Duty Team: 1. Dr. Juhriani Malahayati2. Dr. Irliansyah Putra3. Dr. Isnayu4. Dr. Irfan Hamidi5. Dr. Ria Suci6. Dr. Ryan Andrian7. Dr. Dwi Fenny Amir

Obstetric dan Gynecology DepartmentFaculty of Medicine of USU/ RSUP HAM

2015

Duty ReportMonday , June 12nd 2015

Supervisor on duty: Dr. dr. Sarma N. Lumbanraja, M.Ked(OG), SpOG.K

1. Mrs. K, 29 years old, G4P3A0Dx : IUFD + MG + IUP (28-30) gw + preeclampsia BERAT+ partial HELLP syndromePlanning : - Inj. MgSO4 20% 4 gram loading dose - Inj. MgSO4 40% 12 gram maintenance dose - Inj. Dexamethasone 10 – 10 – 5 – 5 gram (48 hours)

PATIENT 1

1. Mrs. K, 29 years old, G4P3A0, moslem , housewife wife of Mr.

E ,40 yo,, moslem,admitted at Adam Malik Hospital at August

30th 2015, 03.00 a.m. with :

CC : Decreased of consciousness (alloanamnesis)

E : Experienced by the patient since this morning,

history of fever (+) since 3 days ago. The characteristic of fever is

intermitten and get little better with antipyretic. history of nausea and

vomiting (-) history of blood from vagina (-). History of abdominal

pain (-) . History of water from vagina (-), History of hypertension before

pregnancy (-). History of hypertension on the previous pregnancy (-).

Headache (-), blurred vision (-). Defecation and micturition normal.

Previous ilness: Diabetes (-), Hypertension (-), asthma (-)

Previous medical hist: -

HPHT : Unclear

TTP : Unclear

ANC : Midwife 5 x

Hystory of pregnancy :

1. ♂ ,aterm, 2500 gram, PSP, Midwife, clinic, 12 yo, healthy

2. ♂ ,aterm, 3500 gram, PSP, Midwife, clinic, 6 yo, healthy

3. ♀, aterm, ? gram, PSP, Midwife, clinic, 2 yo, healthy

4. This pregnancy

Vital SignCons : apatis Anemic : ( - )BP : 180/100 mmHg Icteric : ( - )Pulse : 94x/i Cyanosis : ( - )RR : 28 x/i Dypsnoe : ( + )Temp : 36,2°C Edema : ( -)

Proteinuria : +3

Localized State :

Head : Conj Palpebra inferior anemic ( -)/(-), icteric (-)/(-)

Neck : in normal limit

Thorax: Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki

(-)/(-)

Obstetrical state :• Abdomen : assymetricaly enlarged• Fundal Height : 3 fingers above umbilical• Teregang : right• Terbawah : head• Movement : -• His : -• FHR : -

• VT : Servix closed

• Dx : IUFD + MG + IUP (28-30) gw + preeclampsia BERAT+ partial HELLP syndrome

• Planning: - Inj. MgSO4 20% 4 gram loading dose - Inj. MgSO4 40% 12 gram maintenance dose - Inj. Dexamethasone 10 – 10 – 5 – 5 gram (48 hours)

– Report to supervisor Dr. dr. Sarma N. Lumbanraja, M.Ked(OG), SpOG.K Acc

LABORATORY FINDINGS on 30/08/2015

Hb : 14.9gr/dl N: 12-14/gr/dl

Leukocyte : 34,23 /mm3N: 4000-11000/uL

Hematocrit : 45,8 % N: 36,0-42,0/%

Platelet : 52 /mm3N:150.000-400.000/uAd Random Glucose : 30 mg/dlN: < 200 mg/dl• APT : 129,8 C= 33,5 S• PT : 65,2 C= 14 S• TT : 29,5 C = 17,8 S• Ureum : 14,87 N : 10-50 mg/dl• Creatinin : 1,3 N : 0,6-1,2 mg/dl• Natrium : 128 mg/dl N : 135-155 mg/dl• Kalium : 6,9 mg/dl N : 3,6- 5,5 mg/dl• Klorida : 85 mg/dl N : 96-106 mg/dl

• USG belum ada

USG TAS• Single fetus, head presentation• FM (-), FHR (-)• BPD 7,69 cm• FL 5,31 cm• AC 25, 69 cm• HC 28,22 cm• Placenta corpus anterior• Amnion fluid : MVP = 4Kesan : IUFD + IUP (29-30) gw + Head

presentation

THANK YOU