal height
examination unpalpable, there was a nephrostomy tube. mass (-), tenderness (+), free fluid
sign (+), shifting dullness (+)
Inspeculo : patient refuse to get examined
VT : patient refuse to get examined
RT : patient refuse to get examined
US ER  Uterine size and shape within normal limit, 6.52x9.98 in size
FTA  There was an irregular mass on cervix -> cervical malignancy was suspected
 There was an hypoechoic mass on bladder -> metastatic process was
suspected
 There was pelvicocalycheal enlargement in both kidney, bilateral
hydronephrosis was suspected
C/ cervical malignancy was suspected + metestatic process in bladder was
suspected + bilateral hydronephrosis
Laboratory Hb 12 g/dL, WBC 14.200/mm3, Ht 34%, PLT 137.000/mm3 Total bilirubin 0.70
Examination SGOT/SGPT 78/41 ur/cr 135/4.61 Na 132 K 8.0

Diagnosis Cervical cancer stg IVA + bilateral hydronephrosis + post right nephrostomy

Therapy • Observed of vital signs and bleeding

• IVFD RL xx titration/min
• Surgery and internal dept. assesment
• Pronalges supp (prn)
• Plan for abdominal CT scan (9/1/2019)
 Identity Mrs.MUL/40 yo/UA JANUARY, 4TH 2019 4.30 PM

Chief complain for chemotherapy

History Patient was referred to oncology outpatient with diagnosed cervical cancer std
IB2 + post radical hysterectomy. Patient was suggested to hospitalize for general
condition improvement and to get chemotherapy (paclitaxel – carboplatin) third
series. History of radical hysterectomy oi cervical cancer std IB2 (23/10/2018)
with PA result 4535/A/2018 c/ keratinizing cervical cancer of squamous cell and
invading vaginal cuff, miocervix, uterine corpus, parametrium, and left pelvic
lymph nodes. There is no abnormality on both fallopian tube.
Previous illness • History of pacli-carbo chemotherapy
• 1st series : 20-1-2018
• 2nd series (17/12/2018)
Marital status 1x, 20 years
Obstetric P3A1
history

Physical E4M6V5, BP : 120/70 mmHg, P : 90 x/min, T : 36.5 C, RR : 20 x/min

examination
 Identity Mrs.MUL/40 yo/UA
Gynecology Inspection & Palpation : Abdominal flat, symmetric, Fundal height unpalpable,.
examination mass (-), tenderness (-), free fluid sign (-)
Inspeculo : vaginal cuff was normal
VT : vaginal cuff was normal
RT : anal spinchter was normal, normal mucous, empty ampula recti, intralumen
mass (-), No protruded douglas pouch
US ER  Nonvisualized Uterine and both ovarium ~ post TAHSOB
FTA  Liver and both kidney was normal
 C/ there is no abnormality in internal genital organ
Laboratory Hb 10.1 g/dL, WBC 3700/mm3, PLT 125.000/µL SGOT/SGPT 27/30 albumin 4.2
Examination
4/1/2019
Diagnosis Cervical cancer stg IB2 post radical hysterectomy + leucophenia

Therapy • Observed of vital signs

• IVFD RL xx titration/min
• Leucogen 1 vial SC
• Plan for TC transfusion
• Plan for chemotherapy paclitaxel – carboplatin 3rd series