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    Obstetric Outpatient: Friday, April 20 2018

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    Riyan W. Pratama
    The obstetric outpatient report summarizes visits from two patients. For patient 1, Mrs. JAM is 33 weeks pregnant with a single fetus in cephalic presentation. Her vitals and exam were normal. She was diagnosed with gestational age of 33 weeks and given iron and calcium supplements. For patient 2, Mrs. MAR is 27 weeks pregnant with a history of uncontrolled hyperthyroidism and a single intrauterine fetus. Her vitals were evaluated and she was also given iron and calcium supplements. Both patients received ultrasounds to confirm gestational age and fetal well-being.

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    Obstetric Outpatient: Friday, April 20 2018

    Uploaded by

    Riyan W. Pratama
    32 views14 pages
    The obstetric outpatient report summarizes visits from two patients. For patient 1, Mrs. JAM is 33 weeks pregnant with a single fetus in cephalic presentation. Her vitals and exam were normal. She was diagnosed with gestational age of 33 weeks and given iron and calcium supplements. For patient 2, Mrs. MAR is 27 weeks pregnant with a history of uncontrolled hyperthyroidism and a single intrauterine fetus. Her vitals were evaluated and she was also given iron and calcium supplements. Both patients received ultrasounds to confirm gestational age and fetal well-being.

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    20 april

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    The obstetric outpatient report summarizes visits from two patients. For patient 1, Mrs. JAM is 33 weeks pregnant with a single fetus in cephalic presentation. Her vitals and exam were normal. She was diagnosed with gestational age of 33 weeks and given iron and calcium supplements. For patient 2, Mrs. MAR is 27 weeks pregnant with a history of uncontrolled hyperthyroidism and a single intrauterine fetus. Her vitals were evaluated and she was also given iron and calcium supplements. Both patients received ultrasounds to confirm gestational age and fetal well-being.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    32 views14 pages

    Obstetric Outpatient: Friday, April 20 2018

    Uploaded by

    Riyan W. Pratama
    The obstetric outpatient report summarizes visits from two patients. For patient 1, Mrs. JAM is 33 weeks pregnant with a single fetus in cephalic presentation. Her vitals and exam were normal. She was diagnosed with gestational age of 33 weeks and given iron and calcium supplements. For patient 2, Mrs. MAR is 27 weeks pregnant with a history of uncontrolled hyperthyroidism and a single intrauterine fetus. Her vitals were evaluated and she was also given iron and calcium supplements. Both patients received ultrasounds to confirm gestational age and fetal well-being.

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    OBSTETRIC OUTPATIENT

    REPORTth
    Friday, April 20 2018
    Residents:
    Dr. Raden Bagus Prakoso
    Dr. Tomas Ediba
    Dr. Riyan Wira Pratama
    Dr. Terry Mutia
    Dr. Ismail Hadyatma

    Supervisor:
    Dr. Peby Maulina Lestari, Sp.OG(K)
    NO Identity Diagnosis ICD-10 Management ICD-9
    .
    1 . Mrs. JAM/ G1P0A0 33 weeks of Z34.00 IEC 88.78
    31 yo/UA gestational age SLF US
    cephalic presentation Ferrous Sulfate 1x300mg
    Calcium Lactate 1x500mg
    2 . Mrs. MAR/ G3P2A0 27 weeks of O99.284 IEC 88.78
    31 yo/UA gestational age with US
    uncontrolled Ferrous Sulfate 1x300mg
    hyperthyroidism SLF Calcium Lactate 1x500mg
    intrauterine
    1. MRS JAM/ 31 yo/ UA BACK

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


    Uterine contraction (-), bloody show(-), watery discharge (-)

    Birth status 1. This pregnancy

    Reproduction Menarche 13 years old, regular menstrual period, 7 days, LMP : 31/08/2017
    History
    Physical Vital Signs
    Examination BP: 120/80 mmHg P: 80 bpm RR: 20 x/mnt
    Height: 150 cm Weight: 59 kg
    Obstetric Uterine fundal palpable 4 fingers below processus xyphoideus (27cm),
    Examination longitudinal left back, head presentation, his (-), FHR : 146 bpm EFW :
    2170g
    US Confirmation 33 weeks of gestational age SLF cephalic presentation

    Diagnosis G1P0A0 33 weeks of gestational age SLF cephalic presentation

    Management - US
    - Ferrous Sulfate 1x300mg
    - Calcium Lactate 1x500mg
    BACK

    US examination
    In USG Examination was found:

    Single life fetus cephalic presentation


    Fetal Biometry:
    BPD: 8.2 cm HC: 29.6cm EFW : 2078g
    AC: 28.9 cm FL : 6.3 cm
    Amniotic fluid is sufficient
    Placenta at posterior corpus

    /- 33 weeks of gestational age SLF cephalic presentation


    2. MRS MAR/ 31 yo/ UA BACK

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


    Uterine contraction (-), bloody show(-), watery discharge (-) history of
    uncontrolled Hyperthyroidism
    Birth status 1.2009. Female. Aterm. 3600g. Spontaneus, midwife. Healthy
    2.2013. Female. Aterm. 3300g. Spontaneus, midwife. Healthy
    3.This pregnancy

    Reproduction Menarche 13 years old, regular menstrual period, 7 days, LMP : 5/08/2017
    History
    Medical history Take unroutine medicine : Tyrozol 1x1. propanolol 1x1
    Physical Vital Signs
    Examination BP: 130/90 mmHg P: 100 bpm RR: 20 x/mnt
    Height: 156 cm Weight: 58 kg
    Obstetric Uterine fundal palpable 2 fingers above umbilical, ballottement externa (+),
    Examination Mass (-), tenderness (-)
    US Confirmation 27 weeks of gestational age SLF intrauterine
    Diagnosis G3P2A0 27 weeks of gestational age with uncontrolled hyperthyroidism SLF
    intrauterine
    Management - US
    - Ferrous Sulfate 1x300mg
    - Calcium Lactate 1x500mg
    BACK

    US examination
    In USG Examination was found:

    Single life fetus intrauterine


    Fetal Biometry:
    BPD: 6.8 cm HC: 24.7 cm
    AC : 24.8 cm FL: 4.7 cm EFW : 1185g
    Amniotic fluid is sufficient. SDP 4.6cm
    Placenta at anterior corpus

    /- 27 weeks of gestational age SLF intrauterine


    THANK YOU

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