DUTY REPORT

Sunday, August 18th 2019 at 07.00 AM – Monday, August 19th 2019 at 07.00 AM
Consultant on Duty : Dr. Awan Nurtjahyo, OBGYN(C)

Resident on duty:
Dr. Mustika Dharma (Obstetrical Chief )
Dr. Chaerannisa Akmelia ( Gynecological Chief )
Dr. Gerry Irawan
Dr. Andini Zuita Sari
Dr. Aprian Ilhami
Dr. Bagus Hilmawan
Dr. Febi Stevi Aryani
Dr. Siti Khadijah
Dr. Achmad Fachroni
Dr. Vicella P Virgyna
1
 DUTY REPORT
Sunday, August 18th 2019 at 07.00 AM – Monday, August 19th 2019 at 07.00 AM
Consultant on Duty : Dr. Awan Nurtjahyo, OBGYN(C)

• Physiologic obstetrical patient : 1 case

• Pathologic obstetrical patient : 3 cases
• Gynecological patient : 3 case
• Passed Away : 0 case
Total patients : 7 cases

• Obstetric ward patients : 19 patients

• Gynecology ward patients : 40 patients
• ICU/P1/HCU patient : 1/0/0 patient
Total patients : 67 patients

2
OBSTETRIC
No. Patient’s ID Admission Diagnosis ICD 10 Procedure ICD 9 Recent Diagnosis
Sunday, August 18th 2019 at 07.00 AM – Monday, August 19th 2019 at 07.00 AM

G1P0A0 35 weeks gestational • Observation Vital Sign

Mrs. LEL/ 19 y.o/ RA / age in labor first stage with • Laboratory Examination P2A0 post spontaneous
1 O60.0 650
AW prolonged latent phase SLF • P/ Vaginal delivery with oxytocin delivery
cephalic presentation drip

• Observation Vital Sign P2A0 Post spontaneous

P2A0 Post spontaneous
• Laboratory examination delivery ( outside ) 5 hours
Mrs. PIR/ 19 y.o/ UA/ delivery ( outside ) 5 hours
2 • PRC tranfusion 666 with Post partum
AW with Post partum hemorrhage O72.0
• IVFD RL + Oxytocin 20 IU gtt hemorrhage e.c Uterine
c.b Uterine Hypotonia
XX/min Hypotonia

G3P2A0 37 weeks gestational

P3A0 Post spontaneous
Mrs .RUS/ 37 y.o/ RA age in labor second stage with
O14.13 delivery + severe
3 / AW severe preeclampsia SLF • P/ Vaginal Delivery 650
preeclampsia
cephalic presentation.
Gynecology
No. Patient’s ID Admission Diagnosis ICD 10 Procedure ICD 9 Recent Diagnosis
Sunday, August 18th 2019 at 07.00 AM – Monday, August 19th 2019 at 07.00 AM

Observation Vital Sign and Bleeding • AUB ec Susp M1

• AUB ec Susp M1
Laboratory Examination • Right Endometriosis Cyst
• Right Endometriosis Cyst
Mrs. WIN/ 29 y.o/ UA/ N93.9 PRC transfusion 626 was suspected
was suspected
1 AW D64.9 General Condition Improvement 68.12 • Moderate Anemia
• Moderate Anemia
I16.0 Medicinally 99.0 • Emergency
• Emergency Hypertension
Internal Medicine Asessment Hypertension
P/ Hysteroscopy D n C

Observation Vital Sign,Bleeding

Laboratory Examination
• Residive Cervical cancer C53.9 • Residive Cervical cancer
Mrs. MUR/ 43 y.o/ PRC transfusion 99.0
2 • Bilateral Hydronephrosis N13.30 • Bilateral Hydronephrosis
UA/ AW General condition improvement 92.2
• Cancer Pain G89.3 • Cancer Pain
Internal Departement Assessment
Us confirmation
Us Abdominal

Observation Vital Sign • G1P0A0 10 weeks of

• G1P0A0 10 weeks of
Mrs. HAR/ 25 y.o/ UA/ O36.3 Laboratory Examination gestational age with
3 gestational age with 656.40
AW E05.90 Internal Departement Assesment Hyperthyroidism and
Hyperthyroidism and IUFD
IUFD
OBSTETRIC
Identity Mrs. LEL/ 19 y.o/ UA / AW
Chief complaint In Labor with preterm pregnancy
History Patient came with preterm pregnancy with referral from Banyu Asin Hospital with G1P0A0 35 weeks gestational age in labor
18.08.2019 first stage with prolonged latent phase SLF cephalic presentation,History of abdominal contraction spreading to waist and
03.30 PM back (+) since 12 hour ago. History of bloody show (+), History of watery discharge (-), History of Hypertension in pregnancy
(-) History of leucorrhea (+),yellowish (+), odour (+), History of abdominal massage (+),History of post coital (-)Patient
admitted that her pregnancy was preterm and fetal movement (+)
Marital status Married 1 times, 4 months
Reproduction status Menarche since 12 yo, regular, cycle of 28 days, lasts 5 days, LMP : 20/12/2018
Obstetric history 1. This pregnancy

Physical Examination Vital sign: BP = 110/70mmHg, HR = 84x/m, temp = 36.7 C, RR = 20x/m, BW: 52 kg, BH: 154cm
Obstetrical examination Palpation: Fundal height was 4 fingers below proc. xyphoideus (29 cm), longitudinal lie, right fetal spine, head, U 4/5
contraction: ( 2X/10’/20”), FHR: 142 x/ m, EFW: 2645g
VT: Soft portio, medial, eff 100 %, Ø 2 cm, head, H I-II , amniotic membrane (+), denominator tranverse sagitalis suture
Laboratory examination Routine blood count
Hb: 10.6 g/dL, WBC: 16.360/mm3, Ht: 32 %, PLT: 368.000/mm3
Urine analysis
Leucocytes 2- 4 , Bacteria +, CRP non reactive
US ER (WDS) • SLF cephalic presentation
• Biometry: BPD: 9.00 cm, HC: 32.09 cm, AC: 29.46 cm , FL: 6.85 cm, TCD : 5.08 cm EFW: 2918g
• Placenta at anterior uterine corpus
• Amniotic fluid sufficient, SDP : 2.41 cm

C/ 35 weeks gestational age SLF cephalic presentation

Diagnosis G1P0A0 35 weeks gestational age in labor first stage with prolonged latent phase SLF cephalic presentation
Identity Mrs. LEL/ 19 y.o/ UA / AW
Therapy • Observation vital sign, FHR, Inlabor sign
• Laboratory examination
• valuate with WHO modification partograph -> active phase
• Plan for vaginal delivery with oxytocin drip

Follow up S : Preterm pregnancy

At delivery room O : Sens : CM BP 120/80 mmHg Pulse 80 bpm RR 20x/m T 36.50C
18/08/2019 Pl : Fundal height was 4 fingers below proc. xyphoideus (29 cm), longitudinal lie, right fetal spine, head, U 4/5 contraction: ( 2X/10’/25”),
07.30 AM FHR: 140 x/ m, EFW: 2645g
VT: Soft portio, medial, eff 100 %, Ø 3 cm, head, H I-II , amniotic membrane (+), denominator tranverse sagitalis suture
A : G1P0A0 35 weeks gestational age in labor first stage with prolonged latent phase SLF cephalic presentation +
P/
• Observation vital sign, FHR, contraction
• Acceleration with oxytocin drip 5 IU + RL 500 cc gtt X/min  titrates until adequate contraction
• evaluate with WHO modification partograph  active phase
• Vaginal delivery
Follow up S : Preterm pregnancy
At delivery room O : Sens : CM BP 120/80 mmHg Pulse 80 bpm RR 20x/m T 36.80C
18/08/2019 Pl : Fundal height was 4 fingers below proc. xyphoideus (29 cm), longitudinal lie, right fetal spine, head, U 4/5 contraction: ( 3X/10’/30”),
11.30 AM FHR: 130 x/ m, EFW: 2645g
VT: Soft portio, anterior, eff 100 %, Ø 3 cm, head, H II , amniotic membrane (+), denominator tranverse sagitalis suture
A : G1P0A0 35 weeks gestational age in labor first stage with prolonged latent phase SLF cephalic presentation
P/
• Observation vital sign, FHR, contraction
• Acceleration with oxytocin drip 5 IU + RL 500 cc gtt XXX/min
Identity Mrs. LEL/ 19 y.o/ UA / AW
Follow up S : Preterm pregnancy
At delivery room O : Sens : CM BP 110/80 mmHg Pulse 78 bpm RR 20x/m T 36.40C
18/08/2019 Pl : Fundal height was 4 fingers below proc. xyphoideus (29 cm), longitudinal lie, right fetal spine, head, U 3/5 contraction: ( 4X/10’/40”),
01.00 PM FHR: 138 x/ m, EFW: 2645g
VT: Soft portio, medial, eff 100 %, Ø 6 cm, head, H II-III , amniotic membrane (+), denominator tranverse sagitalis suture
A : G1P0A0 35 weeks gestational age in labor first stage active phase SLF cephalic presentation
P/
• Observation vital sign, FHR, contraction
• Acceleration with oxytocin drip 5 IU + RL 500 cc gtt XXX/min
• evaluate with WHO modification partograph
• Vaginal delivery
Follow up S : Preterm pregnancy
At delivery room O : Sens : CM BP 120/80 mmHg Pulse 80 bpm RR 20x/m T 36.80C
18/08/2019 Pl : Fundal height was 4 fingers below proc. xyphoideus (29 cm), longitudinal lie, right fetal spine, head, U 1/5 contraction: ( 4X/10’/45”),
04.40 PM FHR: 136 x/ m, EFW: 2645g
VT: portio not palpable, anterior, eff 100 %, Ø 10 cm, head, H III + , amniotic membrane (+), denominator right occiput anterior
A : G1P0A0 35 weeks gestational age in labor second stage SLF cephalic presentation
P/ Conduct delivery
Episiotomy mediolateral
Identity Mrs. LEL/ 19 y.o/ UA / AW
Delivery report 04.45 PM Male live baby was born BW 2700 g BL 46 cm A/S 8/9
18-08-2019 FTAGA
04.50 PM Placenta delivered completely with PW 550 g PL 45 cm diameter 16 x 17 cm

Follow up S : Post preterm spontaneous delivery

At delivery room O : Sens : CM BP 110/80 mmHg Pulse 78 bpm RR 20x/m T 36.40C
18/08/2019 Pl : Fundal height 2 fingers below umbilicus, Contraction was good, active bleeding (-), Lochia rubra (+)
06.50 PM P/
• Observation vital sign, contraction, bleeding
• IVFD RL + Oxytocin 20 IU gtt XX/min / 24 H
• Lab examination
• Informed consent contraception  patient refused
• Asi on demand
• Mefenamic acid 500 mg / 8 hours
• Cefadroxyl 500 mg / 12 hours
• Multivitamin tab / 24 hours
Foto bayi
Identity Mrs. LEL/ 19 y.o/ UA / AW

x
x

x x
x x
Identity Mrs. LEL/ 19 y.o/ UA / AW
23.00 (17/08/2019) 13.00
13.00
Identity Mrs. FIR/19 y.o/RA/AW
Chief complain Vaginal bleeding after delivery
History ± 5 hours before admisssion ago, patient has been done spontaneous delivery by midwife with male life baby was born, BW 3900 g,
19.08.19 crying directly, followed by placenta delivered with excessive vaginal bleeding, darkness red, 2 times changing napkins. History of fever
01.00 AM (-), history of abdominal pain (-). Patient then referred to Moh. Hoesin hospital
Marital status Married 1x, 4 years
Reproduction status Menarche since 13 yo, regular, cycle of 28 days, lasts 7 days
Obstetric history 1. 2017. female. aterm. 3000 g. Spontaneous delivery. Midwife. Died at 37th days after delivered
2. 2019. male. aterm. 3900g. Spontaneous delivery. Midwife. Healthy
Physical examination BP : 100/70 mmHg, P : 100x/m, RR : 20x/m, T : 36.0 C, BW: 56 kg, BH: 160cm
Obstetry examination Palpation : Uterine fundal height was as height as umbillical, contraction was not sufficient ,tenderness (-), mass (-), free fluid sign (-)
Inspeculo : portio was livide, opened OUE, fluor(-), fluxus (+) not active bleeding, darkness, smelly (-), E/L/P (-)
VT : portio was soft, opened OUE , CUT ~ 24 weeks,AP right and left was not tense, CD not protrude
US ER • Uterine was AF, size and shape > days of post partum (10.2x5.4cm) ~ sub involution was suspected, homogen myometrium, regular
stratum basalis, opened uterine cavity with blood clotting and mass, size 7.2x3.2cm ~ rest of placenta was suspected
• portio and endocervix in normal limit
• both of ovarian in normal limit
• liver and both of kidney in normal limit
C/ sub involution and rest of placenta was suspected
Laboratory Examination Hb: 9.7 g/dl WBC 30.000/ mm3 PLT 319.000/mm3, Ht 30%, INR 1.04,APTT 30.3
Diagnosis P2A0 Post spontaneous delivery ( outside ) 5 hours with Post partum hemorrhage e.c Uterine Hypotonia

Therapy • Observed vital signs, uterine contraction, bleeding

• Laboratory examination
• IVFD RL + oxytocin 20 IU gtt xx dpm
• Cefazoline 2g IV
Identity` Mrs. RUS / 37 YO / UA / AW
Chief complaint In labor with high blood pressure
History 12 hours before admission patient complained about abdominal contraction (+). History of blood show (+), history of amniotic leakage
19-08-2019 (-), History high blood pressure before pregnancy (+), History high blood pressure prior pregnancy (-), History high blood pressure in thi
(02.00 AM) s pregnancy (+), history of headache (-), history of blurry vision (-), history of nausea and vomit (-). History of epigastric pain (-). history
HIL-IJA
of trauma (-), history of abdominal massage (-), Patient admitted that she has a fullterm pregnancy and fetal movement (+)

Marital status 1x, 14 years

Reproduction status Menarche since 12 yo, regular cycle 28 days, 3 days. LMP: December 1st 2019
Obstetric history 1. 2007,aterm,female,3500 g, midwife, spontaneous delivery,healthy
2. 2010,aterm, female,3500 g, midwife, spontaneous delivery,healthy
3. current pregnancy

Past iIlness history -

Physical Examination Sens: CM BP 150/110, Pulse : 102 bpm T: 36.6 C, RR: 20x/m BW: 50 kg, Height: 152 cm, pretibial edema
Obstetrical examination Palpation : Fundal uterine palpable 3 fingers below Proc. xyphoideus (29 cm), longitudinal lie, right fetal spinecephalic presentation, U
IG : 5 1/5, uterine contraction 4x/10’/40”, FHR 142 bpm, EFW: 2945 g
Vaginal Toucher : Portio soft, anterior Eff 100%, Ø 10 cm, head H III+ , amnionic membrane (-) and denominator right occiput anterior.

Diagnosis G3P2A0 39 weeks gestational age in labor second stage with severe preeclampsia SLF cephalic presentation

Therapy P/ Conduct delivery

Identity` Mrs. RUS / 37 YO / UA / AW
Delivery report 02.30 PM female live baby was born BW 2800 g BL 48 cm A/S 8/9
19-08-2019 FTAGA
02.40 PM Placenta delivered completely with PW 450 g UCL 48 cm diameter 17 x 18 cm

Follow up S : Post spontaneous delivery + severe preeclampsia

O : Sens : CM BP 150/100 mmHg Pulse 78 bpm RR 20x/m T 36.80C
Pl : Fundal height 2 fingers below umbilicus, Contraction was good, active bleeding (-), Lochia rubra (+)
P/
• Observation vital sign, contraction, bleeding
• Inj MgSO4 ~ protocol
• Urine Catheterization / 24 H
• IVFD RL + Oxytocin 20 IU gtt XX/min / 24 H
• Lab examination
• Asi on demand
• Internal medicine and ophthalmology assessment
• PCT 500 mg / 8 hours
• Cefadroxyl 500 mg / 12 hours
• Multivitamin tab / 24 hours
Laboratory Examination Hb: 14.4 g/dl WBC 24.840/ mm3 PLT 207.000/mm3, Ht 42%, AST/ALT 29/19,LDH 345, BSS 70, Ureum/creatinine/uric acid 15/0.72/6.8
 Identity Mrs. WIN/ 29 y.o/ UA/P4A0/ AW

Chief complaint Vaginal bleeding

History + 4 months ago patient complained vaginal bleeding (+) 1-2x change pads,reddish with blood clotting and pain (+),
18-08-2019 10.00 PM abdominal lump (-), dyschezia (-), dyspareunia (+), post coital bleeding (+),nausea (-),vomit (-), dysuria (+), defecation
was normal, Patient felt her condition become worse and came to Moh.Hoesin Hospital for medication
Marital status 1x 11 years
Obstetric history P4A0
Reproduction status Menarche 12 yo, regular cycles 30 days, for 7 days,
LMP (August) 5/8/2019 until 9/8/2019, 13/8/2019 until now
LMP (July) 5/7/2019 until 28/7/2019, 4x change pads
LMP (June) 4/6/2019 until 8/6/2019 , 15/6/2019 until 27/6/2019 3x change pads
Past Illness History Hypertension since 2010  routine hypertension drugs (amlodipine 10 mg )
CVD at June 2017  Hemiparese sinistra
USG at OBGYN ( C ) 2019  bilateral ovarian cyst
Family Illness History Hypertension (+)  Mother
Diabetes Melitus (+)  Mother
Physical examination BP : 200/130 mmHg, P : 103 x/min, T : 36.3 C, RR : 20 x/min Weight 84 kg Height 160 cm
3 3
Laboratory examination Hb: 11.6 g/dL, Ht: 34%, WBC: 8.040/mm , PLT : 346.000/mm
Total Bilirubin 0.50, Direct bilirubin 0.20, SGOT 25 SGPT 21 LDH 264 Albumin 3.8 Urea 32 Creatinine 0.95 BSS 95 Ca
9.2 Na 143 K 3.9 AFP 1.73 CEA 4.50 Ca 125 16.8
Urine Analysis
Protein +++,
 Identity Mrs. WIN/ 29 y.o/ UA/ AW
Gynecology Inspection & Palpation :
examination Abdomen flat, Fundal height was one finger above symphysis, symmetric, tenderness (-), free fluid sign (-), mass
(-).
Extremitas : 5. 3
5. 3
Inspeculo : portio, not livide, OUE closed, fluor (-), fluxus (-), E/L/P (-)
VT : portio was firm, OUE closed, AP left/ right not tense, mass (-), CUT ~ 12 weeks, CD not protruded
US Confirmation : ˗Uterus AF,size and shape bigger than normal 9.58 x 3.63 x 6.41 cm
˗Homogen myometrium, endometrial line thickened (+) 1.84 cm  ,stratum basal regular
˗Portio and Endocervix within normal limit
˗Left Ovary within normal limit
˗At Right adnexa there was cystic mass with clear border + internal echo size 5.1 x 3.8 cm 
endometriosis cyst was suspected
˗Kidney and hepar within normal limit
Conclusion: Endometrial thickening c.b susp endometrial hyperplasia
Right Endometriosis cyst was suspected
Diagnosis • AUB ec Susp M1
• Right Endometriosis Cyst was suspected
• Moderate Anemia
• Emergency Hypertension
Management • Observation Vital Sign and Bleeding
• Laboratory Examination
• PRC transfusion
• Internal Medicine Assesment
• General Condition Improvement
• P/ Hysteroscopy D n C after General Condition Improvement
 Identity Mrs. WIN/ 29 y.o/ UA/ AW

Internal Medicine A/ Urgency Hypertension + CVD was suspected + AUB

Assesment P/ Amlodipine 10 mg / 24 h
Candesartan 16 mg / 24 h
Clonidine 0.15 / 8 h
Monitoring urine output  0.8 cc/body weight (kg)/hour
Neurology Assesment A/ Spastic Hemiparesis sinistra + parese N VII sinistra + N XII sinistra c.b sequele Hemorrhagic CVD
P/ Therapy as obgyn department was suggested
Reconsult if there was neurological worsening condition
Opthamology A /Hypertension Retinopathy stage I
assesment Refraction anomaly
P/ BP regulation
Identity Mrs. MUR/ 43 y.o/ UA/P4A0/ AW
Chief complaint Body Weakness + Abdominal pain

History ± 1 weeks before admission, patient was complained about body weakness + abdominal pain, nausea (+), Vomitus (+), decrease of appet
18-08-2019 ite (+), History of leukorea (+) , odor (+), history of dispareunia (+), history of post coital bleeding (-), patient complained that abdominal
(11.00 PM) pain get worse than before. Patient was diagnosed with cervical cancer stadium III B since 2017 and underwent routine chemotherapy
for 6 series and had a radiation 25 series after chemotherapy at Moh.Hoesin Hospital and patient continued internal radiotherapy at RS
CM at 2018,patient felt an abdominal pain with VAS score 4 and came to Moh.Hoesin Hospital

Marital status 1x, 27 years

Reproduction status Menarche 13 years old, patient didn’t have menstruation since her first chemotherapy

Obstetric history P4A0

Past iIlness history Chemotherapy 6 series at Moh.Hoesin Hospital  completed
Radiotherapy 25 x at Moh.Hoesin Hospital
Internal Radiotherapy 3 x at RSCM

Physical Examination Sens: CM BP 120/80 mmHg, Pulse : 84 bpm T: 36.4 C, RR: 20x/m

Obstetrical examination Palpation : Abdomen flat, symetrical, fundal uterine unpalpable, free fluid sign (-), Mass (-), tenderness (-).
Inspeculo : Portio was bumpy, fragile,easily bleeding,exofitic mass size 2x3 cm there is infiltrating 2/3 proximal vaginal anterior
Vaginal Toucher : Portio was bumpy,fragile,easily bleeding,exofitic mass size 2x3 cm there is infiltrating 2/3 proximal vaginal anterior.
Adnexa and parametrium bilateral tense.CUT ~ Normal.douglas pouch not protrude.
Rectal Toucher : Spinghter Ani tone good, Smooth Mucosa, intra lumen mass (-), Ampula recty : feses, Adnexa and parametrium
bilateral tense. CFS 25%-25%, douglas pouch not protrude.
Identity Mrs. MUR/ 43 y.o/ UA/ AW

US ER (GER) • Uterus AF shape and size was smaller 4.5 x 1.97 X 3.16 cm ~ post radiation effect
• homogen Myometrium. Stratum basalis reguler, endometrial line (+) 0.24 cm ~ post radiation effect
• There is solid mass at cervix non homogen with increasing vascularization size 2,3 x 2.3 cm x 2 cm ~ malignancy
cervix mass
• Ascites (-)
• Hepar normal and bilateral kidney there are widening calix: dextra 1.8 x 1.69 cm and sinistra 3.07 x 2.73 cm ~
Bilateral hydronephrosis
• There are no sign of enlargement lymph para aorta and para iliaca
C/ - malignancy cervix mass
- Bilateral hydronephrosis
Diagnosis • Residive Cervical cancer
• Bilateral Hydronephrosis
• Cancer Pain

Therapy • Observation of vital sign, pain,bleeding

• IVFD RL gtt xx/mnt
• Laboratory examination
• General condition improvement
• Consult internal department
• PRC Transfusion
• Us confirmation
• Us abdominal
3 3
Laboratory results Hb:8.6 g/dL, Ht: 27 %, WBC: 9.860 /mm , PLT: 299.000/mm SGOT 14,SGPT 9,Urea 45,Creatinin 2.44
Identity Mrs. MUR/ 43 y.o/ UA/ AW
Assessment Internal A : AKI Stage II c.b obstructive neuropathy
Department Residive Cervical cancer
19/08/2019 at 03.30 AM Anemia Hipokrom mikrositer
Hipoalbumin
P : conservative
consult to internal department
 Mrs. HAR/ 25 y.o/ UA/ AW
Chief complain Early pregnancy with hyperthyroidism and no presence of fetal heart beat

Patient came to hospital referral from Bunda Hospital with diagnosis G1P0A0 12 weeks of gestational age with
HEG,Hyperthyroidism and IUFD, history of abdominal contraction (-),history of bloody show (+),history of watery
discharge (-),History of leucorrhae (-), Odour (-),abdominal massage (-),history of vaginal bleeding (-), post coital (-),
History nausea vomitting (-), The history of tissue discharge such as clotting (-), tissue discharge such as fish eye (-),patient
admitted that her menstruation was delayed 2 month and breast tense (+). History body weight decrease (+), history
palpable mass at the neck (+),pain (-)
2 months
Reproduction Menarche 12 yo, regular menstrual cycles, 28 days, for 5 days, LMP 22/05/2019
status
Marital status 1x, 1 year
Reproduction 1. Current pregnancy
status
Head : pale conjunctiva (-),Icteric sclera (-)
General Exam Neck : lump was palpable with well-defined border,size 9 x 4 cm, pain (-)
BP: 120/80 mmHg, HR: 133 x/m, T: 36.5oC, RR: 20 x/m, BW: 45 kg, BH: 158 cm
Inspection & Palpation :
Gynecology
Abdomen flat, symmetric, no tense, fundal height not palpable, mass (-), tenderness (-), free fluid sign (-).
Examination
Insp: portio was livide, OUE was closed, fluor (-) fluxus (-), not active bleeding,E/L/P (-)
Wayne indexs 11
VT: Soft portio, posterior, eff 0 %, Ø 0 cm, amniotic membrane and denominator cant be assessed
Burch – Wartofsky
score : 55
Laboratory HB: 11.2, WBC: 4.310 , PLT: 272.000,d/c: 0/0/55/36/10 faal thyroid ?
Single death fetus intrauterine
CRL 3.03 cm ~ 10 weeks
US IR (GER)
FHR (-)
C/ IUFD
Diagnosis G1P0A0 10 weeks of gestational age with Hyperthyroidism and IUFD

Therapy Obs Vital sign

O2
Laboratory examination
EKG
Internal medicine assessment

Assessment A : impending thyroid storm

Internal Grave disease was supected
Department G1P0A0 10 weeks of gestational age with Hyperthyroidism and IUFD
19/08/2019 at
P : PTU 3 x 100 mg
01.30 AM
Propanolol 2x 10 mg
lugolisation
joint care internal department
Follow Up Patient stable in ward

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