Weekly Report FINAL

WEEKLY REPORT
Supervised by :
dr. Yuma Sukadarma, Sp.OG
Written by :
Jevon Andra 2015.061.112
Cindy Amadea 2015.061.197
Yonathan Ardhana 2015.061.201
DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY
FACULTY OF MEDICINE
ATMA JAYA CATHOLIC UNIVERSITY OF INDONESIA
MARCH 20th 2017 – MAY 27th 2017

OBSTETRICS
No Date of Admission Identity Working Diagnosis Final Diagnosis Diagnosis of the Baby
1. 30th March 2017 Mrs. AMS G3P2A0, 31 years old, 38 weeks of P3A0, 31 years old, post partus Term male neonate, appropriate for
gestation according to USG, maturus by normal vaginal delivery gestational age, 38-39 weeks of
currently not in labor yet, with gestational age according to New
premature rupture of membrane, Ballard Score, birth weight 3,350
single alive intrauterine fetus, head gram, birth length 50 cm, APGAR
presentation score 1st minute : 9, 5th minute : 9.
Diagnosed as healthy neonate
2. April 1st 2017 Mrs. S G2P1A0, 29 years old, 37-38 weeks P2A0, 29 years old, post partus Term male neonate, appropriate for
of gestation according to USG, in maturus by normal vaginal delivery gestational age, 38 – 39 weeks of
1st stage of labor, latent phase, with perineum rupture grade II gestational age according to New
history of prior cesarean section, Ballard Score, APGAR score 8/9,
with single live intrauterine fetus, birth weight 3620 gram, birth length
head presentation 50 cm, well newborn
3. April 2nd 2017 Mrs. K G1P0A0, 17 years old, 31 – 32 P1A0, 1 years old, post partus Preterm male neonate, small for
weeks of gestation according to prematurus by normal vaginal gestational age, 35 – 36 weeks of
USG, in 1st stage of labor, active delivery with perineal rupture grade I gestational age according to New
phase, with single live intrauterine Ballar Score, APGAR score 7/9,
fetus, head presentation birth weight 1520 gram, birth
length 39 cm, preterm neonate, low
birthweight with HMD grade II
CASE 1
G3P2A0, 31 years old, 38 weeks of gestation according to USG, currently not in labor
yet, with premature rupture of membrane, single alive intrauterine fetus, head
presentation
I. IDENTITY
 Name : Mrs. AMS
 Age : 31 years old
 Ethnicity : Javanese
 Religion : Moslem
 Occupation : Housewife
 Education : Senior high school
 Date of admission : 30th March 2017
II. HISTORY
 Chief complaint:
Patient came to Atma Jaya Obstetric and Gynecology policlinic for pregnancy control.
 History of present illness:

Patient came to Atma Jaya Obstetric and Gynecology policlinic for pregnancy
control. According to USG examination, the amniotic fluid starts depleting. 2
weeks prior to admission, the patient experienced spotting bleeding colored
bright red in a little amount. 2 days prior to admission, there was a discharge
of white-cloudy liquid in a small amount, preceded by cough. History of fever,
vaginal itchiness, leucorrhea, abdominal pain, and urination and defecation
problem are denied.
 History of past ilness:

o History of hypertension : denied
o History of diabetes mellitus : denied
o History of allergy : denied
o History of trauma : denied
o History of surgery : denied
o History of asthma : denied
 Family history:
 History of menstrual cycle:

o Menarche : 10 years old
o Menstrual cycle : 28-30 days, regularly, with duration of 7 days,
changed 2 pads a day (about 40 cc), dysmenorrhea (-)
o First day of last menstrual period: July 6th, 2016
 Marital history:
Married once, 9 years with this husband.
 Contraception history:
Injectable birth control (every 3 months) since 2013 until 2015, and stopped
because the couple plan to have another baby.
 History of antenatal care:

Patient has routine antenatal care with 12 visits at Puskesmas during this
pregnancy.
 Obstetric history:
No Years Gestational Labor History Sex Birth Breast
Age Weight Feeding
1. 2009 9 months Spontaneous Male 2,750 Exclusive
pervaginam grams
2. 2013 9 months Spontaneous Male 3,000 Exclusive
pervaginam grams
3. This pregnancy
III. PHYSICAL EXAMINATION

 General condition : appeared mildly ill
 Level of conciousness : compos mentis
 Vital signs:
o Blood pressure : 140/90 mmHg
o Heart rate : 93 beats per minute
o Respiratory rate : 20 breaths per minute
o Body temperature : 37,2oC
 Height : 165 cm
 Weight : 65 kg
 BMI : 23.87 kg/m2
General Examination:
 Eyes : anemic conjunctiva -/-, icteric sclera -/-
 Mouth : wet oral mucosal membrane
 Thorax :
o Heart : regular 1st and 2nd heart sounds, gallop (-), murmur (-)
o Lung : vesicular breath sounds +/+, rhonki -/-, wheezing -/-
o Mammae : areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-
 Abdomen :
o Inspection : convex, linea nigra (+), striae gravidarum (+)
o Palpation : supple, tenderness (-)
o Auscultation : bowel sounds (+), 6 times per minute
 Extremities : edema (-/-/-/-), CRT <2 seconds, physiologic reflex (+/+/+/+),
pathologic reflex (-/-/-/-)
Obstetric Examination:
 First day of last menstrual period : July 6th, 2016
 Estimated day of delivery : April 13th, 2017
 Fundal height : 29 cm
 Estimated fetal weight : 2,790 gram
 Uterine contraction: none
 Fetal heart rate: 135 beats per minute
 Leopold maneuver:
o Leopold 1: buttock
o Leopold 2: back on the right
o Leopold 3: head
o Leopold 4: divergent 4/5
 Inspection : edema (-), secrete (-), blood (-), cicatrix (-)
 Vaginal toucher :
o Vulvovagina : no abnormality found
o Portio : position : anteflexion
Dilatation : 2 cm
Effacement : 10%
Consistency : thick and soft
o Head presentation
o Hodge I
o Amniotic sac (-)
 Inspeculo :
o Fluxus (+) clear liquid, erosion (-), tissue (-), stoll cell (-), nitrazine test
(+)
 Rectal toucher : not performed
Cardiotocography:
 Fetal Heart Rate:
Baseline 145 bpm; normal variability; acceleration (+) 6 time in 20 minutes;
deceleration (-); fetal movement (+) 6 times in 20 minutes ; his (-)
 Uterus Contraction: 0
 Fetal Movement: 6 times in 20 minutes
 Conclusion: reactive
IV. LABORATORY EXAMINATION
Examination Results Unit
Hemoglobin 11.7 g/dL
Hematocrit 35 %
Trombocyte 343 ribu/uL
Leucocyte 10.3 ribu/uL
Eritrocyte 4.79 juta/uL
MCV 72.2 fL
MCH 24.6 pg
MCHC 34.1 g/dL
Qualitative HBsAg negative
V. WORKING DIAGNOSIS
G3P2A0, 31 years old, 38 weeks of gestation according to USG, has not been in
labor yet, with premature rupture of membrane, single alive intrauterine fetus,
head presentation
VI. PLANNING
VII. FINAL DIAGNOSIS

o Mother : P3A0, 31 years old, post partus maturus by normal vaginal
delivery
o Baby : Term male neonate, 38-39 weeks of gestational age according
to New Ballard Score, birth weight 3,350 gram, birth length 50 cm, APGAR
score 1st minute : 9, 5th minute : 9. Diagnosed as healthy neonate
VIII. TREATMENT
IX. TAKE HOME MEDICINE

o Cefadroxil 3 x 500 mg p.o.
o Mefenamic acid 3 x 500 mg p.o.
o Molocco B12 3 x 1 tab p.o.
CASE 2
G2P1A0, 29 years old, 37 – 38 weeks of gestation according to USG, in 1st stage of labor,
latent phase, history of prior cesarean section, with single live intrauterine fetus, head
presentation
I. IDENTITY
Name : Mrs. S
Sex : Female
Age : 29 years old
Address : Muara Angke 011 / 011
Ethnicity : Javanese
Religion : Moslem
Occupation : Housewife
Education : Senior High School
Date of admission : April 1st, 2017
II. HISTORY
Chief Complaint
Abdominal discomfort since 2 hours before admission.
History of Present Illness

Patient was having an abdominal discomfort since 2 hours before admission to the
hospital. She said it was a frequently increasing and radiating discomfort from abdomen
to the lower back. It’s neither relieved nor aggravated by any factors. She also
complained about some discharge from her vagina consisting of blood and mucus since
2 hours before admission. She denied ever having a fever during pregnancy, nausea,
vomiting, blurring of vision, abdominal pain, or gushing of water through her vagina
throughout this pregnancy.
History of Past Illness

 History of hypertension : Denied
 History of diabetes mellitus : Denied
 History of allergy : Denied
 History of asthma : Denied
 History of trauma : Denied
 History of surgery : Cesarean section in 2008
Family History
History of Menstrual Cycle

 Menarche : 15 years old
 Menstrual cycle : 28 days, regularly, duration of 5 days, 3 – 4 pads a day
(± 60 – 80 cc), dysmenorrhea (-)
Marital History
Married once, it’s been 10 years with this husband.
Contraception History
Contraceptive implant for 3 years (2008 – 2011)
3-monthly contraceptive injection for 1 year (2012)
1-monthly contraceptive injection for 3 years (2013 – 2016)
History of Antenatal Care

Patient has a routine antenatal care with 9 visits at community health center and Atma
Jaya Hospital during this pregnancy.
Obstetric History
 G2P1A0
 First day of last menstrual cycle : July 5th, 2016
 Estimated due date : April 12th, 2017
No Husband Year Age of Mode of Complications Sex Current Birth Breastfed
no - Gestation Delivery Age Weight
1 1 2008 8 months CS - ♂ 8 years 3.300 +
old grams
2 1 Current
pregnancy

General condition : Appeared mildly ill
Level of consciousness : Compos mentis
Vital signs
 Blood pressure : 120/80 mmHg

 Heart rate : 96 beats per minutes
 Respiratory rate : 24 breaths per minutes
 Body temperature : 36.7o C
Nutritional status
Current weight : 71 kg
Pre-pregnancy weight : 65 kg
Height : 155 cm
BMI : 27.01 kg/m2
General Examination
Head : Normocephalic, deformity (-)
Eyes : Anemic conjunctiva (-/-), icteric sclera (-/-)
Nose and ear : Discharge (-), deformity (-)
Mouth : Wet oral mucosal membrane
Thorax
 Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
 Lung : Vesicular breath sounds (+/+), rhonchi (-/-), wheezing (-/-)
 Mammae : Areolar hyperpigmentation (+/+), nipple retraction (-/-), breast
milk (-/-)
Abdomen
 Inspection : Convex, striae gravidarum (+), linea nigra (+)
 Auscultation : Bowel sounds (+), 6 times per minute.
 Palpation : Supple, tenderness (-)
Extremities : Edema (-/-/-/-), CRT < 2 seconds
Physiologic reflex (+/+/+/+), pathologic reflex (-/-/-/-)
Obstetric Examination
Fundal height : 30 cm
Estimated fetal weight : 2.945 gram
Uterine contraction : 1x in 10 minutes, duration 30 seconds
Fetal heart rate : 152 bpm
Leopold maneuver
o Leopold I : Buttock
o Leopold II : Back on the left side
o Leopold III : Head
o Leopold IV : Divergent
Inspeculo : Not performed
Vaginal toucher : Vulva and vaginal within normal limit, portio retro-flexed,
cervical dilatation 2 cm, cervical effacement 30%, thick and soft
cervix, amnion sac (+), head presentation, Hodge I
Rectal toucher : Not performed
Cardiotocography
Fetal Heart Rate
 Baseline : 145 bpm
 Variability : Normal
 Acceleration : (+) 1 times in 20 minutes
 Deceleration : (-)
 Fetal movement : (+) 5 times in 20 minutes
Uterus Contraction : 1 times, duration of 30 seconds, amplitude of 40 mmHg
Conclusion : Reassuring
LABORATORY EXAMINATION
Types Results Units Normal Value
Hematology
Hemoglobin 10.0 g/dL 12.0 – 15.8

Hematocrit 32 % 36 – 48
Leucocytes 10.4 103/µL 3.54 – 9.06
Platelets 378 103/µL 165 – 415
Erythrocyte 4.47 106/ µL 4.0 – 5.2
MCV 71.1 fL 79 – 93.3
MCH 22.4 pg 26.7 – 31.9
MCHC 31.4 g/dL 32.3 – 35.9
Blood Type B/ Rh (+)
Serology
HBsAg (-) Negative
IV. WORKING DIAGNOSIS
G2P1A0, 29 years old, 37 – 38 weeks of gestation according to USG, in 1st stage of
labor, latent phase, history of prior cesarean section, with single live intrauterine fetus,
head presentation
V. PLANNING
Pro vaginal delivery
VI. FINAL DIAGNOSIS
 Mother
P2A0, 29 years old, post partus maturus by normal vaginal delivery with
perineum rupture grade II.
 Baby
Term male neonate, appropriate for gestational age, 38 – 39 weeks of gestational
age according to New Ballard Score, APGAR score 8/9, birth weight 3620
gram, birth length 50 cm, well newborn.
VII. TREATMENT
 Cefadroxil 3 x 500 mg po
 Mefenamic acid 3 x 500 mg po
 Molloco B12 3 x 1 tab po
 Kaltrofen 1 x 1 supp
 Tramal 1 x 1 supp
CASE 3
G1P0A0, 17 years old, 31 – 32 weeks of gestation according to USG, in 1st stage of labor,
active phase, with single live intrauterine fetus, head presentation
I. IDENTITY
Name : Mrs. K
Sex : Female
Age : 18 years old
Address : Muara Baru 013 / 017
Religion : Moslem
Occupation :-
Date of admission : April 2nd, 2017
II. HISTORY
Chief Complaint
Gushing of water through vagina since 3 hours before admission.

Patient complained about some discharge from her vagina consisting of mucus without
blood since 2 days before admission. She came to a public health center and underwent
a USG examination. The results were good and she went home.
3 hours before admission, she complained about a lot of water flowed from her vagina
accompanied by abdominal discomfort from the abdomen and radiating to the lower
back. She confessed ever having a fever during pregnancy, at about 16 weeks of
gestation. She went to a midwife and was given antipyretic drug. She denied ever
having nausea, vomiting, headache, blurring of vision, abdominal pain or bleeding from
her vagina throughout this pregnancy.

 History of surgery : Denied
Family History

 Menstrual cycle : 30 days, regularly, duration of 3 days, 2 – 3 pads a day
(± 40 – 60 cc), dysmenorrhea (-)
Marital History
Married once, it’s been 4 months with this husband.
-

Patient doesn’t have a routine antenatal care with 2 visits at community health center
during this pregnancy.
Obstetric History
 G1P0A0
 First day of last menstrual cycle : September 2nd, 2016
 Estimated due date : June 12th, 2017
1 1 Current
pregnancy

General condition : Appeared moderately ill
Vital signs
Nutritional status
Current weight : 55 kg
Pre-pregnancy weight : 50 kg
Height : 152 cm
BMI : 21.64 kg/m2
General Examination
Thorax
 Mammae : Areolar hyperpigmentation (+/+), nipple retraction (-/-), breast
milk (-/-)
Abdomen
 Inspection : Convex, striae gravidarum (+), linea nigra (+)
 Palpation : Supple, tenderness (-)
Obstetric Examination
Fundal height : 20 cm
Estimated fetal weight : 1.395 gram
Uterine contraction : Not performed
Fetal heart rate : 128 bpm
Leopold maneuver
o Leopold I : Buttock
o Leopold II : Back on the left side
o Leopold III : Head
o Leopold IV : Divergent
Inspeculo : Not performed
Vaginal toucher : Vulva and vaginal within normal limit, portio retro-flexed,
cervical dilatation 10 cm, cervical effacement 100%, thin and
soft cervix, amnion sac (-), head presentation, Hodge IV
Cardiotocography : Not performed
LABORATORY EXAMINATION
Types Results Units Normal Value
Hematology
Hemoglobin 11.7 g/dL 11.1 – 15.7
Hematocrit 34 % 34 – 44
Leucocytes 25.1 103/µL 4.8 – 10.8
Platelets 440 103/µL 150 – 450
Erythrocyte 4.27 106/ µL 4.2 – 5.4
MCV 81.3 fL 75 – 89
MCH 27.4 pg 25 – 31
MCHC 33.7 g/dL 32 – 36
Blood Type O / Rh (+)
Serology
HBsAg (-) Negative

G1P0A0, 17 years old, 31 – 32 weeks of gestation according to USG, in 1st stage of
labor, active phase, with single live intrauterine fetus, head presentation
V. PLANNING
Pro vaginal delivery
VI. FINAL DIAGNOSIS

 Mother
P1A0, 17 years old, post partus prematurus by normal vaginal delivery with
perineum rupture grade I.
 Baby
Preterm male neonate, small for gestational age, 35 – 36 weeks of gestational
age according to New Ballard Score, APGAR score 7/9, birth weight 1520
gram, birth length 39 cm, preterm neonate, low birthweight with HMD grade II.
VII. TREATMENT
Post partum treatment
 Observation for
o Hemorrhage and uterine contraction
o Spontaneous micturition 6 hours after delivery
 IVFD RL + Oxytocin 20 UI/8 hours then IV stopper
 Cefotaxime 1 x 2 gr IV
 Methergin 3 x 0.125 mg po
 Sangobion 1 x 1 caps po
Take Home Medicine

GYNECOLOGY
No. Date of Admission Identity Working Diagnosis Final Diagnosis
1. March 30th 2017 Mrs. R G5P3A1, 35 years old, 11-12 weeks of gestation P3A2, 35 years old, post curretage indicated by
according to first day of last menstrual period , incomplete abortus
with antepartum hemorrhage and hypovolemic
shock ec. incomplete abortion
2. March 31st 2017 Mrs. S P3A2, 41 years old, with blighted ovum P3A2, 41 years old , post curretage indicated by
blighted ovum
3. April 1st 2017 Mrs. L G2P1A0, 30 years old, 7 weeks of gestation P1A1, 30 years old, post dilation and curettage as
according to USG, with suspected for threatened indicated by inevitable abortion ec blighted ovum
abortus DD/ blighted ovum
CASE 4
G5P3A1, 35 years old, 11-12 weeks of gestation according to first day of last menstrual
period, with antepartum hemorrhage and hypovolemic shock e.c. incomplete abortion
I. IDENTITY
 Name : Mrs. R
 Occupation : Housewife
 Education : Junior high school
 Date of admission : 30th March 2017
II. HISTORY
Patient was having a vaginal bleeding since 10 hours prior to admission to the
hospital.

Patient came to Atma Jaya Emergency Unit referred from a clinic
caused by massive vaginal bleeding and lower abdominal pain since 10 hours
prior to admission. Some of the bleeding was dark red and some was bright
red, gushing, and some has clotted. The patient changed cover and pad twice,
both full of blood. On her way to the Emergency Unit, the patient’s sight
blacked out.
Since 2 days prior to admission, patient experienced spotting bleeding
in small amount. The day after, patient went to the clinic and examined with
USG. It was stated that the patient’s pregnancy was in a good shape, so does
the gestational sac and the patient was given a pregnancy strengthening drug.
 History of past ilness:

o History of asthma : denied
o History of surgery : denied
 Family history:

o Menstrual cycle : 28-30 days, regularly, with duration of 5 days,
changed 2-3 pads a day (about 40-60 cc), dysmenorrhea (-)
o First day of last menstrual cycle: January 10th, 2017
 Marital history: married once, 15 years of marital age with this husband
 Contraception history: denied
 History of antenatal care: once, in a private clinic
No Years Gestational Labor Sex Birth Breast
Age History Weight Feeding
1 2004 9 months Spontaneous Male 3,000 Exclusive
per vaginam grams
2 2008 3 months Abortus
per vaginam grams
per vaginam grams
5 This pregnancy

 General condition : appeared severely ill
 Level of conciousness : somnolen
 Vital signs:
o Body temperature : 36,6ºC
 Height : 160 cm
 Weight : 75 kg
 BMI : 29.3 kg/m2
 Eyes : anemic conjunctiva +/+, icteric sclera -/-
 Mouth : dry oral mucosal membrane, appeared cyanotic
 Thorax :
o Mammae : areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-
 Abdomen :
o Inspection : convex, linea nigra (+), striae gravidarum (-)
o Palpation : supple, tenderness (+)
 Extremities : cold, CRT > 2 seconds, edema (-/-/-/-), physiologic reflex
(+/+/+/+), pathologic reflex (-/-/-/-)
Gynecologic Examination
 First day of last menstrual period : January 10th, 2017
 Inspection : massive and active bleeding
 Inspeculo : blood (+), fluxus (+) bright red, stoll cell (+), erosion (-)
 Vaginal Toucher : cervical motion tenderness (-), dilatation 2-3 cm, a small
amount of tissue palpated at portio cervicis uteri.
 Rectovaginal Toucher : not performed
Examination Results Unit
Hemoglobin 8.2 g/dL
Hematocrit 23 %
Trombocyte 202 ribu/uL
Leucocyte 14.3 ribu/uL
Eritrocyte 2.79 juta/uL
MCV 81.7 fL
MCH 29.4 pg
MCHC 36.0 g/dL
BT 3 Minutes
CT 5 Minutes
V. WORKING DIAGNOSIS
G5P3A1, 35 years old, 11-12 weeks of gestation according to first day of last
menstrual period, with antepartum hemorrhage and hypovolemic shock e.c.
incomplete abortion
VI. PLANNING
 Pro curretage
VII. FINAL DIAGNOSIS

P3A2, 35 years old, post-curretage indicated by incomplete abortion
VIII. TREATMENT
 Vital sign observation
 Bleeding and urine output observation
 PRC transfusion 2 bag
 Normal diet
 Step by step mobilization
 IVFD Lactate Ringer 500 cc + Oxytocin 1 ampoule + Methergin 1 ampoule
for the first 8 hours, continued with Lactate Ringer 500 cc + Oxytocin 1
ampoule + Omeprazole 1 ampoule for the next 8 hours, then put stopper
IX. TAKE HOME MEDICINE

a. Cefadroxil 3x500 mg
b. Mefenamic acid 3x500 mg
c. Tranexamic acid 3x500 mg
d. Sangobion 2x1
e. Metronidazole 3x500 mg
f. Methergin 3x0.125 mg
CASE 5
P3A2, 41 years old, with antepartum hemorrhage ec. blighted ovum
I. IDENTITY
 Name : Mrs. S
 Occupation : housewife
 Education : Junior High School
 Date of admission : 31st March 2017
II. HISTORY
Vaginal bleeding 5 days before admission to hospital

Patient came to Atma Jaya Obstetric and Gynecologic clinic with complaint of
vaginal bleeding 5 days before admission to hospital, the colour of blood was
dark red, and the amount approximately 5cc.
Patient went to clinic 1 day before admission to hospital and had a USG and
only appeared a gestational sac only. Abdominal pain complaint was denied.
History of past ilness:

o History of surgery : sectio caesarea in 2011
o History of epilepsy : denied
o History of hematologic disease : denied
o History of urinary tract/kidney disease : denied
 Family history:

o Menstrual cycle :28 days, regularly, with duration of 7-8 days,
changed 3 pads a day (about 45 cc), dysmenorrhea (-)
o First day of last menstrual cycle: 19th December 2016
 Marital history:
Married once, 22 years with this husband.
 Contraception history:
Injectable birth control and was stopped in September 2016
 History of antenatal care:

4 times (in public health center and midwife)
No Years Gestational Labor History Sex Birth Breast
Age Weight Feeding
1 1996 9 months Spontaneous male 3100 Yes
per vaginam gram
2 2001 9 months Spontaneous male 3300 yes
per vaginam gram
3 2005 Abortus
4 2009 Abortus
5 2011 9 months Caesarian Male 3700 Yes
Section gram

 General condition : appeared no ill
 Level of conciousness : compos mentis
 Vital signs:
o Body temperature : 36,7oC
 Height : 149 cm
 Weight : 64 kg
 BMI : 28 kg/m2
 Eyes : anemic conjunctiva -/-, icteric sclera -/-
 Mouth : wet oral mucosal membrane
 Thorax :
o Mammae : areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/-
 Abdomen :
o Inspection : convex, linea nigra (-), striae gravidarum (-)
o Palpation : supple, tenderness (-)
 Extremities : edema (-/-/-/-), CRT <2 seconds, physiologic reflex
(++/++/++/++), pathologic reflex (-/-/-/-)
Gynecologic Examination:
 First day of last menstrual : December 19th 2016
 Inspection : vulva edema -, laceration -, blood -
 Inspeculo : erosion -, fluksus (-), stoll cell (-),
cicatrix –, tissue (-)
 Vagina Toucher : vulva and vaginal within normal limit,
position : anteflexion, cervical dilatation 0 cm, cervical effacement 0%,
consistency: thick and soft, cervical motion : (-).
 Recto-vaginal Toucher : not performed
Examination Results Normal Value Unit
Hematology
Hemoglobin 13.4 12.0-15.8 g/dL
Hematocrit 40 36-48 %
Trombocyte 245 165-415 ribu/uL
Leucocyte 6.8 3.54-9.06 ribu/uL
Eritrocyte 4.55 4.0-5.2 juta/uL
MCV 87.5 79-93.3 fL
MCH 29.5 26.7-31.9 pg
MCHC 33.7 32.3-35.9 g/dL
Blood type A Rh +
Immunoserology
Qualitative HBsAg Negative negative
V. USG
Gestational sac +, Fetal pole –
VI. WORKING DIAGNOSIS

P3A2, 41 years old, with antepartum hemorrhage ec. blighted ovum
VII. PLANNING
Pro curretage
VIII. FINAL DIAGNOSIS

P3A2, 41 years old, post curretage as indicated by blighted ovum
IX. TREATMENT
Discharge with take home medicine
X. TAKE HOME MEDICINE

 Metronidazole 2x500 mg
 Methergine 3x0.125 mg
 Ranitidine 2x1 tab
 Asam mefenamat 3x500 mg
CASE 6
G2P1A0, 30 years old, 7 weeks of gestation according to USG, suspected for threatened
abortion DD/ blighted ovum
I. IDENTITY
Name : Mrs. L
Sex : Female
Age : 30 years old
Address : Muara Karang 011 / 017
Religion : Moslem
Occupation : Private employees
Date of admission : April 1st, 2017
II. HISTORY
Chief Complaint
Bleeding from vagina since 6 days before admission.

Patient complained about bleeding from her vagina since 6 days before admission. For
the first 4 days, the blood was bright red accompanied by some clump. She confessed
that she had to change 2 pads a day and did not feel any pain or discomfort in her
abdomen.
Starting from 2 days before admission, she complained about more profuse bleeding
than she had had before that she had to change up to 4 pads a day. This time, it was
accompanied by abdominal pain especially on the lower part of the abdomen. She didn’t
know whether the bleeding was followed by some tissue. She denied ever having this
kind of condition before.

 History of hypertension : (+) in 1st preganancy
 History of surgery : Cesarean section in 2015
Family History

 Menstrual cycle : 28 days, regularly, duration of 5 days, 3 pads a day (±
60 cc), dysmenorrhea (-)
Marital History
Married once, it’s been 3 years with this husband.
-

Patient has a routine antenatal care with 3 visits at community health center during this
pregnancy.
Obstetric History
 G2P1A0
 First day of last menstrual cycle : January 13th, 2017
 Estimated due date : November 12th, 2017
1 1 2015 40 weeks CS Hypertension ♀ 1.7 3.000 +
years grams
old
2 1 Current
pregnancy
General condition : Appeared moderately ill
Vital signs
Nutritional status
Weight : 51 kg
Height : 151 cm
BMI : 23.1 kg/m2
General Examination
Thorax
 Mammae : Areolar hyperpigmentation (-/-), nipple retraction (-/-), breast
milk (-/-)
Abdomen
 Inspection : Flat, linea nigra (-), striae gravidarum (-)
 Palpation : Supple, tenderness (+) in hypogastric region
 Percussion : Tympanic in all quadrants
Gynecologic Examination
Inspection : Vulva edema (-), laceration (-), blood (+), cicatrix (-)
Inspeculo : Fluksus (+) blood, erosion (+), tissue (-), stoll cell (+)
Vaginal toucher : Vulva and vaginal within normal limit, portio ante-flexed, no
cervical dilatation, no cervical effacement, thick and soft cervix
USG EXAMINATION
 Gestational sac (+)
 Fetal pole (-)

G2P1A0, 30 years old, 7 weeks of gestation according to USG, with suspected for
threatened abortus DD/ blighted ovum.
V. PLANNING
Pro dilation and curettage
VI. FINAL DIAGNOSIS

P1A1, 30 years old, post dilation and curettage as indicated by inevitable abortion ec
blighted ovum.
VII. TREATMENT
Pre dilation and curettage treatment
 Oxytocin 1 x 1 amp
 Methergin 1 x 1 amp
 Tranexamic acid 1 x 1 gr
Post dilation and curettage treatment

 D5 + Duvadilan 1 amp 12 tpm
 Duvadilan 3 x 10 mg po
 Duphaston 2 x 10 mg po
 Cygest 1 x 400 mg supp
 Folavit 1 x 400 mcg po
Take Home Medicine


Weekly Report FINAL

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Weekly Report FINAL

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WEEKLY REPORT

dr. Yuma Sukadarma, Sp.OG

Jevon Andra 2015.061.112

Cindy Amadea 2015.061.197

Yonathan Ardhana 2015.061.201

DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY

ATMA JAYA CATHOLIC UNIVERSITY OF INDONESIA

MARCH 20th 2017 – MAY 27th 2017

 History of present illness:

 History of past ilness:

 History of menstrual cycle:

 History of antenatal care:

III. PHYSICAL EXAMINATION

VII. FINAL DIAGNOSIS

IX. TAKE HOME MEDICINE

History of Present Illness

History of Past Illness

History of Menstrual Cycle

History of Antenatal Care

III. PHYSICAL EXAMINATION

 Blood pressure : 120/80 mmHg

Types Results Units Normal Value

Hemoglobin 10.0 g/dL 12.0 – 15.8

History of Present Illness

History of Past Illness

History of Menstrual Cycle

History of Antenatal Care

III. PHYSICAL EXAMINATION

Cardiotocography : Not performed

Types Results Units Normal Value

Hemoglobin 11.7 g/dL 11.1 – 15.7

Leucocytes 25.1 103/µL 4.8 – 10.8

Platelets 440 103/µL 150 – 450

Erythrocyte 4.27 106/ µL 4.2 – 5.4

MCHC 33.7 g/dL 32 – 36

Blood Type O / Rh (+)

HBsAg (-) Negative

VI. FINAL DIAGNOSIS

Take Home Medicine

 History of present illness:

 History of past ilness:

 History of menstrual cycle:

III. PHYSICAL EXAMINATION

VII. FINAL DIAGNOSIS

IX. TAKE HOME MEDICINE

P3A2, 41 years old, with antepartum hemorrhage ec. blighted ovum

 History of present illness:

History of past ilness:

 History of menstrual cycle:

 History of antenatal care:

III. PHYSICAL EXAMINATION

VI. WORKING DIAGNOSIS

VIII. FINAL DIAGNOSIS

X. TAKE HOME MEDICINE

History of Present Illness

History of Past Illness

History of Menstrual Cycle

History of Antenatal Care

IV. WORKING DIAGNOSIS

VI. FINAL DIAGNOSIS

Post dilation and curettage treatment

Take Home Medicine

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