DUTY REPORT

Saturday, March 2nd 2019 07:00 AM - Sunday March 3th 2019 07:00 AM

Consultant on Duty :
dr. Awan Nurtjahyo, OBGYN (C)
Resident on Duty :
dr. Joko Prasanto (Obstetrical Chief)
dr. Santa Maria (Gynecological Chief)
dr. Veny Melinda
dr. Willyam Danles
dr. Uci Elisa
dr. Ceza Kautsar L
dr. Bagus Hilmawan
dr. Radinal Prayitno
dr. Sartika Nopradilova
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 Duty Report
Saturday, March 2nd 2019 07:00 AM - Sunday March 3th 2019 07:00 AM

• Physiologic obstetrical patient : 3 cases

• Pathologic obstetrical patient : 4 cases
• Gynecological patient : 3 cases
• Passed Away : 0 case
Total patients : 10 cases

• Obstetric ward patients : 48 patients

• Gynecology and Oncology ward patients : 33 patients
• P1/ HCU/ ICU patient : 3 patients
Total patients : 84 patients

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 Obstetrical Patients
NO Identity Diagnosis ICD 10 Previous Procedure ICD 9 Recent Diagnosis Condition
Mrs. EVI G4P3A0 39 weeks of O36.4 • Laboratory 650
st examination
33/UA/AW gestational age inlabor 1 P4A0 post
• Informed consent
stage active phase with spontaneous delivery Stable in
1 • TOLAC
Prior CS 1X (oi with prior CS 1x + IUD ward
anhydramnios) SLF cephalic insertion
presentation
G2P1A0 35 weeks O60.0 •Stabilization 650 P2A0 Post LSCS oi
gestational age not inlabor •MgSO4 40% protocol impending eclampsia not
with impending eclampsia •Antihypertension inlabor + IUD insertion
with prior CS 1X (oi Severe
Mrs. SEB •Gestosis Evaluation Stable in
2. Preeclampsia) + type II
34/UA/RK diabetes mellitus SLF • Consult to Internal an ward
cephalic presentation d Ophthalmology depa
rtment
•LSCS
 Obstetrical Patients
ICD ICD
No Identity Diagnosis Management Recent Diagnosis Condition
10 9
G2P1A0 37 weeks G2P1A0 37 weeks
gestational age not Stable in
gestational age not • O2 2L/m
ward
Mrs FIT inlabor with severe O36. • Laboratorium examination 69.0 inlabor with severe
3.
32/RA/AW anemia SLF cephalic 4 • PRC Transfusion 1 anemia SLF cephalic
presentation with • Consult to Internal department presentation with IUGR
IUGR
P1A0 Post LSCS oi Stable in
G1P0A0 40 weeks
anhydramnios ward
gestational age not • Informed consent
Mrs MAY
inlabor with PROM • Antibiotic
4 23/UA/AW • LSCS
12 hours SLF cephalic
presentation +
anhydramnios
 Gynecological Patients
No Identity Diagnosis ICD 10 Management ICD 9 Recent Diagnosis Condition
Cervical cancer stage IIIB Cervical cancer stage
post chemotherapy + IIIB post chemotherapy Stable in
+ right Solid ovarian ward
right Solid ovarian
Mrs. SUC • Medicinalis neoplasm and Left
1. neoplasm and Left C53.9
25/UA/RS • US confirmation Multiloculare cystic
Multiloculare cystic
• plan for radiation ovarian neoplasm was
ovarian neoplasm was
suspected + cancer pain suspected + cancer pain
• Consult intraoperatif from Endometriosis ASRM Stable in
Peritonitis cb appendixitis Surgery department grade IV (ASRM score ward
Ms. CYN N93.9 96) post bilateral
perforation was • Bilateral cystectomy +
2 23/UA/AW D68.9 cystectomy +
suspected, adhesiolysis + stab wound
dd/ ruptured ovarian cyst drain adhesiolysis + stab
wound drain
 Gynecological Patients
ICD
No Identity Diagnosis ICD 10 Management Recent Diagnosis Condition
9
G4P3A0 18 weeks G4P3A0 18 weeks
gestational age not gestational age not Stable in
• Consult from Internal inlabor with severe ward
inlabor with severe
Mrs NOV/ department malnutrition +
malnutrition +
3. 22 yo/UA/ C53.9 • Medicinalis dehydration low intake
dehydration low
AW • Fluid rehydration + new case Tuberculosis
intake + new case
• Thorax radiograph SLF intrauterine
Tuberculosis SLF
intrauterine
OBSTETRIC
Identity 1. Mrs. EVI/33/UA/AW March 2nd 2018 (11.00 AM)
Chief complaint Aterm pregnancy inlabor with prior CS 1X
History 3 hours before admitted to Moh. Hoesin hospital, patient complained about abdominal
contraction(+), History of amniotic leakage (-), history of bloody show (+). Patient
admitted that she was aterm pregnancy and still can felt the fetal movement.
Marital status 1x , 14 years
Reproduction status Menarche since 13 yo, regular 28-day cycle, lasts 5 days, LMP: 3rd June 2018
Obstetric history 1. 2005, male, 3500g, spontaneous delivery, midwife healthy
2. 2017, male, 3500g, spontaneous delivery, midwife, healthy
3. 2017, male, 3500g, LSCS (oi anhydramnios), Siti Khadijah hospital, healthy
4. current pregnancy
Physical Examination BP: 110/70 mmHg Pulse : 88 x/m T: 36.5oC RR: 20 x/m
Obstetrical Palpation: Uterine fundal 3 fingers below proc. xypoideus (33cm),longitudinal lie, back in
examination the right axis, U 3/5, cephalic, FHR 140 x/m, contraction 3x/10'/30”, EFW 2945 g
VBAC 6: 77%) VT: soft portio, anterior, eff 100%, dilatation 7cm, head, HII-III, amniotic membrane (+),
denomanator was right anterior occipital
Lab Examination Hb: 11.9 g/dL, WBC: 10.900/mm3, PLT: 285.000/mm3

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Identity 1. Mrs. EVI/33 yo/UA/ AW
US ER (VNY) - SLF cephalic presentation
- BPD: 9.14 cm HC: 31.68 cm AC: 32.78 cm FL: 7.00 cm EFW: 3093 g
- Placenta on anterior corpus
- Amniotic fluid was sufficient, SDP: 2.5cm
- C/ 39 weeks gestational age SLF cephalic presentation
Diagnose G4P3A0 39 weeks of gestational age inlabor 1st stage active phase with Prior CS 1X (oi anhydramnios) SLF cephalic
presentation
Therapy • Observation of vital signs, contraction, FHR
• IVFD RL gtt xx/mnt
• Urine catheterization
• Plan for vaginal delivery  TOLAC
Follow Up D/ G4P3A0 39 weeks of gestational age inlabor 2nd stage with Prior CS 1X (oi anhydramnios) SLF
2.3.19 – 01. 20 PM cephalic presentation
P/ conduct the labor
01.35 PM Life female baby was born with BW 3100 g, BL 46 cm, A/S 8/9 FTAGA
01.45 PM Placenta delivery completely with PW 520 g UCL 50 cm Ø 18x19 cm  performed IUD insertion
D/ P4A0 post spontaneous delivery with prior CS 1x + IUD insertion
Lab Result Hb: 9,9 g/dL, WBC: 15.900/mm3, PLT: 325.000/mm3

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Identity 2. Mrs. SEB/34/UA/RK March 2nd 2019 03.50 PM
Chief complaint Preterm pregnancy with high blood pressure and priot CS 1x
History ± 6 hours before admission, patient complained about headache. Patient had been hospitalized 2 d
ays before at Charitas hospitas with diagnosed preterm pregnancy and severe preeclampsia and go
t expectative management. Then, patient refer to Moh. Hoesin hospital. History of abdominal contr
action (-), bloody show (-), amniotic leakage (-). History of hypertension before pregnancy (-), hyper
tension in this pregnancy (+), hypertension in previous pregnancy (+), hypertension in family (+), Hi
story of headache (+) nausea and vomitus (-), epigastric pain (-), seizure (-). She admitted that her p
regnancy was preterm & fetal movement was felt.
Marital status 1x 7 years
Reprodu St. Menarche since 13 yo, regular 28-day cycle, lasts 7 days, LMP: 30th June 2018
Past Illness History History of vertigo (+)
History of hospitalized cb severe preeclampsia (+) and got lung maturation 2days
Obstetric history 1. 2012, Male 2700 g, aterm, CS oi Severe preeclampsia, Lampung General Hospital, healthy
2. This pregnancy
Physical exam BP: 190/110 mmHg Pulse : 92 x/m T: 36,2oC RR: 20 x/m,
Obstetrical exam Palpation: Uterine fundal 4 fingers below proc.xyph(27cm), longitudinal lie, right fetal spine,
GI: 8 cephalic, U 5/5, uteine contration (-), FHR: 148 x/m, EFW:2170g
BS: 2 VT: soft portio, posterior, eff 0%, dilatation (-), cephalic, H I, amniotic membrane and denominator
cannot be assesed yet
Identity 2. Mrs. SEB/34 yo /UA/ RK
Lab Hb:11.7g/dL, WBC:17.600/mm3, Plt:212.000/mm3, SGOT 19, SGPT 13, LDH:281 Ur/Cr: 27 / 0.8 Magnesium 1,78
Examination Urien protein +2, BSS: 228mg/dL, GTT V: 215 mg/dL, PP BSS: 152 mg/dL
US (ER) - VNY - SLF cephalic presentation
- BPD: 8.03 cm HC: 28,76 cm AC: 30.71 cm FL: 6.41cm EFW: 2249 g
- Placenta on anterior uterine corpus
- Amniotic fluid was sufficient, SDP 3.2cm
C/ 35 weeks gestational age SLF cephalic presentation
Diagnose G2P1A0 35 weeks gestational age not inlabor with impending eclampsia with prior CS 1X (oi Severe
Preeclampsia) + type II diabetes mellitus SLF cephalic presentation
Management • Stabilization
• Observation of vital signs, contraction, FHR
•Urine catheterization
•IVFD RL xx bpm
•MgSO4 40% protocol
• Nicardipine 10mg, x bpm
• Gestosis Evaluation
• Consult to Internal and Ophthalmology department
• plan for LSCS
Identity 2. Mrs. SEB/34 yo /UA/ RK March 2nd 2019 03.50 PM
Assasment from Internal A/ emergency of hypertension + type II diabetes mellitus
Medicine P/ Nicardipine x bpm (micro) IV
Novorapid 6IU/8hours SC
blood glucose evalutaion + HbA1c exam
Assasment from A/ No abnormality
Opthalmoogy Therapy ~ OBGYN
Department

Follow Up D/ G2P1A0 35 weeks gestational age not inlabor with impending eclampsia with prior CS
2.3.19 – 07.00 PM 1X (oi Severe Preeclampsia) + type II diabetes mellitus SLF cephalic presentation
BP: 160/90mmHg P/ Plan for LSCS
IG: 6
BS: 2

08.05 PM Male life baby was born BW 2450 BL 45 cm A/S 6/8 PTAGA
08.10 PM Placenta delivered compeletely with PW: 450g, UCL: 40cm, diameter 16x17cm 
performed IUD insertion
D/ P2A0 Post LSCS oi
impending eclampsia not inlabor + IUD insertion
Ballard Score
Identity 3. Mrs. FIT/32 yo/RA. March 2nd 2019 02.10 PM
Chief complain Aterm pregnancy with anemia
History Patient complained about weakness. Patient reffered from Az Zahra hospital with diagnosed
aterm pregnancy and severe anemia + IUGR. History of abdominal contractions (-), bloody
show (-), amniotic leakage (-), history of having anemia at previous pregnancy (+), with small
baby. History of routine blood transfusion (-). History blood transfusion cb bleeding before
pregnancy (+), patient had been controlled to hematology oncology and diagnosed with iron
defeciency. She admit that her pregnancy was aterm and fetal movement (+).
Marital status 1x, 5 years
Reproduction status Menarche since 13 yo, regular cycle 28 days, 5 days, LMP: 17th June 2018
Obstetric history 1. 2015, female, 2000g, aterm, spontaneous delivery, Moh. Hoesin hospital, healthy
2. This pregnancy
Physical exam BP:120/80 mmHg, Pulse:89 x/minute, RR: 18 x/minute T:36.5oC BL 155cm BW 65 kg,
Conjunctiva was pale (+),
Obstetrical Inspection: Uterine fundus 3 fingers below xyphoid process (28 cm), longitudinal lie, right fetal
Examination spine, cephalic, U 5/5, uterine contraction (-), FHR 142x/mnt, EFW: 2325g
Vaginal toucher: portio soft, posterior, eff 0%, OUE closed, head, H I, amnioitic membrane
and denominator can’t assesed yet
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Identity 3. Mrs. FIT/32 yo/RA. March 2nd 2019 02.10 PM
US ER (VNY) - SLF cephalic presentation
- Fetal biometry: BPD : 8.65 cm, AC : 29.5 cm, HC : 30.87 cm, FL: 6.30 cm, EFW : 2200 g
- Amniotic fluid sufficient SDP : 2.41 cm
- placenta at anterior corpus
C/ 37 weeks gestational age SLF cephalic presentation
Diagnosis G2P1A0 37 weeks gestational age not inlabor with severe anemia SLF cephalic presentation with IUGR
Laboratory Hb: 4.5 g/dL, Ht: 16%, WBC: 10.560/mm3, Plt: 224.000/mm3 SGOT/SGPT: 17/9 U/L
examination MCV: 59.9, MCH: 17, MCHC: 28 RDW-CV: 23% (n: 11-15).0 direct Bilirubin : 0.5 mg/dL (0-0.2) Ferritin:
5.0, TIBC: 586 (n: 112-346ug/dL) Serum iron: 26 (n: 61-157)
Management • Medicinalis
•O2 2-4L/m
•Observation of vital signs, FHR, Contraction
•Lab examination: peripheral blood exam, hemostatic function, Feces routine
•IVFD RL xx drops/minute
•PRC Transfusion
•Internal medicine department assessment
Internal med A/ Microcytic Hypochromic Anemia cb Iron Deficiency DD/ Anemia cb Chronic disease
department P/ blood transfusion
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assessment others therapy ~ OBGYN
 Identity 4. Mrs. MAY/23yo/UA/AW March 2nd 2019 (10: 08 PM)
Chief complain Aterm pregnancy with watery discharged
History Since 12 hours before admission patient complain amniotic leakage(+), clear, smelly (-), 2times changing clothes. History of
abdominal contraction (-), bloody show (-). History of leukorrhea (-), skin infection (-), abdominal massage (-), post coital (-),
trauma (-), history of fever (-).
Patient admit that her pregnancy was full term and fetal movement was exist.
Marital st Married once for 1.5 years
Reprod. st Menarche since 13 years old, regular cycle 28 days, 3 days, LMP: May 24th 2018
Obs. history 1. current pregnancy
Physical exam Vital sign: BP: 120/80 mmHg, Pulse: 82 bpm, temp: 36.7 C, RR: 18x/mt, BH: 150cm, BW: 68kg
Obstetrical Palpation: Fundal height 3 fingers below proc.xyphoid (33cm), longitudinal lie, left fetal spine, head, U 4/5, uterine contraction
examination (-), FHR:144bpm, EFW:3100g,
BS: 2 Inspeculo: portio livide, OUE closed, fluor -, fluxus (+), not active amniotic fluid, clear, smell (-), titrazine test (+), E/L/P (-)
VT: portio soft, posterior, eff 0%, dilatation (-), head, HI, amniotic membrane (-), denominator difficult to assessed
US ER (VNY) - Single life fetus Cephalic presentation
- Fetal Biometry: BPD 909 mm, AC 317 mm, HC: 317 mm, FL: 73 mm, EFW: 2985gr,
- Placenta at anterior uterine corpus
- Amniotic was decrease, AFI: 1.2 cm ~ anhydramnios
C/ 40 weeks gestational age SLF cephalic presentation + anhydramnios
Lab exam Hb: 12.5 g/dL, Ht: 36%, WBC: 13.830/mm3, Plt: 334.000/mm3, CRP +13,
Diagnosis G1P0A0 40 weeks gestational age not inlabor with PROM 12 hours SLF cephalic presentation + anhydramnios

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 Identity 4. Mrs. MAY/23yo/UA/AW March 2nd 2019 (10: 08 PM)
Management Observes vital sign, FHR, inlabor sign
IVFD RL XX bpm
Cefazoline 2g IV (skintest)
Plan for LSCS
Follow Up Male life baby was born, BW 3200 gr, BL 52 cm, A/S 3/6/9 FTAGA
3.3.19 – 04.35 AM placenta was delivered completely, PW 500 gr, UCL 48 cm, diameter: 18x19 cm

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GYNECOLOGIC
Chief complaint Right Lower abdominal pain
History • Since 1 days before admitted to the hospital patient complain about abdominal pain (+), vaginal Bleeding(-),
Miction in normal limit. History of difficult to defecation (+). History of prolonged leucorrhea (-), history of
irregular menstruation (-). Patient had been laparotomy at Hermina hospital (12th April 2018 – no data of
operating report) with PA’s result: PA No 806/PA-HR/18 non keratinizing squamous cell carcinoma right
paracervical and right pararectal DD/ carcinoid like tumors, Small cell carcinoma
• Patient had been chemotherapy 6th course at Hermina hospital (last at August 2018). Patient refer from
Hermina cause of cancer pain and plan for radiotherapy
Marital status Not married yet
Reproduction status Menarche since 12 years old, regular 28-days cycle, lasts 5 days
Obstetric history P0A0
Vital Sign BP 130/90 Pulse : 68x/m T: 36.5 RR: 20x/m
VAS: 4
Obstetrical examination Palpation: flat abdominal, supple symmetric, mass(+) suprapubic sized 8x5cm, immobile, 3 finger above simphysis
as upper border, simphysis as lower border, right parasternalis as right border, left parasternalis as left border,
uterine fundal difficult to assess, tenderness(-), free fluid sign(-),
Inspeculo and VT : do not performed
Rectal examination : spinchter anal tonus was good, intralumen mass (-), rectal ampulla was empty, adnexal and
parametria was tense, mass (+), immobile, size 8x5x5cm

BACK
Identity Mrs SUC/ 25 yo/UA/ RS
US IRD - VNY Uterus AF, size and shape in normal limit, homogen myometrium, endometrial line (+) size 0.3cm, regular stratum basalis,
postio and endocervix in normal limit. There’s hyperechoic mass at paracervical, size 9x4cm, vascularization (+) urge the uterus
~ paracervical mass malignancy was suspected
Ascites (+)
There’s cystic mass, multiloculare at left ovarian, size 5x3cm ~ multiloculare cystic ovarian neoplasm was suspected
There’s solid mass at right ovarian, size 5x4cm ~ right solid ovarian neoplasm was suspected
There’s enlargement of calyx right kidney, size 1.3cm ~ right hydronephrosis was suspected
Liver and left kidney in normal limit
C/ paracervical mass malignancy was suspected
ascites with multiloculare cystic ovarian neoplasm was suspected + right solid ovarian neoplasm was suspected
right hydronephrosis was suspected
Laboratorium Hb 10.8 Leu 10.800 Plt 333000 Ca 125: 157.2, AFP: 2.24, CEA: 1.1, Ca125: 157.2
Diagnosis Cervical cancer stage IIIB post chemotherapy + right Solid ovarian neoplasm and Left Multiloculare cystic ovarian neoplasm was
suspected + cancer pain
Management • Medicinalis
• IVFD RL XX dpm
•Pirocetal 5 mg/ 8 hours IV
• plan for US confirmation
•Plan for radiotherapy

BACK
Identity Miss CYN / 22 y.o. / UA / P0A0
Chief complain Abdominal pain
History Patient consult from Surgery departemnt with peritonitis cb appendicitis perforation was suspected. Since 1 day before
admission, patient complain of abdominal pain, especially at right lower quadrant abdomen. History of fever (+) 2 days
ago, history of nausea and vomiting (-). Patient had been controlled to OBGYN at Muara enim and said have cyst but
unclear, history of irregular menstruation (-), history of dysmenorrhea (-), history of prolonged leucorrhea (-), history of
vaginal bleeding (-), history of abdominal pain (-), history of decreasing of appetite (+), histroy of abdominal trauma /
massage (-).
Reproductive status Menarche 13 yo, regular menstrual cycle, last for 3-5 days, LMP febr 16th 2019
Marital status Not married yet, P0A0
Physical exam BP : 110/70 mmHg, P : 99 x/min, T : 36.3 C, RR : 20 x/min
Gynecology Palpation: abdominal was flat, symmetric, muscular defense (+), tenderness (+) at whole of abdomen, tympani, rebound
examination tenderness (+), uterine fundal and mass difficult to evaluate
VAS: 6 Inspeculo and VT do not performed
Alvarado score: 6 RT  patient refuse not
US ER Uterus was AF, size and shape in normal limit
Right ovarian in normal limit, contralateral difficult to evaluate
There’s hyperechoic mass, non homogen, irregular at right side ~ appendicits perforation was suspected, dd/ rupture
ovarian cyst was suspected
Liver, gallblader, both of kidney in normal limit
C/ appendicits perforation was suspected, dd/ rupture ovarian cyst was suspected
Diagnosis Peritonitis cb Appendicitis perforation was suspected
Organic abnormality of internal genitalia can’t be excluded
Identity Miss CYN / 22 y.o. / UA / P0A0
Management Consult intra operative if there’s internal genitalia abnormality
Radiology - abdominal Left Ovarian cyst with hemorrhagic cyst was suspected + Ascites + Appendicitis undetachable
US Paralytic of bowel (bowel dilation with decrease of peristaltic movement)
Intraoperative
 IDENTIT Mrs. NOV/35/UA BACK
2/3/19 -12:13 AM

Chief complain Early pregnancy with weakness

History Patient consult from Internal department with diagnosis new case tuberculosis + malnutrition + DLI and
pregnancy. 3 days before admission, patient complain for weakness and fatique. History of prolonged
coughing (+), history of fever (+). History of abdominal contraction (-), history of bloody show (-), history of
vaginal bleeding (-), history of amniotic leakage (-). History of decrease of body weight (+) decrease of
apetite (+). History of amenorrhea 5 months.
Marital status 1. 1x, 14 tears

Reproduction status Menarche since 13 yo, regular cycle 28 days, for 5 days, LMP : November 10th 2018
Obstetric history P3A0
Physical examination BP : 110/70 mmHg, P : 84 x/min, T : 36.3 C, RR : 20 x/min, BW: 35 kg, BMI: 15.5

Obstetrical Palpation : abdomen flat, simetris, uterine fundal between umbilical – simphysis, ballotement (+), free fluid
examination sign(-), mass (-), tenderness (-)
Laboratory Hb: 13.2 g/dl, WBC 11.500/ mm3, Plt 288.000/mm3, Ht 37%
examination
 Mrs. NOV/35/UA
US ER - SME - SLF intrauterine
- BPD: 4.10 cm HC: 15.19 cm AC: 12.70 cm FL: 2.65 cm EFW: 203.52 g
- Placenta on posterior uterine corpus
- Amniotic fluid was sufficient
C/ 18 weeks gestational age SLF intrauterine
Diagnosis G4P3A0 18 weeks gestational age not inlabor with severe malnutrition + dehydration low intake
+ new case Tuberculosis SLF intrauterine
Therapy Obs. Vital sign, FHR, contraction
Plan for thorax radiograph  consult to OBGYN  advice consultant on duty (Dr. Awan
Nurtjahyo, OBGYN (C), consult to Fetomaternal (dr. Abarham M, OBGYN (C)  performed
thorax radiograph
Other therapy ~ Internal Department
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