WEEKLY REPORT

January 24th 2016 January 31st 2016

Supervised by:
dr. Arie Polim, Sp.OG K-FER

By:
Klarissa Chrishalim

2014-061-182

Sharon Issabel

2014-061-189

Felix Sumampow

2014-061-190

Department of Obstetric and Gynecology

Faculty of Medicine Indonesian Catholic University of Atma Jaya
2016

OBSTETRIC PATIENT

No

Date
admission

Name

First diagnosis

Final Diagnosis

Neonates
diagnosis
I: Male neonate, 36
weeks according to
NBS with birth
weight of 2150

1.

27/01/16

Mrs. Y

G3P2A0, 28 years old,

P3A0, 28 years

gravid 35-36 weeks

old, post partus

based on USG

prematurus by

examination, in labor,

spontaneous per

1st active phase, with

vaginam delivery,

two intrauterine living

post episioraphy

fetuses, cephalic

indicated by

presentation of both

perineum rupture

fetuses.

grade I

grams, length of 46
cm and APGAR
Score 7/9, with
diagnose healthy
neonate
II: Male neonate, 36
weeks according to
NBS with birth
weight of 2710
grams, length of 48
cm and APGAR
Score 7/9, with
diagnose healthy
neonate

G2P1A0, 19 years old,

gravid 37-38 weeks
based on the first day
of last menstruation
2

28/01/16

Mrs. U

period, with severe

Preeclampsia, in labor
1st active phase, with a
single intrauterine
living fetuses, cephalic
presentation

28/01/16

Mrs. H
G1P0A0 18 years old,

P2A0, 19 years
old, post partus

Male neonate, 37-

maturus by

38 weeks according

spontaneous per

to NBS, birth

vaginam labor,

weight of 3,150

post episioraphy

gram, length of 50

indicated by

cm, and APGAR

perineum rupture

Score 9/9, with

grade II, with

diagnose healthy

history of severe

neonate.

preeclampsia
P1A0, 18 years

Male neonate, 38-

old, post partus

39 weeks according

gravid 38-39 weeks

based on first day of
the last menstruation
period with severe
preeclampsia, in labor
with prolonged 2nd
phase, with a single
intrauterine living
fetus, cephalic
presentation.

29/01/16

Mrs. N

maturus by
spontaneous per
vaginam labor,
post episioraphy
indicated by
perineum rupture
grade II, with
history of severe
preeclampsia

to NBS with birth

weight of 3130
grams, length of 49
cm and APGAR
Score 8/9, with
diagnose healthy
neonate.

G1P0A0 19 years old,

P1A0, 19 years

Male neonate, 37-

gravid 37-38 weeks

old, post partus

38 weeks according

based on USG, in labor

maturus by

to NBS with birth

with prolonged 1st stage spontaneous per

weight of 3035

with a single

vaginam delivery,

grams, length of 46

intrauterine living

post episioraphy

cm and APGAR

fetuses, cephalic

indicated by

Score 7/9, with

presentation

perineum rupture

diagnose healthy

grade II

neonate.

CASE 1
G3P2A0, 28 years old, gravid 35-36 weeks based on USG examination, in
labor, 1st active phase, with two intrauterine living fetuses, cephalic
presentation of both fetuses.
Identity

Name

: Mrs. Y

Age

: 28 years old

Ethnic

: Sundanese

Religion

: Moslem

Education

: Bachelor Degree

Occupation

: Housewife

Date of admission : January 27, 2016

Anamnesis

Chief complaint:
Patient complaints of abdominal discomfort since 3 hours before admission to
hospital
History of present illness:
Patient complaints of abdominal discomfort since 3 hours before admission to
hospital. She also feel contraction that become more frequent. According to the
mother, there are no bloody vaginal discharge and leakage of fluid. She has done
routine Antenatal Care with no pregnancy induced hypertension, anemia, and STDs. 2
days earlier, she was given dexamethasone injection 10 mg IM each day.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

o History of surgery

: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder

: Denied
: Denied
: Unknown
: Unknown
: Unknown
: Unknown

Habitual history

History of menstrual cycle:

o Menarche
: 11 years old
o Menstrual cycle
: regularly, with duration of 5
days, cycle every 30 days, 60 ml/day, dysmenorrhea (-)
o First day of last menstrual cycle
: April 8th, 2015

Marital History

years.
Obstetric history
No
1
2
3

Date
2005
2011

: alcoholic (-), smoking (-), drugs (-)

: Married twice, has been with this husband for 4.5

Gestational

Labor

Age

History

Sex

Result
Birth

Breast Feeding

9 months

Per

Weight
2500 gr

7 months

Vaginam
Per

1300 gr

35-36

Vaginam
-

Present

weeks

Contraception History
Last used

: Injections
: 2011

History of antenatal care

: 8 times at Puskesmas and 3 times at Atma Jaya,

pregnancy induced hypertension (-), anemia (-), tetanus toxoid (-), sexual transmitted
disease (-)
Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 110/70 mmHg

Pulse rate

: 72 beats/minutes

Respiratory rate

: 16 breaths/minutes

Body temperature

: 36.3C

Body weight before pregnancy : 50 kg

Height

: 153 cm

BMI before pregnancy

: 21,19 kg/m2

Current body weight

: 62 kg

Total weight gain

: 12 kg

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-

Abdomen
Inspection
Auscultation
Palpation
Extremities

: Convex, linea nigra (+), striae gravidarum (+)

: Bowel sounds (+), 6 x/min
: Supple, pain with palpation (-)
: Warm extremities,
Edema -++-

,CRT < 2 seconds

Physiologic reflex
++ ++ , pathologic reflex-++-

Obstetrics examination

Estimated due date

Fundal height
Fetal weight estimation
Uterine contraction
Fetal heart rate

Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV

++ ++

: January 15th, 2015

: 42 cm
:: (+) 5x/10 menit (40-45)
:
- 1st Baby: 140 bpm
- 2nd Baby: 136 bpm
:
: Buttock
: Back on left side, extremities on the right side
: Head
: Divergent 3/5

Vaginal toucher

Inspeculo

- Vulvovaginal: within normal limits

- Position: Anterior
- Dilatation: 8 cm
- Effacement: 80%
- Amniotic membrane: Intact (+)
- Presentation: Head
- Denominator: Minor Fontanelle
- Fetal Station: +1
: not performed

Cardiotocography
1st baby (back on the left side)
Baseline

: 150 bpm

Variabilitas

: normal

Acceleration

: (+)

Deceleration

: (-)

Fetal movement

: (+), 7 times in 20 minutes

Uterine contraction

: (-)

Interpretation

: NST reactive

2nd baby (extremities on the right)

Baseline

: 120-130 bpm

Variabilitas

: normal

Acceleration

: (+)

Deceleration

: (-)

Fetal movement

: (+)

Uterine contraction

: (-)

Interpretation

: NST reactive

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
BT
CT

: 11,9 g/dL
: 36 %
: 11.800/L
: 197.000/L
: O/Rh (+)
: (-)
: 2 mins
: 4 mins

Blood glucose

: 85 mg/dL

Initial Diagnosis
G3P2A0, 28 years old, gravid 35-36 weeks based on USG examination, in labor, 1 st active
phase, with two intrauterine living fetuses, cephalic presentation of both fetuses.
Planning
Pro Spontaneous per-vaginam labor
Final Diagnosis
P3A0, 28 years old, post partus prematurus by spontaneous per vaginam delivery, post
episioraphy indicated by perineum rupture grade I
Neonatal Diagnosis
I: Male neonate, 36 weeks according to NBS with birth weight of 2150 grams, length of 46
cm and APGAR Score 7/9, with diagnose healthy neonate
II: Male neonate, 36 weeks according to NBS with birth weight of 2710 grams, length of 48
cm and APGAR Score 7/9, with diagnose healthy neonate
Placenta
Placentas size 32x32x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), Calcification (-),
umbilical chords length 59 cm and 63 cm, umbilical cord are implanted in two places:
marginal and central, bleeding 200 cc, placental weight 900 gram.
Therapy
Post-partus:
-

Cefadroxil 3 x 500 mg PO
Mefinal 3 x 500 mg PO
Methergin 3 x 0,125 mg PO

CASE 2
G2P1A0, 19 years old, gravid 37-38 weeks based on the first day of last
menstruation period, with severe Preeclampsia, in labor 1st active phase,
with single intrauterine living fetuses, cephalic presentation
Identity

Name

: Mrs. U

Age

: 19 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Elementary School

Occupation

: Housewife

Date of admission : January 28th , 2016

Anamnesis

Chief complaint:
Patient complain of abdominal discomfort since 9 hours before admission to
the hospital

History of present illness:

Patient came to the hospital because the abdominal discomfort since 9 hours
before admission, patient also felt contraction since 7 hours before admission to the
hospital. The patient went to primary care 4 hours earlier and at that time her blood
pressure was 180/90 mmHG and a positive protein dipstick. She was diagnosed with
severe Preeclampsia and was initially given MgSO 4 4g as a loading dose. Patient had
done ANC twice in primary care, and she had pregnancy induced hypertension. She
also had a history of preeclampsia in previous pregnancy.

History of past illness:

o
o
o
o
o
o
o
o

History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of hematologic disease
History of urinary tract/kidney disease
History of trauma
History of surgery

Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder

Habitual history

History of menstrual cycle:

o Menarche
o Menstrual cycle

: (+) Induced by pregnancy

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

: Alcoholic (-), smoking (-), drugs (-)

: 15 years old
: Regularly, every 28 days, with duration

of 4 days, 45 ml/day, dysmenorrhea (-)

o First day of last menstrual cycle
: Mei 15th, 2015

Marital History

Obstetric history
N
o
1

Date
2012

: Married once, has been with this husband for 5 years.

Gestation

Labor

al Age

History

Sex

9 months

Per

Vaginam
2

Prese
nt

Birth
Weight
2600 gr

Result
Breast
Feeding
+

Notes
Preeclamps
ia (+)

Contraception History

: None

History of antenatal care

: 2 times at Puskesmas, pregnancy induced hypertension

(+), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 180/90 mmHg

Pulse rate

: 120 beats/minutes

Respiratory rate

: 24 breaths/minutes

Body temperature

: 37.4C

Body weight before pregnancy : 52 kg

Height

: 160 cm

BMI before pregnancy

: 20.3 kg/m2

Current body weight

: 62 kg

Total weight gain

: 10 kg

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities

: Pale conjunctiva +/+, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/: Convex, linea nigra (+), striae gravidarum (+)
: Bowel sounds (+), 8 x/min
: Supple, pain with palpation (-)
: Warm extremities,
Edema -++-

,CRT < 2 seconds

Physiologic reflex
++ ++ , pathologic reflex-++++ ++

Obstetrics examination

Estimated due date

Fundal height
Fetal weight estimation
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV

: February 22nd, 2015

: 32 cm
: 3255 grams
: (+) 2x in 10 minutes (< 20 sec)
: 148 bpm
:
: Buttock
: Back on the left side
: Head
: Divergent, 3/5

Vaginal toucher

Inspeculo

- Vulvovaginal: within normal limits

- Position: Anterior
- Dilatation: 10 cm
- Effacement: 100%
- Consistency: Soft
- Amniotic membrane: (-)
- Presentation: Head
- Denominator: Minor Fontanelle
- Fetal Station: +2
: Not performed

Cardiotocography

Baseline

: 150 bpm

Variabilitas

: normal (5-10 bpm)

Acceleration

: (+) 2x in 20 minutes

Deceleration

: (-)

Uterine contraction

: (+), 4x in 10 minutes

Interpretation

: CST negative

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
BT
CT
Blood glucose
SGOT
SGPT
HbsAg

: 7.2 g/dL
: 26 %
: 15,000/L
: 268,000/L
: A/Rh (+)
: 2 minutes
: 4 minutes
: 84 mg/dL
: 20 U/l
: 5 U/l
: (-)

Urinalysis:

Protein

: ++

Initial Diagnosis
G2P1A0, 19 years old, gravid 37-38 weeks based on the first day of last menstruation period,
with severe Preeclampsia, in labor 1st active phase, with a single intrauterine living fetuses,
cephalic presentation
Planning
Maintenance dose of MgSo4 1gr/hour
Pro spontaneous per vaginam delivery
Final Diagnosis

P2A0, 19 years old, post partus maturus by spontaneous per vaginam labor, post episioraphy
indicated by perineum rupture grade II, with history of severe preeclampsia
Neonatal Diagnosis
Male neonate, 37-38 weeks according to NBS, birth weight of 3,150 gram, length of 50 cm,
and APGAR Score 9/9, with diagnose healthy neonate.

Placenta
Placentas size 21x21x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), kalsifikasi (-),
umbilical chord length 57 cm, umbilical cord are implanted in the center, bleeding 90 cc,
placental weight 360 gram.
Therapy
Post-partus:
-

2 Bags of PRC Blood transfusion

Cefadroxil 3 x 500 mg PO
Nifedipin 3 x 10 mg PO
Mefenamic Acid 3 x 500 mg PO
Check Hemoglobin 6 hours post-partus
Re-check SGOT/SGPT and Ur/Cr

CASE 3
G1P0A0 18 years old, gravid 38-39 weeks based on first day of the last menstruation
period with severe preeclampsia, in labor with prolonged 2nd phase, with a single
intrauterine living fetus, cephalic presentation.
Identity

Name

: Mrs. H

Age

: 18 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Junior High School

Occupation

: Seller

Date of admission : January 28th , 2016

Anamnesis

Chief complaint:
Patient was referred from primary car with prolonged 2nd stage.

History of present illness:

Patient has been feeling abdominal discomfort since one day before she was
admitted to the hospital, she went to primary care first. She had her 2 nd phase going
about 4 hours, so she was taken to the hospital by the primary care unit. Patient had
done ANC 6 times in primary care, and she had pregnancy induced hypertension.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder

: Denied
: Denied
: Unknown
: Unknown
: Unknown
: Denied

Habitual history

History of menstrual cycle:

o Menarche
o Menstrual cycle

: alcoholic (-), smoking (-), drugs (-)

: 13 years old
: regularly, every 30 days, with duration

of 5 days, 60 ml/day, dysmenorrhea (-)

o First day of last menstrual cycle
: May 8th, 2015

Marital History

Obstetric history
No

Date

: Married once, has been with this husband for 1 year

Gestationa

Labor

Result

l Age
1

present

History

Sex

Birth

Breast

Weight

Feeding

38-39
weeks

Contraception History

: None

History of antenatal care

: 6 times at Puskesmas, pregnancy induced hypertension

(+), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 150/90 mmHg

Pulse rate

: 90 beats/minutes

Respiratory rate

: 30 breaths/minutes

Body temperature

: 37.2C

Body weight before pregnancy : 50 kg

Height

: 150 cm

BMI before pregnancy

: 22,2 kg/m2

Current body weight

: 57 kg

Total weight gain

: 7 kg

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st & 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/: Convex, linea nigra (+), striae gravidarum (+)
: Bowel sounds (+), 5 x/min
: Supple, pain with palpation (-)

Extremities

: Warm extremities,
Edema

-++-

,CRT < 2 seconds

Physiologic reflex ++ ++

++ ++

, pathologic reflex-++-

Obstetrics examination

Estimated due date

Fundal height
Fetal weight estimation
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
Vaginal toucher

Inspeculo

Cardiotocography

: February 15th, 2016

: 36 cm
: 3565 g
: (+) 2x in 10 minutes (30-40)
: 130 bpm
:
: Buttock
: Back on left side
: Head
: Divergent, 3/5
:
- Vulvovaginal: within normal limits
- Position: Anterior
- Dilatation: 10 cm
- Effacement: 100%
- Consistency: Soft
- Amniotic membrane: (-)
- Presentation: Head
- Denominator: Minor Fontanelle
- Fetal Station: +2
: not performed

Baseline

:130 bpm

Variability

: Normal

Acceleration

:+

Deceleration

: (+) late deceleration: 2x/ 10 minutes

Fetal movement

:-

Uterine Contraction

: (+) 2x in 10 minutes

Interpretation

: Non-reassuring

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
GDS
SGOT
SGPT
Ur/Cr
Cr
Bleeding time
Clotting time

: 12,2 g/dL
: 37 %
: 24.200/L
: 328.000/L
: B/Rh (+)
: (-)
: 110
: 13
:7
: 10
: 0.6
: 3 minutes
: 5 minutes

Urinalysis

Protein

:+++

Initial Diagnosis
G1P0A0 18 years old, gravid 38-39 weeks based on first day of the last menstruation period
with severe preeclampsia, in labor with prolonged 2 nd phase, with a single intrauterine living
fetus, cephalic presentation.
Planning
Initial loading dose of MgSo4 4g in 100cc of saline solution
Pro spontaneous per vaginam delivery
Final Diagnosis

P1A0, 18 years old, post partus maturus by spontaneous per vaginam labor, post episioraphy
indicated by perineum rupture grade II, with history of severe preeclampsia
Diagnosa Neonatus
Male neonate, 38-39 weeks according to NBS with birth weight of 3130 grams, length of 49
cm and APGAR Score 8/9, with diagnose of a healthy neonate.

Placenta
Placentas size 18x18x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), kalsifikasi (-),
umbilical chord length 48 cm, umbilical cord are implanted marginally, bleeding 580 cc,
placental weight 340 gram.

Therapy
-

Cefadroxil 3 x 500 mg PO
Mefenamic Acid 3 x 500 mg PO
Maintenance MgSo4 1 gr/hour IV

CASE 4
G1P0A0 19 years old, gravid 37-38 weeks based on USG, in labor with prolonged 1st stage
with a single intrauterine living fetuses, cephalic presentation

Identity

Name

: Mrs. N

Age

: 19 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Senior High School

Occupation

: Housewife

Date of admission : January 29th , 2016

Anamnesis

Chief complaint:
Patient was referred by primary care because of prolonged 1 st phase from
primary care unit

History of present illness:

Patient came to the hospital after initially been in the primary care for 15 hours
due to the frequent abdominal discomfort the patients has been having. According to
the midwifes in primary care, she came to primary care with 2 cm opening and when
she was brought to the hospital the opening is 5 cm. The patient had done 6 time of
ANC and had no difficulties during her pregnancy.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia

: Denied
: Denied
: Unknown

o History of gestational diabetes

o History of preterm labor
o History of genetic disorder

Habitual history

History of menstrual cycle:

o Menarche
o Menstrual cycle

: Unknown
: Unknown
: Denied

: alcoholic (-), smoking (-), drugs (-)

: 13 years old
: regularly, every 30 days, with duration

of 4 days, 60 ml/day, dysmenorrhea (-)

o First day of last menstrual cycle
: April 13th, 2015

Marital History

Obstetric history
No

Date

present

: Married once, has been with this husband for 1 year

Gestationa
l Age

Labor
History

Sex

Result
Birth
Weight

Breast
Feeding

37-38
week

Contraception History

: None

History of antenatal care

: 6 times at Puskesmas, pregnancy induced hypertension

(-), anemia (-), tetanus toxoid (-), sexual transmitted disease (-)
Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 120/70 mmHg

Pulse rate

: 80 beats/minutes

Respiratory rate

: 20 breaths/minutes

Body temperature

: 36.5C

Body weight before pregnancy : 47 kg

Height

: 151 cm

BMI before pregnancy

: 20.8 kg/m2

Current body weight

: 55 kg

Total weight gain

: 8 kg

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st & 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-

Abdomen
Inspection
Auscultation
Palpation

: Convex, linea nigra (+), striae gravidarum (+)

: Bowel sounds (+), 5 x/min
: Supple, pain with palpation (-)

Extremities

: Warm extremities,
Edema -++-

,CRT < 2 seconds

Physiologic reflex
++ ++ , pathologic reflex-++++ ++

Obstetrics examination

Estimated due date

Fundal height
Fetal weight estimation
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV

: January 20th, 2016

: 29 cm
: 2790 g
: (+) 3x in 10 minutes (30)
: 148 bpm
:
: Buttock
: Back on left side
: Head
: Divergent, 3/5

Vaginal toucher

Vulvovaginal: within normal limits

Position: Middle
Dilatation: 5 cm
Effacement: 30%
Consistency: Thick
Amniotic membrane: Intact (+)
Presentation: Head
Denominator: Minor Fontanelle

Inspeculo

Fetal Station: +1

: not performed

Cardiotocography

Baseline

:140 bpm

Variability

: Normal (5-10 bpm)

Acceleration

:+

Deceleration

:-

Fetal movement

: 2x in 20 minutes

Contraction

: (+) 3x in 10 minutes

Result

: reassuring

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HbsAg
GDS

: 9.3 g/dL
: 28 %
: 14.200/L
: 399.000/L
: O/Rh (+)
: (-)
: 91 mg/dL

Initial Diagnosis
G1P0A0 19 years old, gravid 37-38 weeks based on USG, in labor with prolonged 1 st stage
with a single intrauterine living fetuses, cephalic presentation
Planning

Observe dilatation with Misoprostol 25 g/4 hours

Final Diagnosis
P1A0, 19 years old, post partus maturus by spontaneous per vaginam delivery, post hecting
indicated by perineum rupture grade II
Neonatal Diagnosis
Male neonate, 37-38 weeks according to NBS with birth weight of 3035 grams, length of 46
cm and APGAR Score 7/9, with with diagnose healthy neonate.
Placenta
Placentas size 22x21x2 cm, Cotyledon intact, hematoma (-), stoel cell (+), calcification (-),
umbilical chord length 47 cm, umbilical cord are implanted marginally, bleeding 220 cc,
placental weight 450 gram.

Therapy
Post-Partus
-

Cefadroxil 3 x 500 mg PO
Asam Mefenamat 3 x 500 mg PO

No.

Date of
Admission

Identity

Working Diagnosis
P3A0, 45 years old, with

1.

24/01/16

Mrs.S

bilateral ovarian cyst

Final Diagnosis
P3A0, 45 years old, with post
bilateral cystectomy suspect
endometriosis

27/01/16

Mrs. MI

P0A0, 28 years old, with

P0A0, 28 years old, post

endometrium cyst dextra

cystectomy per laparotomy

indicated by endometrium

P6A0 42 years old,with

cyst dextra
P6A0 42 years old,with

30/01/16

Mrs. SR

menometorrhagia

menometorrhagia

31/01/16

Mrs. SU

P5A0 43 years old, with pelvic

P5A0 43 years old, with pelvic

inflammatory disease

inflammatory disease

31/01/16

Mrs.MA

P3A0, 50 years old, with

P3A0, 50 years old, with

myoma uteri, hypertension

myoma uteri, hypertension

stage I, CHF NYHA I

stage I, CHF NYHA I

GYNECOLOGY PATIENT

CASE 1
P3A0, 45 years old, with bilateral ovarian cyst
Identity

Name

: Mrs. S

Age

: 45 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Junior high school

Occupation

: Housewife

Date of admission : January 24th, 2016

Anamnesis

Chief complaint:
Patient felt pain in her lower abdominal part especially when she had a second
day of menstruation.

History of present illness:

Patient admitted to have bilateral ovary cyst cystectomy. Patient felt pain in
her lower abdominal part when she had the second day of menstruation. The pain
started when she have her IUD removed last year.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus
o History of preeclampsia
o History of gestational diabetes
o History of preterm labor
o History of genetic disorder

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Habitual history

: Alcoholic (-), smoking (-), drugs (-)

History of menstrual cycle:

o Menarche
o Menstrual cycle

: 15 years old
: Regularly every 28 days, with duration

of 5 days, 45 ml/day, dysmenorrheal (-)

o First day of last menstrual cycle
: January 15th, 2015

Marital History

: Married 1 times, has been with this husband for 26

years

Obstetric history
Date

No
1

1991

Result
Birth

Gestation

Labor

al Age

History

Sex

9 months

Spontaneo

Male

Weight
3400 g

Feeding
Yes

Femal

2900 g

Yes

3300 g

Yes

Breast

us
2

1992

9 months

pervaginal
Spontaneo
us

1997

9 months

pervaginal
Spontaneo

e
Male

us
pervaginal

Contraception History

: Yes, IUD for 8 years, removed in April 2015

History of antenatal care

:-

Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:

Weight

Blood pressure

: 120/80 mmHg

Pulse rate

: 72 beats/minute

Respiratory rate

: 16 breaths/minute

Body temperature

: 36.4C
: 61 kg

Height

: 160 cm

BMI

: 23.8 kg/m2

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/-

Abdomen
Inspection
Auscultation
Palpation
Percution

: Convex, lineanigra (-), striaegravidarum (-)

: Bowel sounds (+), 5 x/ minute
: Supple.
: Tympanic in almost all regio, shifting dullness (-),

undulated test (-), dullness (+) in suprapubic regio.

Extremities
: Warm extremities, skin turgor normal
Edema

-++-

,CRT < 2 seconds

Physiologic reflex ++ ++ , pathologic reflex-++++ ++

Gynecology examination

Last menstrual period

: January 15th , 2015

Vaginal toucher

: Not performed

Inspeculo

: Not performed

Laboratory examinations

Hemoglobin

: 14.6g/dL

Hematocrit

: 43%

Leucocyte

: 5,200/L

Platelets

: 250,000/L

Blood glucose

: 95

Blood type

: A/Rh (+)

Bleeding Time

:2

minutes

Clotting Time

:4

minutes

SGOT

: 11

U/L

SGPT

: 10

U/L

Ureum

: 14

mg/dL

Creatinin

: 0.7

mg/dL

Natrium

:137

mmol/L

Kalium

: 3.77

mmol/L

Calcium

: 1.18

mmol/L

Chloride

:108

mmol/L

HbsAg

: (-)

mg/dL

First Diagnosis
P3A0, 45 years old, with bilateral ovarian cyst

Final Diagnosis
P3A0, 45 years old, with post bilateral cystectomy suspect endometriosis
Final Treatment:
-

Cefadoxil 3x500 mg
Mefenamic acid 3x500 mg
Ketroz sup 2x1
Ranitidine 2x 150 mg

CASE 2
P0A0, 28 years old, with endometrium cyst dextra
Identity

Name

: Mrs. MI

Age

: 28 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Elementary School

Occupation

: Housewife

Date of admission : January 27th, 2016

Anamnesis

Chief complaint:
Patient felt pain in her lower abdominal part since 8 years before the admission
to the hospital.

History of present illness:

Patient felt painin her lower abdominal part since 8 years ago, and getting
worse since 3 months before the admission to the hospital. She denied any trauma
history, fever, vaginal bleeding/discharge, or any menstrual disruption.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus

: Denied
: Denied

Habitual history

History of menstrual cycle:

o Menarche
o Menstrual cycle

: Alcoholic (-), smoking (-), drugs (-)

90 ml/day, dysmenorrhea (+)

: 12 years old
: not regularly, with duration of 7 days,

o First day of last menstrual cycle

Marital History

: December 7th, 2015

: Married 1 times, has been with this husband for 8

years

Obstetric history
Date

No

Gestation

Labor

al Age

Contraception History

History
-

Sex
-

Result
Birth
Weight
-

Breast
Feeding
-

: No

Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 120/80 mmHg

Pulse rate

: 96 beats/minute

Respiratory rate

: 20 breaths/minute

Body temperature

: 36.5C

Bpdy weight

: 70 kg

Height

: 155 cm

BMI

: 29.1 kg/m2

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/: Convex, linea nigra (-), striae gravidarum (-)
: Bowel sounds (+), 5 x/ minute

Palpation

: Supple, pain with palpation (+) in suprapubic regio,

ascites (-). There was a mass with the size 10 cm x 10 cm, immobile, tender

consistency, berbatas tegas, and smooth surface.

Percution
: Tympanic in almost all regio, shifting dullness (-),

undulated test (-), dullness (+) in suprapubic regio.

Extremities
: Warm extremities, skin turgor normal
Edema

-++-

,CRT < 2 seconds

Physiologic reflex ++ ++ , pathologic reflex-++++ ++

Gynecology examination

Last menstrual period

: December 7th , 2015

Vaginal toucher

: Not performed

Inspeculo

: Not performed

Laboratory examinations

Hemoglobin

: 12.3g/dL

Hematocrit

: 40%

Leucocyte

: 10,700/L

Platelets

: 412,000/L

Blood glucose

: 118

Blood type

: B/Rh (+)

Bleeding Time

:2

minutes

Clotting Time

:4

minutes

PT

: 13.6

seconds (Control: 14.6 seconds)

APTT

: 30.4

seconds (Control: 29.7 seconds)

mg/dL

SGOT

: 22

U/L

SGPT

: 29

U/L

Ureum

: 21

mg/dL

Creatinine

: 0.6

mg/dL

Natrium

:132

mmol/L

Kalium

:4

mmol/L

Calcium

: 1.17

mmol/L

Chloride

:109

mmol/L

HbsAg

: (-)

USG Abdomen
There was a hypoechoic image in the right endometrium, suspect of cyst with the size of 11.3
cm x 10.49 cm.
First Diagnosis
P0A0, 28 years old, with endometrium cyst dextra pro cycstectomy per laparotomy
Final Diagnosis
P0A0, 28 years old, with post cystectomy per laparotomy indicated by endometrium cyst
dextra
Treatment post op:
-

Kaen mg 3: RL = 2:1

Ceftriaxone 2 x 1 gr IV

Tramadol 3x1 amp

Kaltrofen 2x1 supp

Perform laboratory check up on hemoglobin 6 hours after surgery

CASE 3
P6A0 42 years old, with menomettorrhagia
Identity

Name

: Mrs. SR

Age

: 42 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: SMP

Occupation

: Employee

Date of admission : January 30th , 2016

Anamnesis

Chief complaint:
Patient complaints of vaginal bleeding 2 weeks before admission to hospital

History of present illness:

Patient came to Atma Jaya Hospitaal and had complaints of vaginal bleeding 2 weeks
before admission to hospital. The blood color is bright red, with volume 150cc/ day.
The patient denied if theres mucus or tissue. Patient had no abdominal pain,
dysmenorhea, and trauma.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension
o History of diabetes mellitus

: Denied
: Denied

37

Habitual history

History of menstrual cycle:

o Menarche
: 14 years old
o Menstrual cycle
: regularly, with duration of 7
days, cycle every 30 days, 60 ml/day, dysmenorrhea (-)
o First day of last menstrual cycle
: January 17th, 2016

Marital History

Obstetric history
No

Date

1992

2
3

: Married once, has been with this husband for 23 years.

Result
Birth

Gestational

Labor

Age

History

Sex

9 months

Spontaneous

Male

Weight
3000

Feeding
+

9 months

per vaginam
Spontaneous

Male

grams
3100

9 months

per vaginam
Spontaneous

Male

grams
3000

Femal

grams
3000

e
Male

grams
3000

+
+

1996
1998

2006

9 months

per vaginam
Spontaneous

2009

9 months

per vaginam
Spontaneous

9 months

per vaginam
Spontaneous

Femal

grams
3000

per vaginam

grams

: alcoholic (-), smoking (-), drugs (-)

2012

Contraception History

Breast

: yes. Type IUD. Implanted on 2012

Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 140/90 mmHg

Pulse rate

: 80 beats/minute

Respiratory rate

: 18 breaths/minute

38

Body temperature

: 36.5C

Body weight

: 58 kg

Height

: 147 cm

BMI

: 26,8 kg/m2

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities

: Pale conjunctiva +/+, icteric sclera -/:wet oral mucosa membrane

: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/: Flat, linea nigra (-), striae gravidarum (-)
: Bowel sounds (+), 5 times per minute
: Supple, pain with palpation (-)
: Warm extremities,
Edema -++-

,CRT < 2 seconds

Physiologic reflex
++ ++ , pathologic reflex-++++ ++

Gynecologic examination

First day of last menstrual period : January 17th, 2016

Vaginal toucher
: not performed
Inspeculo
:

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
Bleeding time
Clotting time
Pregnancy test

: 10.6 g/dL
: 32 %
: 8.400/L
: 245.000 /L
: 2 minutes
: 4 minutes
: (-)

First Diagnosis
P6A0 42 years old,with menometorrhagia

39

Final Diagnosis
P6A0, 42 years old, with menometorrhagia
Final Treatment:
-

Observe patients vital signs

IVF

: RL 500 cc + 1 gr Tranexamic acid+ 1 amp methergin (8 hours)

: RL 500 cc + 1 amp methergin (8 hours)
: RL 500 cc + 1 amp Extrace (8 hours)

Oral therapy :

Progynova 2x2 mg PO

Tranexamic acid 3x 500 mg PO

Mefenamic acid 3x500 mg PO

Pospargin 2x 0,125 mg PO

40

CASE 4
P5A0 43 years old, with pelvic inflammatory disease
Identity

Name

: Mrs. SU

Age

: 43 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Elementary

Occupation

: Employee

Date of admission : January 31st , 2016

Anamnesis

Chief complaint:
Patient complaints of lower abdominal pain 2 months before admission to hospital

History of present illness:

Patient came to Atma Jaya Hospital complaints about pain in her lower abdominal 2
months before admission to hospital, intermittent, pulsatile. Patient also complaints
about vaginal discharge 1 months before admission to hospital. The characteristic of
vaginal disharge is mucoid, yellowish colour, berbau busuk, 30 cc/day. Patient had
no history of fever, she denied receieving any treatment.

History of past illness:

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of urinary tract/kidney disease
o History of trauma
o History of surgery

: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied
: Denied

Familial history:
o History of hypertension

: Denied

o History of diabetes mellitus

: Denied

Habitual history

History of menstrual cycle:

o Menarche
: 13 years old
o Menstrual cycle
: regularly, with duration of 7
days, cycle every 30 days, 90 ml/day, dysmenorrhea (-)
o First day of last menstrual cycle
: January 30th, 2016

Marital History

: alcoholic (-), smoking (-), drugs (-)

: Married twice, has been with this husband for 17

years.

Obstetric history
No

Date

1989

Gestational

1991

Labor

Result
Birth

Breast

Age

History

Sex

9 months

Spontaneous

Femal

Weight
3000

Feeding
+

9 months

per vaginam
Spontaneous

e
Male

grams
3100

Male

grams
3000

2000

11 months

per vaginam
Spontaneous

2003

9 months

per vaginam
Spontaneous

Male

grams
3000

2005

9 months

per vaginam
Spontaneous

Femal

grams
3000

per vaginam

grams

Contraception History

: yes. Type IUD. Last used on december 7th 2015

Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

: Compos mentis

Vital signs:
Blood pressure

: 110/70 mmHg

Pulse rate

: 80 beats/minute

Respiratory rate

: 22 breaths/minute

Body temperature

: 36.6C

Body weight

: 50 kg

Height

: 150 cm

BMI

: 22,22 kg/m2

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
Inspection
Auscultation
Palpation
Extremities

: Pale conjunctiva +/+, icteric sclera -/:wet oral mucosa membrane

: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/: Flat, linea nigra (-), striae gravidarum (-)
: Bowel sounds (+), 5 x/min
: Supple, pain with palpation (+) lower abdomenVAS II
: Warm extremities,
Edema -++-

,CRT < 2 seconds

Physiologic reflex
++ ++ , pathologic reflex-++++ ++

Gynecologic examination

Last menstrual period

Vaginal toucher
Inspeculo

: January 30th, 2016

: not performed
: not performed

Laboratory examinations

Hemoglobin
Hematocrit
Leucocyte
Platelets
LED
Diff count
SGOT
SGPT
Ureum
Creatinine
GDS
Natrium

: 10 g/dL
: 33 %
: 15.100/L
: 510.000/L
: 100 mm/hour
: 0/1/1/73/17/8
: 12 U/L
: 7 U/L
: 10 mg/dL
: 0.6 mg/dl
: 94 mg/dl
: 136 mmol/L

Kalium
Calcium
Chloride

: 4 mmol/L
: 1.13 mmol/L
: 105 mmol/L

Urinalysis

Glucose
Protein
Bilirubin
Uroblinogen
pH
BJ
Occult blood
Ketone
Leucocyte
Sediments
Thorax x-ray
CT abdomen
USG abdominal

:::: normal
: 6.0
: <1005
: +1
:: +1
: eritrocyte 5-6/ / Lpb
: Leucocyte 3-4 / Lpb
: normal
: adnexitis bilateral especially right (PID)
: peritonitis local lower abdomen and lymphadenopathy
mesenterica abdomen 1,1x0,6 suggestif chronic PID/ adnexitis
Hydronephrosis right grade 1-2 ec suspect compression of
ureter because of PID.

First Diagnosis
P5A0 43 years old,with PID
Final Diagnosis
P5A0, 43years old, with PID
Final Treatment:
-

Metronidazole 3x500 mg PO

CASE 5
P3A0, 50 years old, with myoma uteri, hipertension stage 1, CHF NYHA I
Identity

Name

: Mrs. MA

Age

: 50 years old

Ethnic

: Javanese

Religion

: Moslem

Education

: Elementary

Occupation

: Housewife

Date of admission : January 31th, 2016

Anamnesis

Chief complaint:
Patient was scheduled for operation hysterectomy.

History of present illness:

Patient came to Atma Jaya Hospital complained about abdominal discomfort
(mulas) 10 days prior to admission to hospital, the patient also complained about frequent
vaginal bleeding, the colour is dark red, volume 10cc, spotting. When she was examined
in policlinic, there was a myoma, and she scheduled for a hysterectomy. There was no
symptoms of her heart disease such as dyspneu, edema. She denied any trauma history.

History of past illness:

o History of hypertension
12.5 mg 3 times daily
o History of diabetes mellitus
o History of allergy

: for 5 years, controlled by captopril

: Denied
: Denied

o
o
o
o
o

History of epilepsy
History of hematologic disease
History of urinary tract/kidney disease
History of trauma
History of surgery

Familial history:
o History of hypertension
o History of diabetes mellitus

Habitual history

History of menstrual cycle:

o Menarche
o Menstrual cycle

: Denied
: Denied
: Denied
: Denied
: Denied

: Denied
: Denied

: Alcoholic (-), smoking (-), drugs (-)

: 12 years old
: Regularly every 30-40 days, with duration

of 5-7 days, 90 ml/day, dysmenorrhea (-)

o First day of last menstrual cycle
: Menopause for 2 years

Marital History

Obstetric history

No
1

Date
1992

: Married 1 times, has been with this husband for 30 years

Gestationa

Labor

l Age

History

Sex

10 months

Spontaneou

Male

s
2

1996

10 months

vaginam
Spontaneou
s

1998

10 months

per

per

Weight
2900

Breast
Feeding
+

grams
Male

per

vaginam
Spontaneou

Result
Birth

3100

grams
Male

3000

grams

vaginam

Contraception History

: Yes, type: injection 3 months. Last used : 1998

Physical Examination

General appearance

: Looks moderately ill

Level of consciousness

Vital signs:

: Compos mentis

Blood pressure

: 130/90 mmHg

Pulse rate

: 72 beats/minute

Respiratory rate

: 20 breaths/minute

Body temperature

: 36C

Weight

: 65 kg

Height

: 155 cm

BMI

: 28.8 kg/m2

General examination

Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae

: Pale conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur (-) , gallop (-)
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-,
breast milk -/-

Abdomen
Inspection
Auscultation
Palpation
Percution

: Convex, lineanigra (-), striaegravidarum (-)

: Bowel sounds (+), 5 x/ minute
: Supple, pain with palpation (-)
: Tympanic in almost all regio, shifting dullness (-),

undulated test (-)

Extremities

: Warm extremities, skin turgor normal

Edema

-++-

,CRT < 2 seconds

Physiologic reflex ++ ++ , pathologic reflex-++++ ++

Gynecology examination

Last menstrual period

: Menopause for 2 years

Vaginal toucher

: Not performed

Inspeculo

: Not performed

Laboratory examinations

Hemoglobin

: 12.5g/dL

Leucocyte

: 3.400/L

Platelets

: 364.000/L

Blood glucose

: 102

Blood type

: AB/Rh (+)

Bleeding Time

:2

minutes

Clotting Time

:4

minutes

SGOT

: 28

U/L

SGPT

: 13

U/L

Ureum

: 23

mg/dL

Creatinin

: 0.8

mg/dL

HbsAg

: (-)

mg/dL

Echocardiography: diastolic function , early impending decompensation, ejection fraction

24%
First Diagnosis
P3A0, 50 years old, with myoma uteri, hipertensive heart diasease, CHF NYHA I
Treatment
Pro operation hysterectomy not accepted by anesthesia
Fix the heart condition first