OBSTETRIC OUTPATIENT

REPORT
Wednesday, March 27th, 2019
Residents:
Dr. Eka Handayani Oktharina
Dr. Sary Indriani
Dr. M. Fauzi Chairul Husna
Dr. Wadhit Taubah
Dr. Wisman Agustian
Dr. Alia Desmalia
Dr. M. Izwan Iqbal Tyasta

Supervisor:
Dr. Hj. Fatimah Usman, OBGYN(C)
Recapitulation Obstetric Outpatient
th
Wednesday, March 27 , 2019
Physiology Patient 0
Pathology Patient 2
Total 2
 Friday, March 22th 2019 – Thursday, March 28th 2019

Physiology Pathology Total

Friday, Mar 22th ,2019 0 1 1

Monday, Mar 25th 2019 0 0 0
Tuesday, Mar 26th 2019 0 2 2
Wednesday, Mar 27th 2019 0 2 2
Thursday, Mar 28th 2019
Total
NO. IDENTITY DIAGNOSIS ICD-10 MANAGEMENT ICD-9

1 Mrs. MEI/30 G1P0A0 27 weeks gestational Z34.01 - CIE 89.0

88.78
Y.O/RA/AA age with intramural uterine B06.9 - US Examination
myoma SLF transverse lie - Calcium Lactate 3 x 500mg
- Ferrous Sulphate 1 x 300 mg

2 Mrs. TIN/26 G2P1A0 33 weeks gestasional Z34.0 - CIE 89.0

Y.O/ RS/ NS age with HIV infection SLF
cephalic presentation
V72.62
O98.7 - US Examination
88.78
- Laboratory examination
- - Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral
Mrs. MEI/ 30 Y.0/ RA/ AA
Chief Complain Preterm Pregnancy with myoma uterine intramural
Anamnesis Patient came to Fetomaternal Polyclinic control her pregnancy. History of abdominal contraction spread to
waist and back (-), history of bloody show (-), history of amnionic leakage (-). At January 27th 2019 patient
was referred from Banyuasin Hospital with diagnosis G1P0A0 17 weeks gestational age with uterine
myoma SLF intrauterine. Patient admitted that her pregnancy was preterm and fetal movement (+).

Marital status 1x, 1 years

Reproduction History Menarche since 13 yo, regular, lasts 7 days, LMP: forgot
Obstetric status 1. Current pregnancy

Physical Examination Vital Signs

Sens: Compos Mentis BP: 120/80 mmHg Pulse : 86 x/m T: 36,5oC RR: 18 x/m BW 49 kg BH 153 cm

Obstetric Palpation: Uterine fundal ½ umbilical - proc xyphoideous (27 cm), transverse lie, dorso inferior, uterine
Examination contraction (-), FHR 147 bpm.

Lab examination Hb: 9,6 g/dL, RBC : 3.460/mm3, WBC: 17.200/mm3, HT 29 % PLT: 371.000/mm3, MCV 83,2 , MCH 28 ,
(02-01-2019) MCHC 33, Fe 31, TIBC 329 , SGOT 10, SGPT <6 , BSS 80, Ur 15, Cr 0,61 Uric acid 5,0 ,Ca: 10,0, Mg: 1,80,
Na : 144 , K: 4,3 , Cl : 107, ferritin 307,60, HBsAg non reactive, anti HIV non reactive, VDRL non reactive,
TPHA non reactive
Mrs. MEI/ 30 Y.0/ RA/ AA
US Examination - SLF transverse lie
PM - Fetal Biometry
(27-03-2019) BPD 6,7 cm HC 25,4 cm AC: 23,1 cm FL : 5,1 cm EFW 1107 g
- Nuchal cord 2x
- Placenta at posterior corpus
- Amniotic fluid sufficient, SDP 4,2
- Hypoechoic mass with clear border without vascularization, with echointerna at right anterior corpus,
intramural uterine myoma with cyst degeneration was suspected.
C/ 27 weeks gestational age with intramural uterine myoma with cyst degenaration SLF transverse lie
Diagnosis G1P0A0 27 weeks gestational age with intramural uterine myoma, SLF transverse lie
Therapy
- CIE
- US Examination
- Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)
Mrs. TIN/ 26 Y.0/ RA/ NS
Chief Complain Preterm Pregnancy with HIV Infection
Anamnesis Patient came to Fetomaternal Polyclinic control her pregnancy. History of abdominal contraction spread to
waist and back (-), history of bloody show (-), history of amnionic leakage (-). Patient admitted that her
pregnancy was aterm and fetal movement (+). She was diagnosed with HIV Infection since 16 weeks
gestational age. She consumed ARV (neviral and duviral) regullary since then.

Marital status 1x, 3 years

Reproduction History Menarche since 12 yo, irregular, lasts 7 days, LMP: forgot
Obstetric status 1. 2018. female. 2700 g. spontaneous delivery. Midwife. ✝︎(after birth)
2. Current pregnancy
Physical Examination
Vital Signs
Sens: Compos Mentis BP: 120/80 mmHg Pulse : 84 x/m T: 36,8oC RR: 18 x/m BW 56 kg BH 153 cm
Obstetric
Examination Palpation: Uterine fundal 3 fingers below proc xyphoideous (35 cm), longitudinal lie, right back, cephalic,
U 5/5, uterine contraction (-), FHR 135 bpm
Lab examination
(26-03-2019) Hb: 10,1 g/dL, RBC : 3.370/mm3, WBC: 2.410/mm3, HT 30 % PLT: 309.000/mm3, PT 12,8 (control 14,6), INR
0,94 , APTT 30,7 (control 29,6), fibrinogen 351,0 (control 320,0), D-Dimer 1,39, HBsAg non reactive, anti
HAV Ig M non reactive, Anti HCV non reactive, anti HIV reactive, VDRL non reactive, TPHA non reactive
Mrs. TIN/ 26 Y.0/ RA/ NS
US Examination - SLF cephalic presentation
PM - Fetal Biometry
(27-03-2019) BPD 8,4 cm HC 29,9 cm AC: 29,9 cm FL : 6,4 cm EFW 2283 g
- Placenta an anterior corpus
- Amniotic fluid sufficient
C/ 33 weeks gestational age SLF cephalic presentation
Diagnosis G2P1A0 33 weeks gestational age not Inlabor with HIV Infection, SLF Cephalic presentation
Therapy
- CIE
- US Examination
- Laboratory examination
- Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)
THANK YOU