Fetomaternal Ward Report

Thursday, June 2nd 2016

Duty Team :
1. Rizky Fariza Harahap
2. Paul Alwin Khoman
3. Dedet Steavano

Department of Obstetric and Gynecology

Faculty of Medicine University of Sumatera Utara
Adam Malik General Hospital
2016

Patient :

2 Patient

1. Mrs. M, 28 yo, G2P1A0

Diagnosis
: HIV std II + SG + IUP (37-38) wga +
Head Presentation
+Live fetus
Supervisor : Dr.dr. Sarma Lumbanraja, M.Ked(OG), Sp.OG
(K)
Resident
: dr. Rizky Fachriza
Plan : C-Section

2.Mrs. J, 29 yo, G5P4A0

Diagnosis
: Ca Vulva std II + MG + IUP (30-31)wga +
Live fetus
Lung Tumor Metastatic ec Ca-Vulva(squamous
cell) +
Pleural Effusion Bilateral
Supervisor : dr. Edwin M Asroel, M.Ked(OG), Sp.OG
Resident
: dr. Rizky Fachriza Harahap
Plan
: Monitor FHR, uterine contraction and vital sign
Consult to Pulmonology

PATIENT 1

FOLLOW UP June ,1st 2016

S

(-)

Presens state
Sens
:
CM
TD
: 120/80 mmHg
HR
: 78 x/i
RR
: 22x/i
T
: 36.6 C

Localized state
Abdomen
UFH
: 3 below px
Movement
Tension
Lowest part
His
Fetal Heart Rate

: asymetrically enlarged
: (+)

HIV std II + SG + IUP (37-38) wga + Head Presentation + Live fetus

IVFD RL 20 gtt/i

Tenofovir 1 x 1
Hiviral 2 x 1
Neviral 2 x 1

Planning :
Consult to Posyansus
Consult to Cardiology

: right
: head
: (-)
:142 x/i, regular

FOLLOW UP June ,2nd2016

S

(-)

Presens state
Sens
:
CM
TD
: 110/70 mmHg
HR
: 74 x/i
RR
: 18x/i
T
: 35.9 C

Localized state
Abdomen
UFH
: 3 below px
Movement
Tension
Lowest part
His
Fetal Heart Rate

: asymetrically enlarged
: (+)

HIV std II + SG + IUP (37-38) wga + Head Presentation + Live fetus

IVFD RL 20 gtt/i

Tenofovir 1 x 1
Hiviral 2 x 1
Neviral 2 x 1

Planning :
C - Section

: right
: head
: (-)
:138 x/i, regular

USG TAS

USG TAS
th
May
25
2016
Singleton, Head Presentation, Live fetus

FM (+), FHR (+)

BPD : 8,36 cm
AC : 32,72 cm
FL : 6,98 cm
EFW : 2898 gram
FHR : 144 x/i
Placenta corpus anterior
Amniotic fluid adequate
Conclusion : IUP (36-37) wga + Head Presentation + Live Fetus

Posyansus Departement
1st June 2016
A : HIV std II + SG + IUP (37-38) wga + Head
Presentation + live fetus
P : Tenofovir 1 x 1
Hiviral 2 x 1
Neviral 2 x 1
Continues Therapy
Consedering Standard Universal Precaution before
C - Section

Cardiology Departement
A : HIV std II + SG + IUP (37-38) wga
EKG : Sinus Ritme, reguler, Normo Axis, PR interval
0,12, QRS rate 70 x, ST T Change (-), VES (-), LVH
(-)
Conclusion : Sinus Rhythm

Anesthesiology Departement
1st June 2016
A : HIV std II + SG + IUP (37-38) wga
P : ACC

LABORATORY FINDINGS on May ,25th 2016

Hb
: 12.2 gr/dl
N:
WBC
: 11.720 /mm3 N:
Hematocrit : 35 %
N:
Platelet : 177.000/mm3
SGOT
SGPT

: 16
: 12

BUN
:7
Ureum
: 15
Creatinin : 0.55

12-14/gr/dl
4000 - 11000/uL
36,0 - 42,0/%
N:150.000 - 400.000/uL

N : 5 - 34 U/L
N : 0 - 55 U/L
N : 7 - 19 mg/dl
N : 15 40 mg/dl
N : 0.6 1.1 mg/dl

LABORATORY FINDINGS on May ,25th

2016
HBsAg: Non Reactive
Anti HBs : Non Reactive
Anti HCV: Non Reactive
Imunodeficiency profile
CD 4 %
: 14
N : 31 - 60 %
CD 4 Absolut : 288
N : 410 1590 Cell/uL

PATIENT 2

FOLLOW UP May ,31th 2016

S

(-)

Presens state
Sens
:
CM
TD
: 130/70 mmHg
HR
: 90 x/i
RR
: 28 x/i
T
: 37.2 C

Localized state
Abdomen
: asymetrically enlarged
UFH
: px-umbilical
Movement
: (+)
Tension
: right
Lowest part
: head
His
: (-)
Fetal Heart Rate
: 138 x/i, regular

Ca Vulva std II + MG + IUP (29-30)wga + Live fetus

Mild Hemaptoe ec malignancy
Suspect Pneumonia
O2 2-4 lpm
IVFD RL 20 gtt/i
Inj Ranitidin 50mg/ 12 hours

Planning :
Monitor fetal heart rate, uterine contraction and vital sign

FOLLOW UP June ,1st 2016

S

(-)

Presens state
Sens
:
CM
TD
: 110/70 mmHg
HR
: 82 x/i
RR
: 26 x/i
T
: 36.4 C

Localized state
Abdomen
: asymetrically enlarged
UFH
: px-umbilical
Movement
: (+)
Tension
: right
Lowest part
: head
His
: (-)
Fetal Heart Rate
: 138 x/i, regular

Ca Vulva std II + MG + IUP (29-30)wga + Live fetus

Mild Hemaptoe ec malignancy
Suspect Pneumonia
O2 2-4 lpm
IVFD RL 20 gtt/i
Inj Ranitidin 50mg/ 12 hours
Vip Albumin 2 x1

Planning :

FOLLOW UP June ,2nd 2016

S

(-)

Presens state
Sens
:
CM
TD
: 100/70 mmHg
HR
: 82 x/i
RR
: 26 x/i
T
: 36.0 C

Localized state
Abdomen
: asymetrically enlarged
UFH
: px-umbilical
Movement
: (+)
Tension
: right
Lowest part
: head
His
: (-)
Fetal Heart Rate
: 138 x/i, regular

Ca Vulva std II + MG + IUP (29-30)wga + Live fetus

Methastatic lung cancer ec ca vulva
Bilateral pleural effusion
O2 2-4 lpm
IVFD RL 20 gtt/i
Inj Ranitidin 50mg/ 12 hours
Vip Albumin 2 x1
Aspar K 1x30 mg
Planning :

Spirometry at May, 26 2016

th

Impression : Severe Restriction + Severe

Obstruction + Obstruction of Small Lung vessel.
The patient has done the spirometry in laying
position, she didnt do the manuver so good and
that make the spirometry is not reproductive.
Toleration of Bronchoscopy : high risk

Echocardiography at May, 26 2016

th

Impression : 1st degree AV Block

USG TAS

USG TAS

USG TAS
Singleton, Head Presentation, Live fetus
FM (+), FHR (+)
BPD : 7,61 cm
HC: 28,47 cm
AC : 22,86 cm
FL : 5,62 cm
EFW : 1249,25 gram
FHR : 154 x/i
Placenta corpus anterior
Amniotic fluid adequate
Conclusion : IUP (31-32) wga + Head Presentation + Live Fetus

Pulmonology Departement Div.

oncology at June, 2nd 2016
A : Bilateral pleural effusion + Ca vulva std II + MG
+ IUP(31-32) wga + Methastatic lung cancer
P : Methylprednisolone 3x1 tablet
N-Asetil cystein 20 mg 3x1 tablet
Nystatin drops 3x2 oral
Plan: Awaiting Mantoux test results

LABORATORY FINDINGS on May ,26th 2016

Hb
: 9,9 gr/dl
N: 12-14/gr/dl
WBC
: 7710 /mm3 N: 4000-11000/uL
Hematocrit : 31 %
N: 36,0-42,0/%
Platelet : 337.000/mm3N:150.000-400.000/uL
Albumin : 2.3 g/dL
N : 3.5-5.0 g/dL

THANK YOU