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    pagi klinik

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    Muhammad Fariz Saleh

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    pagi klinik

    Uploaded by

    Muhammad Fariz Saleh
    0 views17 pages

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    0 views17 pages

    pagi klinik

    Uploaded by

    Muhammad Fariz Saleh

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    You are on page 1of 17

    DUTY REPORT

    Wednesday, January 3rd 2019

    Supervisor :
    dr. Letta S. Lintang, M.Ked(OG), SpOG(K)

    Residents :
    1. dr. M. Gamal Darus
    2. dr. T. Amru Umara
    3. dr. Ivan C. Pasaribu
    4. dr. Alyuhaz
    5. dr. Andry H. Sipahutar

    Department of Obstetrics and Gynecology


    Medical Faculty of Universitas Sumatera Utara
    H. Adam Malik General Hospital
    2018
    NEW PATIENT : 1 PATIENTS
    1. Mrs. R 28 y.o, G2P1A0
    Diagnose : Inpartu + SG+IUP (39-40) weeks +head

    presentation+ alive fetus


    Planning : PX, DR, glucose test Random,

    ureum,kretinin,electrolyte, PT, APTT,HbsAg, HIV.

    Montitoreng progress of labor at


    labor unit in 3rd floor

    Consult to perinatology for


    childbirth assistance
    PATIENT 1
    Mrs. R. 28 y.o, G2P1A0, Javanese, Moslem, Senior High School,
    Housewife, Married to Mr. A, 26 y.o, Minangnese, Moslem, Junior
    High School, Enterpreneur. The patient was admitted to Adam
    Malik General Hospital on 24th January 2019, at 01.30 am with:

    Cc : Abdominal pain
    E : This has been experienced by the patient since 7 hours
    ago with accompany wit bloody mucus since 12 hours ago.
    History of amniotic fluid leakage (-). Defecation within normal
    limits.
    History of previous illness :-
    History of Medication :-
    History of Surgery :-
    LMP : 15/04/2018
    EDD : 22/01/2019
    ANC : Obstetrician 1 times and Midwife 5 time

    Obstetric History

    1. Male, preterm, 3900 gr, Spontaneous, Midwife, Clinic, 7 y.o, Healthy

    2. Current Pregnancy
    Vital Signs
    Cons : Alert Anemic : (-)
    BP : 120/80 mmHg Icteric : (-)
    Pulse : 82x/i Cyanosis : (-)
    RR : 19x/i Dypsnoe : (-)
    Temp : 36,7°C Edema : (-)
    Petechiae : (-)
    General state : Moderate
    Nutritional state : Good (BW: 50 kg, BL: 15 cm, BMI: 22)
    Illness State : Moderate

    Generalized State
    • Head : Inferior palpebra conj anemic (-), icteric (-)
    • Neck : Within normal limits
    • Thorax : Respiratory sound : vesiculer
    Additional sound : wheezing(-)/(-), rales (-)/(-)
    • Abdomen : Hepar and Lien no abnormality
    • Extremities sup/inf : Edema (-), Cyanosis (-)
    Obstetrical State :
    • Abdomen : symmetrically enlarged
    • Fundal Height : 3 finger on the umbilical (19 cm)
    • Movement : (+)
    • Uterine Contraction : (+)
    • FHR : (+) 122x/I
    Gynecology State :
    Inspeculo: Not performed
    VT : not performed
    Gloves : not performed
    TAS
    USG TAS
    - Singleton fetus, Head Persentation , alive fetus
    - Fetal movement (+), fetal heart rate (+), 121x/i
    - BPD : 9,01 cm
    - HC : 33,82cm
    - AC : 14,30 cm
    - FL : 3,592 cm

    Conclusion :
    IUP (40w3d) + alive fetus
    Laboratory Findings
    January, 3rd 2019
    • Hb :9,7 N: 12-14 gr/dL
    • Leukocyte : 8,67 N: 4.000-11.000/uL
    • Hematocrite : 31,70 N: 36,0-42,0/%
    • MCV : 83,6 N : 81-99
    • MCHC : 30,6 N : 31-37
    • Platelet : 254.000 N: 150.000-400.000/uL
    • Ureum : 10,4 N: 15-40 mg/dl
    • Creatinin : 0.5 N: 0.6-1.1 mg/dl
    • Glucose ad : 86 N: <200
    • APTT : 25,6 N: 27-39 s
    • PT+ INR : 14,2 N: 14s
    • TT : 13,7 N: 19,2s
    • Natrium : 140 N: 136-155 mmol/dl
    • Kalium : 3,72 N: 3.5-5.5 mmol/dl
    • Chlorida : 105 N: 95-103mmol/dl
    • HbsAg : Non Reactive N: Non Reactive
    Diagnose :
    Inpartu + SG+IUP (39-40) weeks

    Therapy :
    • IVFD RL  20 dpm

    Plan :
    • PX, DR, glucose test Random,
    ureum,kretinin,electrolyte, PT, APTT,HbsAg,
    HIV.
    • Montitoreng progress of labor at labor unit in 3rd floor
    • Consult to perinatology for childbirth assistance

    Reported to Supervisor on duty dr. Arvita Muriany T. Lubis,


    M.Ked(OG), SpOG(K)  approved
    THANK YOU

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