DUTY REPORT

Thursday, December 7th 2017

Supervisor :
dr. Mulda F. Situmorang, Sp.OG

Residents :
1. dr. Irfan Hamidi
2. dr. Donny Mega Surya
3. dr. M. Iqsan
4. dr. Mega Sari Dewi
5. dr. Frida Adhani E.S

Department of Obstetric and Gynecology

Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2017
NEW PATIENT : 1 PATIENT
1. Mrs. D, 26 yo, G2P1A0
Diagnosis : Preterm labor + gemelli + SG + IUP (33-34)
wga + - Head Presentation + alive fetus
- Breech Presentation + alive fetus
Planning : observe labor progress
PATIENT 1
Mrs. D, 26 y.o, G2P1A0, Karonese, Muslim, housewife, married to Mr.
I, 39 y.o, Acehnese, Muslim, Enterpreneur, was admitted to Adam
Malik General Hospital on December, 8th 2017, at 00.10 am with:

Cc : Intermitten labor contraction

Review : this complaint has been experienced by the patient since
December 6th, 2017 at 5 pm, history of sexual intercourse (-). History
of leuchorrea (+), smell (+), pain (-). Micturition and defecation were
within no abnormality. History of blood slime (-). History of amniotic
fluid leakage (+), since December 6th, 2017 at 3 pm

LMP : ?/3/2017
EDD : ?/12/2017
ANC : 1 time, obstetrician
History of Previous illness : -
History of Medication :-
History of Surgery :-

History of pregnancy :
1. Baby boy, 3.500 grams, aterm, SVD, midwife, clinic, 2 years,
healthy.

2. Current pregnancy
Vital Signs
Cons : fully alert Anemic : (-)
BP : 130/80 mmHg Icteric : (-)
Pulse : 80 bpm Cyanosis: (-)
RR : 20 x/i Dypsnoe: (-)
Temp : 36,5C Edema : (-)

Localized Status :
Head : anemic inferior palpebra conj (-), icteric (-)
Neck : no abnormality
Thorax : respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rhales (-)/(-)
Obstetric State
Abdomen : asymetrically enlarge
Fundal Height : 2 fingers below xypoid proccess (28cm)
Tension part :
Lower part :
Fetal Movement : (+)
Uterine contraction : 2x10/10
Fetal Heart Rate : baby140/ baby150 bpm, regularity

Gynecological State
VT : Cx sacral, 3 cm, Eff 40 %, minor fontalnel ?, Head
H I II, amniotic membrane (-)
Gloves : bloodslime (-), amniotic fluid (+)
USG TAS
USG TAS
USG TAS
USG TAS
Transabdominal sonography report
Gamelli, Head presentation, breech presentation
FHR (+), FM (+)
Baby 1 Baby 2
BPD :8.44cm - BPD:8.40cm
HC:29.97cm - HC:29.48cm
AC:29.45cm - AC: 30cm
FL:6.75cm - FL:6.70cm
Placenta Corpus anterior grd I
Separated amniotic membrane (-)
SDP:4cm
Conclusion: IUP (33W 4D)wga+Head presentation, breech
presentation+ alive fetus, monochorionic monoamniotic
LABORATORY FINDINGS on December 8th 2017

Hb : 10.0 N: 12-14 gr/dL

Leukocyte : 12.720 N: 4000-11000/uL
Hematocrite: 31 N: 36,0-42,0/%
Platelet : 402.000 N: 150.000-400.000/uL
Ad Rand Glucose: 79 N: < 200 mg/dl
Ureum : 11 N: 15-40 mg/dl
Creatinine : 0.69 N: 0.6-1.1 mg/dl
Natrium : 133 N: 135-155mEq/L
Kalium : 3.9 N: 3.6-5.5mEq/L
Chloride : 106 N: 96 106mEq/L
HBsAg : Non Reactive
HIV : Non Reactive
Diagnosis : Preterm labor + gemelli + IUP (33-34) wga +
- Head Presentation + alive fetus
- Breech Presentation + alive fetus

Therapy : IVFD RL 20 drop/minute

Dexamethasone injection 6mg/12 hours (for 48 hours)
/IV
Ceftriaxone injection 1 gr/12 hours (skintest)

Planning : observe labor progress

Vital sign, vaginal bleeding, uterine
contraction,fetal heart rate
THANK YOU