DUTY REPORT

Monday, February 4th 2019

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

Residents :
1. dr. Cherry Kumala Sari
2. dr. Luthfi Aditiarahman
3. dr. M. Iman Syahputra
4. dr. Paul Alwin Khoman
5. dr. M. Ramadhan H.
6. dr. Frida Adhani E.S

Department of Obstetric and Gynecology

Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2019
1. Mrs. L, 35 y.o, G2P0010
Diagnose : Chronic Ruptured Ectopic Pregnancy + Post laparatomy (other
hospital) + H1
Planning : - Monitoring Vital Sign, Sign of acute abdomen
- Relaparotomy during office hour (consideration for joint operation
with Surgery department)
- Consult to Gynecology division

2. Mrs. D, 27 y.o, G3P1011

Diagnose : Preeclampsia with severe feature + MG + IUP (28- 30) wga + live
fetus
Planning : - Pregnancy termination after lung maturation
- Monitoring Vital Sign, Fetal Heart Rate, Sign of Inlabour and Sign
of Eclampsia
On 6/2/2019 at 15:45 pm, a baby girl was born with BW: 1050 kg, BL: 38cm, AS:
6/8 , Anal (+)
3. Mrs. R, 36 y.o, G5P3013
Diagnose : Loss of consciousness d/t ? + HIV + MG + IUP (32-34) wga
+ Head presentation + live fetus
Planning : - Monitor vital sign, fetal heart rate, uterine contraction,
and sign of seizure
- Consult to Neurology Departement
PATIENT 1
Mrs. L, 35 y.o, G2P0010, bataknese, moslem, Senior High School, Housewife, married
to Mr. E, 37 y.o, karonese, moslem, junior High School, Entrepreneur.
The patient was admitted to Adam Malik General Hospital on February 4th 2019, at
04.30 pm with:

Cc : Abdominal pain
E : this has been experienced by the patient since 1 hour before. Previously, the
patient underwent laparotomy surgery on February 4th 2019 at 12.00 pm in other
Hospital with diagnosis “ruptured ectopic pregnancy”. During operation, extensive
adhesion was found, the surgery was stopped and patient was referred to Adam
Malik General Hospital.
History of lower abdominal pain (+) intermittent and history of blood spot (+),before
laparotomy. History Vaginal bleeding was found on January 15th 2019, with volume
changing pads 2-4x/ day. History of vaginal discharge (+). Micturition and defecation
within normal limits.
History of previous illness : Ruptured Ectopic Pregnancy ?
History of Medication : Inj. Ceftriaxone 1gr IV, Inj. Ketorolac 30mg IV, Inj.
Ranitidine 50 mg IV
History of operation : Laparatomy (4/2/2019)
LMP : 15/11/2018
EDD : 22/8/2018
ANC : Obstetrician 4x

Obstetrical history:
1. Abortus (2009)
2. Current pregnancy
Vital Signs
Sens : Alert Anemic : (-)
BP : 110/60 mmHg Icteric : (-)
Pulse : 92 x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 37.0°C Edema : (-)

General state : Moderate

Illness State : Moderate
Nutritional state : Good

Generalized Status :
• Head : Inferior palpebra conj. anemic (-), icteric (-)
• Neck : No abnormality
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-/-), rhales (-/-)
• Extremities : Pretibial oedem (-)
VAS
Obstetrical State
•Abdomen : lax, peristaltic (+)
•Operation Wound : pfanensteil, covered by Sterile gauze
•Vaginal bleeding : (-)
•Micturition : (+) via catheter with UOP 70 cc/hours, yellowish colour
•Defecation : (-)

Gynecological state:
Inspeculo : portio was smooth, lividae (+), Blood (-), F/A(-)
Vaginal toucher : Cervical motion tenderness (+), douglas cavity was
protruded, Uterus and adnexa was difficult to
assess(due to pain).
USG TVS
USG TVS
USG TVS
USG TVS
• Bladder was not filled
• UT AF with normal size 6,21 cm x 4,39 cm
• Hypoechoic appereance intrauterine
• Hypoechoic and Hyperechoic appereance was found in douglas cavity
 blood clot ?
• Hipoechoic apparence in adnexa region with size 2,14cm x 1,82cm

Conclusion: Ruptured Ectopic Pregnancy ?

 Laboratory Findings
February, 4th 2018 (05:16 pm)
• Hb : 11,6 N: 12-14 gr/dL
• Leukocyte : 19.010 N:4.000-11.000/uL
• Hematocrite : 34 N: 36,0-42,0/%
• Platelet : 450.000 N:150.000-400.000/uL
• MCV : 92 N : 81-99
• MCHC : 33,9 N : 31-37
• Ureum :9 N: 10-50 mg/dl
• Creatinin : 0,60 N: 0.6-1.2 mg/dl
• KGD ad : 90 N: <200
• BUN :4 N: 7-19mg/dL
• Natrium : 136 N: 136-155 mmol/dl
• Kalium : 4,2 N: 3.5-5.5 mmol/dl
• Chlorida : 105 N: 95-103mmol/dl
• HbsAg : Non reactive
• HIV : Non reactive
• Pregnancy Test : (+)
 Laboratory Findings (08:37 WIB)
February, 4th 2018
• Hb : 11,3 N: 12-14 gr/dL
• Leukocyte : 16.170 N:4.000-11.000/uL
• Hematocrite : 33 N: 36,0-42,0/%
• Platelet : 428.000 N:150.000-400.000/uL
• MCV : 91 N : 81-99
• MCHC : 34,5 N : 31-37
Diagnosis :
Chronic Ruptured Ectopic Pregnancy + Post laparatomy (other hospital) + H1
Therapy :
-IVFD RL  20dpm
-Inj. Ceftriaxone 1gr/12hrs
-Inj. Ketorolac 30 mg/8 hrs

Plan :
- Monitoring Vital Sign, Sign of acute abdomen
-Relaparotomy during office hour (consideration for joint operation
with Surgery department)
- Consult to Gynecology division
Report to Supervisor on duty  dr. Letta S. Lintang, M.Ked(OG), Sp.OG(K) →
Approved.
THANK YOU
PATIENT 2
Mrs. D, 27 y.o, G3P1011, Javanese , Moeslem, senior High School, housewife,
married with Mr. A 30 y.o, Javanese, Moeslem, junior High School, Enterpreneur.
The patient was admitted to Adam Malik General Hospital on February 4th 2018 at
05.00 pm, with:

Cc : Headache
E : This has been experienced by the patient since 3 days ago, worsened since
today, and blurred vision was found since 3 days. Epigastric pain was not found.
History of hypertension during this pregnancy (+), history of hypertension in
previous pregnancy (-), history of hypertension before pregnancy (-).
History of labour contraction (-), History of bloody show (-), history of amnionic fluid
leakage (-). Micturition and defecation no abnormality.
History of previous illness :-
History of Medication : Loading Dose MgSO4 20% (4gr), Maintenance
MgSO4 40% (6gr)  28gtt/I (1gr/hours)
LMP : ?/07/2018
EDD : ?/4/2019
ANC : Obstetrician 1 x, Midwife 5x

History of pregnancy :
1.Abortus (2010)
2. Male, 3200 gr, aterm, SVD, Clinic, Midwife, 7 yo, Healthy
3.Current pregnancy
Vital Signs
Cons : Alert Anemic : (-)
BP : 180/120 mmHg Icteric : (-)
Pulse : 88x/i Cyanosis : (-)
RR : 24x/i Dypsnoe : (-)
Temp : 36,5°C Edema : (-)

General state : Moderate

Nutritional state : Good Upper Arm Cirumference : 25cm
Illness State : Moderate

Generalized State :
• Head : Eye: Inferior palpebra conj. anemic (-), icteric (-),
• Neck : no abnormalities
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
• Abdomen : symetrically enlarged
• Extremities : no abnormalities
Obstetrical State
•Abdomen : Symetrically enlarged
•Fundal height : 3 fingers above navel (28 cm)
•Fetal Heartrate : 150x/i, regular
•Uterine Contraction :-
•Movement : (+)

Gynecological state
Inspeculo : not performed
VT : cervix not dilated
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
- Singleton, live fetus
- Fetal movement (+), Fetal heart rate (+) 151 bpm
- BPD : 7,6 cm
- HC : 27,62 cm
- AC : 25,01 cm
- FL : 5,27 cm
- Placenta : Posterior grade I
- MVP : 7,81 cm
- EFW : 1337 gr
- CEREB : 3,63cm (30w)

Conclusion : IUP (29-30) wga + live Fetus

 Laboratory Findings
February, 4th 2018
• Hb : 12,6 N: 12-14 gr/dL
• Leukocyte : 15.570 N: 4.000-11.000/uL
• Platelet : 235.000 N: 150.000-400.000/uL
• Hematocrite : 37 N: 36,0-42,0/%
• MCV : 89 N : 81-99
• MCHC : 34,1 N : 31-37
• APTT : 25,4 C; 33,0 s
• PT : 15,2 C:14.00s
• INR : 1,05 C: 0,8-1,3
• BUN :5 N: 7-19 mg/dl
• Ureum : 11 N: 15-40 mg/dl
• Creatinin : 0,59 N: 0.6-1.1 mg/dl
• KGD ad : 100 N: <200
• Natrium : 136 N: 136-155 mmol/dl
• Kalium : 3,6 N: 3.5-5.5 mmol/dl
• Chlorida : 103 N: 95-103mmol/dl
• Fibrinogen : 412,0 N: 150-400mg/dL
• D-dimer : 587 N: <500 ng/ml
• HbsAg : Non Reactive N: Non Reactive
• HIV : Non Reactive N: Non Reactive

Urinalysis
Proteinuria : positive (+1)
Follow Up
Time Sens BP HR RR Temp Therapy

05.00 pm Alert 180/120 98 x/i 24x/i 36,7 C Nifedipine 10 mg

06.00 pm Alert 170/110 94 x/I 20x/I 36,8 C Nifedipine 10 mg

07.00 pm Alert 160/100 92 x/I 22x/I 36,6 C Nifedipine 10 mg

08.00 pm Alert 150/100 96 x/I 22x/I 36,5 C

09.00 pm Alert 150/100 92 x/I 20x/I 36,6 C

10.00 pm Alert 150/100 94 x/I 24x/I 36,5 C

11.00 pm Alert 150/100 88 x/I 20x/I 36,6 C

12.00 pm Alert 150/100 86 x/i 20x/i 36,8 C

Follow Up
Time Sens BP HR RR Temp Therapy

01.00 am Alert 150/100 86 x/I 24x/i 36,7 C

02.00 am Alert 150/100 88 x/I 22x/I 36,6 C

03.00 am Alert 150/100 78 x/I 23x/I 36,5 C

04.00 am Alert 150/100 77 x/I 24x/I 36,6 C

05.00 am Alert 150/100 86 x/I 22x/I 36,6 C

06.00 am Alert 150/100 88 x/I 20x/I 36,8 C

07.00 am Alert 150/100 88 x/I 24x/i 36,4 C

08.00 am Alert 150/100 86 x/I 24x/i 36,5 C

Diagnose :
Preeclampsia with severe feature + MG + IUP (28-30) wga + live Fetus

Therapy:
- O2 nasal canul 2-4 L/i
- IVFD RL + MgSO4 40% 30cc (1gr/hr)  14 dpm
- Nifedipine 4x10 mg, if Blood Preassure > 160/110 mmHg administer extra 10 mg
Nifedipine per ½ hours. (Max dose 120 mg / day)
- Inj. Dexamethasone 15mg IV

Plan :
- Pregnancy termination after lung maturation
- Monitoring Vital Sign, Fetal Heart Rate, Sign of Inlabour and Sign of Eclampsia

Report to supervisor on duty dr. Letta S. Lintang, M.Ked(OG) Sp.OG(K) → Approved.

On 6/2/2019 at 15:45 pm, a baby girl was born with BW: 1050 kg, BL: 38cm, AS: 6/8 ,
Anal (+)
THANK YOU
PATIENT 3
 Mrs. R, 37 y.o, G5P3013, Bataknese, Christian, Senior High School, housewife,
married with Mr. S 35 y.o, Bataknese, Christian, Senior High School, Farmer.
The patient was admitted to Adam Malik General Hospital on February 4th 2018 at
11.30 pm, with:

Cc : loss of consciousness
E : This has been experienced by the patient since yesterday after first seizure
(3/2/2019 at 04.00 pm) and another seizure experienced on 4/2/2019 at 04.00 pm.
Severe headache was experienced before seizure. Projectile vomiting (+). Fever (-).
History of hypertension during this pregnancy (-). History of hypertension in
previous pregnancy (-), history of hypertension before pregnancy (-). History of labor
contraction (-), history of bloody show (-), history of amnionic fluid leakage (-).
This patient was refered from other hospital with the diagnosis: “Susp HIV +
Encephalitis + MG + IUP(33-34)wga + live fetus“ . Micturition and defecation no
abnormality.
History of previous illness : Ensephalitis?, HIV?
History of Medication :-
LMP : ?/?/2018
EDD : ?/?/2019
ANC : Obstetrician 1x, Midwife 2x

History of pregnancy :
1. Abortus (2008)
2. Female, 3200 gr, aterm, SVD, Clinic, Midwife, 9 yo, Health
3. Male, 3100 gr, aterm, SVD, Clinic, Midwife, 7 yo, Health
4. Male, 3500 gr, aterm, SVD, Clinic, Midwife, 5 yo, Health
5. Current pregnancy
Vital Signs
Cons : Apatis E3M5V2 (GCS:10) Anemic : (-)
BP : 110/80 mmHg Icteric : (-)
Pulse : 92x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 37,0°C Edema : (-)

General state : Moderate

Nutritional state : Good Upper Arm Cirumference : 27cm
Illness State : Moderate

Generalized State :
• Head : Eye: Inferior palpebra conj anemic (-), icteric (-),
• Neck : no abnormalities
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
• Abdomen : symetrically enlarged
• Extremities : no abnormalities
Obstetrical State
• Abdomen : Symetrically enlarged
• Fundal height : between xyphoid process-umbilical (32cm)
• Tension part : Right
• Lower part : Head
• Fetal Heartrate : (+) 158x/i, regular
• Uterine Contraction : (-)
• Fetal Movement : (+)

Gynecological state
Inspeculo : not performed
VT : cervix not dilated
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
- Singleton fetus, Head presentation, live fetus
- Fetal movement (+), Fetal heart rate (+) 158 bpm
- BPD : 8,31cm
- HC : 32,26 cm
- AC : 30,66 cm
- FL : 7,13cm
- Placenta Lateral Posterior grd II
- MVP : 3,08 cm
- EFW : 2588 gr
- S/D ratio : 2,73

Conclusion : IUP (33-34) wga + Head Presentation + live Fetus

 Laboratory Findings
February, 4th 2018

• Hb : 9,8 N: 12-14 gr/dL

• Leukocyte : 5.400 N: 4.000-11.000/uL
• Platelet : 276.000 N: 150.000-400.000/uL
• Hematocrite : 30 N: 36,0-42,0/%
• MCV : 81 N : 81-99
• MCHC : 32,7 N : 31-37
• APTT : 25,2 C; 33,0 s
• PT : 13,9 C:14.00s
• INR : 0,96 C: 0,8-1,3
• BUN :8 N: 7-19 mg/dl
• Ureum : 17 N: 15-40 mg/dl
• Creatinin : 0,48 N: 0.6-1.1 mg/dl
• KGD ad : 99 N: <200
• Albumin : 3.1 N: 3.5-5.0 g/dL
• LDH : 78 N: 125-220 U/L
• Natrium : 131 N: 136-155 mmol/dl
• Kalium : 3,6 N: 3.5-5.5 mmol/dl
• Chlorida : 101 N: 95-103mmol/dl
• Procalcitonin : 0,26 N: <0.05
• HbsAg : Non Reactive N: Non Reactive
• HIV : Reactive N: Non Reactive
Diagnose :
Loss of consciousness d/t ? + HIV + MG + IUP (33-34)wga + Head presentation + live
Fetus

Therapy:
- IVFD RL  20 dpm

Plan :
- Monitor vital sign, fetal heart rate, uterine contraction and sign of seizure
- Consult to Neurology Departement

Report to supervisor on duty dr. Letta S. Lintang, M.Ked(OG) Sp.OG(K) → Approved.

Neurology Departement (5-2-2019 at 00.30 AM)
• Diagnosis : MG + IUP (33-34) wga + head presentation + live fetus
• Advise :
• General improvement
• There is no abnormality in neurology departement
• Control at neurology outpatient clinic
Internal Medicine Departement (5-2-2019)
• Diagnosis :
• HIV std III
• Susp. Encephalitis Toxoplasmosis
• MG + IUP (33-34) + head presentation + alive fetus
• Advise :
• Therapy based on obgyn departement
• Agree for join care in PTI division
Neurosurgery Departement (5-2-2019)
• Assesment: Immediate Head CT Scan
Head CT Scan Result: no abnormality
Advice: Consult to Neurology departement with Susp.
Meningoensephalitis
THANK YOU