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OBSTETRIC OUTPATIENT

REPORTnd
Monday, April 2 2018
Residents:
Dr. Raden Bagus Prakoso
Dr. Tomas Ediba
Dr. Riyan Wira Pratama
Dr. Terry Mutia
Dr. Ismail Hadyatma

Supervisor:
Dr. Peby Maulina Lestari, OBGYN(C)
Identity Diagnosis ICD- Management ICD-9
10
1 Mrs. RAT/ G3P1A1 30 weeks gestational Z34.0 IEC 88.78
. 28 yo/UA age single life fetus cephalic 0 US
presentation Ferrous Sulfate 1x300 mg
Calcium lactate 1x500 mg
2. Mrs. MAR/ G2P1A0 4 weeks gestational Z34.0 IEC 88.78
26 yo/ UA age intrauterine 0 US
Folic Acid 1x400mcg
3. Mrs. YOS/ G4P3A0 18 weeks Z34.0 IEC 88.78
38 yo/ UA gestasional age with prior CS 0 US
1x + History of ca Thyroid Ferrous Sulfate 1x300 mg
post Thyroidectomy single Calcium lactate 1x500 mg
life fetus intrauterine

4. Mrs. G2P1A0 15 weeks gestational Z34.0 US 88.78


RIC/27 yo/ age single life fetus 0 Laboratory Examination V22.1
RA intrauterine + bicytophenic
1. MRS RAT/ 28 yo/ UA BACK

Anamnesis Pregnant woman came to fetomaternal outpatient to control her third


pregnancy. Uterine contraction (-), bloody show(-), watery discharge (-),
1.2015. Abortus, currettage , YK Madira Hospital
Birth status 2.2016. Male. Aterm. Spontaneous , 3500 g, Moh. Hoesin Hospital healthy
3.This pregnancy
Menarche 13 years old, regular menstrual period, 7 days, LMP : ..October
Reproduction 2017
History
Physical Vital Signs
Examination BP: 120/70 mmHg P: 80 bpm RR: 20 x/mnt
Height: 154 cm Weight: 62 kg
Obstetric Uterine fundal palpable between umbilical and processus xhypoideus
Examination (24 cm), longitudinal right lie, cephalic presentation, His (-), FHR= 142 bpm
US Confirmation 30 weeks gestasional age SLF cephalic presentation
Diagnosis G3P2A0 30 weeks gestational age single life fetus cephalic presentation
Management - Ferrous Sulfate 1x300 mg
- Calcium lactate 1x500 mg
- IEC
- US Confirmation
BACK

US examination
In USG Examination was found:
Single life fetus cephalic presentation
Fetal Biometry:
BPD: 7.6 cm HC: 28.0 cm
AC: 24.8 cm FL : 5.6 cm EFW: 1424 g
Amniotic fluid is sufficient
Placenta at anterior corpus
/- 30 weeks gestasional age SLF cephalic presentation
2. MRS MAR/ 26 yo/ UA
Anamnesis Pregnant woman came to Fetomaternal outpatient to control her second
pregnancy. Uterine contraction (-), blood spotting (-), nausea and
vomiting (-) , Patient said Pregnancy test was positive (+)
Birth status 1.2017. Male. Aterm. Spontaneous , 2900 g, Moh. Hoesin Hospital
healthy
2.This pregnancy
Reproduction Menarche 12 years old, irregular menstrual period,
History LMP : 15-02-2018
Physical Vital Signs
Examination BP: 120/70 mmHg P: 86 bpm RR: 20 x/mnt
Height: 153 cm Weight: 60 kg
Obstetric Uterine fundal not palpable, Abdomen not distended, tenderness (-).
Examination
US Examinantion 4 weeks gestasional age Intrauterine
Diagnosis G2P1A0 4 weeks gestational age intrauterine
Management - IEC
- US
- Folic Acid 1 x 400 ug
US Examination
In USG Examination was found:
- Gestational sac intrauterine diameter: 1.3 cm ~ 4 weeks
- fetal echo (-) yolk sac (-)
• 4 weeks gestasional age intrauterine
3. MRS YOS/ 38 yo/ UA BACK

Anamnesis Pregnant woman came to fetomaternal outpatient to control her fourth


pregnancy. Uterine contraction (-), bloody show(-), watery discharge (-),
history of thyroidectomy cb ca thyroid papillary type in 2017

Birth status 1.2002. Male. Aterm. 2800g, Spontaneous, midwife, healthy


2.2007. Male. Aterm. CS, 2600 g, Bhayangkara Hospital, healthy
3.2011. Female. Aterm. 2600 g. Bhayangkara Hospital. healthy
4.This pregnancy
Reproduction Menarche 13 years old, irregular menstrual period, 5 days, LMP :
History ..November 2017
Physical Vital Signs
Examination BP: 120/70 mmHg P: 80 bpm RR: 20 x/mnt
Height: 163 cm Weight: 69 kg
Obstetric Uterine fundal palpable 2 fingers below umbilical (18 cm), ballotement
Examination externa (+) , Mass (-), tenderness (-)
Laboratory Hb 9.8 g/dL, WBC 7500/mm3, PLT 229000/mm3, Ca 7.0 mmol/L, Na 143
Examination mEq/L, K 3.7 mEq/L, Free T4 1.11 ng/dL, TSH 8.20 mcU/mL

US Confirmation 18 weeks gestasional age SLF intrauterine


Diagnosis G4P3A0 18 weeks gestasional age with prior CS 1x + History of ca
Thyroid post Thyroidectomy single life fetus intrauterine
Management - Ferrous Sulfate 1x300 mg
- Calcium lactate 1x500 mg
- IEC
- US Confirmation
BACK

US examination
In USG Examination was found:
Single life fetus intrauterine
Fetal Biometry:
BPD: 4.4 cm HC: 16.2 cm
AC: 13.5 cm FL : 3.0 cm EFW: 277 g
Amniotic fluid is sufficient
Placenta at posterior corpus
/- 18 weeks gestasional age SLF intrauterine
4. MRS RIC/ 27 yo/ RA BACK

Anamnesis Pregnant woman came to fetomaternal outpatient to control her pregnancy.


Patient was diagnosed with bicytophenic since 3 years ago. Uterine
contraction (-), bloody show(-), watery discharge (-)
Birth status 1.2014. Male. Aterm. 2500 g. Spontaeus. Midwife, healthy
2.This pregnancy
Reproduction Menarche 13 years old, regular menstrual period, 5 days, LMP : 17/12/2017
History

Physical Vital Signs


Examination BP: 120/70 mmHg P: 92 bpm RR: 20 x/mnt
Height: 153 cm Weight: 52 kg
Obstetric Uterine fundal palpable 3 fingers above shympisis, ballottement externa (+) ,
Examination Mass (-), tenderness (-)

Laboratory Hb 7.2 g/dL, PLT 19.000/mm3, Ht 21,2%


Examination

US Confirmation 15 weeks gestasional age SLF intrauterine


Diagnosis G2P1A0 15 weeks gestational age single life fetus intrauterine +
bicytophenic

Management - Laboratory Examination


- US Confirmation
BACK

US examination
In USG Examination was found:
Single life fetus intrauterine
Fetal Biometry:
BPD: 3.03 cm HC: 11.2 cm
AC: 9.49 cm FL : 1.46 cm EFW: 130 g
Amniotic fluid is sufficient
Placenta at posterior corpus
/- 15 weeks gestasional age SLF intrauterine
THANK YOU

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