1.

08-06-16
02:25 PM
IG: 6
BS: 2
Hb : 14.0 g/dl
WBC :
15.800/mm3
PLT :
280.000/mm3
LDH: 1380 U/l
SGOT: 54 U/L
SGPT: 24 U/L
Protein Urine: (+
+)
Ureum: 61 mg/dl
Creatinin: 1,92
mg/dl
Uric acid: 7,20
mg/dl

05:25 PM
IG: 5
BS: 3

11:25 PM

Plan for vaginal delivery

Mrs.
NUR/31/RA/TOM
D/ G4P3A0 22 weeks gestational age with superimposed
preeclamsia in chronic hypertension SDF intrauterine
US ER (RSP):
SDF intrauterine
Biometry :
BPD : 55 mm
AC : 169 mm
EFW : 357 g
HC : 197 mm
FL : 47 mm
Placenta at posterior corpus of uterine
Amniotic fluid was enough
C/ 22 weeks gestational age SDF intrauterine

M/ Stabilisation 3 hours
Observed vital sign, inlabor sign
O2 10L/m NRM
MgSO4 protocol
Nifedipine 10 mg/8 hours
Catheter insertion
IVFD RL xx drops/m
Laboratory examination
Evaluate with gestosis task
Consult to internal department and opthalmology department
P/ Vaginal delivery
Cervical ripening with misoprostol 100 g/ p.v (after stabilisation)
Tubal ligation counseling
D/ G4P3A0 22 weeks gestational age with superimposed
preeclamsia in chronic hypertension SDF intrauterine
M/ Observed vital sign, contraction
Cervical ripening with misoprostol 100 g/ p.v
P/ - Vaginal delivery
D/ G4P3A0 22 weeks gestational age inlabor 2nd stages
with superimposed preeclamsia in chronic
hypertension Partial HELLP syndrome SDF intrauterine

11.40 PM
11.40 PM

2.

08-06-16
09:25 PM

Hb : 12.6 g/dl
WBC : 8.400/mm3
PLT :
250.000/mm3
BSS: 314

3.

08-06-16
09:25 PM

Hb : g/dl
WBC : /mm3

P/ Conduct the labor

Male dead baby was born , BW 350 gr, BL 24 cm, AS 0 PTAGA
Placenta was delivered not completely, PW 80 g, UCL: 34 cm, 10x10
cm
Mother was in good condition.
Ekspectatif management
Mrs.
IND/38/RA/NS-FAR
D/ G4P3A0 35 weeks gestational age not inlabor with prior
CS 2x + uncontrolled DM SLF cephalic presentation +
polyhydramnios
US ER (RSP):
SDF intrauterine
Biometry :
BPD : 83 mm
AC : 310 mm
EFW : 2365 g
HC : 318 mm
FL : 65 mm
Placenta at anterior corpus of uterine
Amniotic fluid 6.8 6.2 = 29.7 cm
8.1 8,6
C/ 34 weeks gestational age SLF cephalic presentation +
polyhydramnios
M/ Observed vital sign
O2 10L/m NRM
Catheter insertion
IVFD RL xx drops/m
Laboratory examination
Dexamethason inj. 6 mg / 12 hours iv
Consult to internal department
P/ US Confirmation
Bracht Manuevre
Mrs. YUA/29/RA/TRI
D/ G2P1A0 37 weeks gestational age inlabor 2nd stages
with severe preeclamsia SLF breech presentation
M/ Stabilisation 1 hours

PLT :/mm3

10:25 PM

10.40 PM
10.45 PM

4.

08-06-16
11:00 PM

Hb : g/dl
WBC : /mm3
PLT :/mm3

00:30 AM

00.40 PM
00.45 PM

Observed vital sign, Contraction, FHR

O2 10L/m NRM
MgSO4 protocol
Nifedipine 10 mg/8 hours
Catheter insertion
IVFD RL xx drops/m
Laboratory examination
Evaluate with gestosis task
Consult to internal department and opthalmology department
D/ G2P1A0 37 weeks gestational age inlabor 2nd stages
with severe preeclamsia SLF breech presentation
M/ Conduct the labor
Male life baby was born , BW 2500 gr, BL 47 cm, AS 8/9 FTAGA
Placenta was delivered not completely, PW 480 g, UCL: 47 cm, 18x19
cm
Mother and baby were in good condition.
Spontaneus delivery
Mrs. RAH/16/RA/RNI
D/ G1P0A0 37 weeks gestational age inlabor 1st stages
active phase with PROM 1 day SLF cephalic
presentation
M/ Observed vital sign, Contraction, FHR
IVFD RL xx drops/m
Laboratory examination
Ampicillin inj. 1g/ 6 hours iv
Acceleration with oxytocin drip
Evaluation with WHO partograph modification

P/ Vaginal delivery
D/ G1P0A0 37 weeks gestational age inlabor 2nd stages
with PROM 1 day SLF vertex presentation
M/ Conduct the labor
Male life baby was born , BW 2500 gr, BL 47 cm, AS 8/9 FTAGA
Placenta was delivered not completely, PW 480 g, UCL: 47 cm, 18x19
cm
Mother and baby were in good condition.

GYNECOLOGY
1.

08-06-16
07:30 PM
Hb : g/dl
WBC : /mm3
PLt : mm3

Medicinalis
Mrs. SUY/41/UA/LAT
D/ Bilateral endometriosis cyst
M/ Observed vital sign
Norethisterone 0,3mg/12 hours po
Mefenamic acid 500mg/8 hours po
Tranexamic acid 500mg/8 hours po

2.

08-06-16
15:15 PM

Medicinalis

Hb : g/dl
WBC : /mm3
PLt : mm3

D/ AUB cb L1

Mrs. HAL/44/RA/LAT

M/ Observed vital sign

P/ US Confirmation
3.

21-05-16
11:00 AM
Hb : g/dl
WBC : /mm3
PLt : mm3

11:00 AM

Passed away
Mrs. ZAL/47/UA/LAT
D/ Stages IIIB cervical cancer was suspected +
moderate anemia
M/ Observed vital sign
IVFD RL xx drops/mnt
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
P/ Biopsi
P/ Nefrostomi
P/ HD
Internal department result:

22-05-16
06:00 AM

23-05-16
06:00 AM

07.00 PM

- Stages IVA cervical cancer

- AKI stage III dd/ CKD
- Chronic anemia
Advice:
- PRC Transfusion
- Consult to urology
- There isn't indication for HD
D/ Stages IVA cervical cancer was suspected + severe
anemia + AKI stage III dd/ CKD stages IV
M/ Observed vital sign
IVFD NaCl xx drops/mnt
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Catheter insertion
Consult to urology
P/ Biopsi after general condition improvement
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion 5 kolf
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
Consult to urology
P/ Biopsi after general condition improvement
Urology result:
A/ Obstructive Nephropathy
Anemia
Hydronefrosis sinistra + AKI Stage III
Advice:
US Confirmation

24-05-16
06:00 AM

25-05-16
06:00 AM

26-05-16
06:00 AM

PRC Transfusion
Plan for nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
P/ Biopsi after general condition improvement
US Confirmation (Urology)
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
P/ Biopsi after general condition improvement
US Confirmation (Urology)
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome
M/ Observed vital sign
IVFD NaCl xx drops/mnt

27-05-16
06:00 AM

16:00 AM

28-05-16
06:00 AM

PRC transfusion until Hb10 mg/dl

Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
P/ Biopsi after general condition improvement
US Confirmation (Urology)
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
Consult to Internal department
P/ Biopsi after general condition improvement
US Confirmation (Urology)
Nephrostomy
HD ( 2x/weeks)
Internal department:
A/ AKI stage III dd/ CKD stages V
Advice:
HD (2x/weeks)
PRC transfusion 150ml on HD
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt

29-05-16
06:00 AM

30-05-16
06:00 AM

PRC transfusion until Hb10 mg/dl

Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
HD ( 2x/weeks)
P/ Biopsi after general condition improvement
US Confirmation (Urology)
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
HD ( 2x/weeks)
P/ Biopsi after general condition improvement
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po

31-05-16
06:00 AM

01-06-16
06:00 AM

Catheter insertion
HD ( 2x/weeks)
P/ Biopsi after general condition improvement
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic + Malnutrition +
Hipoalbuminemia
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
HD ( 2x/weeks)
P/ Biopsi after general condition improvement
Nephrostomy
D/ Stages IVA cervical cancer was suspected + severe
anemia + CKD stages IV + Nephropaathy obstructive +
Uremic syndrome + Septic + Malnutrition +
Hipoalbuminemia
M/ Observed vital sign
IVFD NaCl xx drops/mnt
PRC transfusion until Hb10 mg/dl
Ceftriaxone inj 1gr/12 hours iv
Tranexamic acid 500mg/8 hours iv
Ketorolac inj amp /8 hours iv
Metronidazol 500mg / 8 hours iv
Climix tab/24 hours po
Catheter insertion
HD ( 2x/weeks)
P/ Biopsi after general condition improvement
Nephrostomy