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    Obstetric Outpatient Report Mut 22.11.18

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    Rebeka Anastasia Marpaung
    The document contains obstetric outpatient reports from a hospital in Indonesia. It includes details of two patient cases - a 34 year old woman who is 13 weeks pregnant with HIV, and a 39 year old woman who is 38 weeks pregnant with a history of antiphospholipid syndrome. For each patient it provides their medical history, examination findings, diagnoses, and prescribed treatment.

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    Obstetric Outpatient Report Mut 22.11.18

    Uploaded by

    Rebeka Anastasia Marpaung
    45 views11 pages
    The document contains obstetric outpatient reports from a hospital in Indonesia. It includes details of two patient cases - a 34 year old woman who is 13 weeks pregnant with HIV, and a 39 year old woman who is 38 weeks pregnant with a history of antiphospholipid syndrome. For each patient it provides their medical history, examination findings, diagnoses, and prescribed treatment.

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    The document contains obstetric outpatient reports from a hospital in Indonesia. It includes details of two patient cases - a 34 year old woman who is 13 weeks pregnant with HIV, and a 39 year old woman who is 38 weeks pregnant with a history of antiphospholipid syndrome. For each patient it provides their medical history, examination findings, diagnoses, and prescribed treatment.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    45 views11 pages

    Obstetric Outpatient Report Mut 22.11.18

    Uploaded by

    Rebeka Anastasia Marpaung
    The document contains obstetric outpatient reports from a hospital in Indonesia. It includes details of two patient cases - a 34 year old woman who is 13 weeks pregnant with HIV, and a 39 year old woman who is 38 weeks pregnant with a history of antiphospholipid syndrome. For each patient it provides their medical history, examination findings, diagnoses, and prescribed treatment.

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    © All Rights Reserved
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    You are on page 1of 11

    OBSTETRIC OUTPATIENT

    REPORT
    Tuesday, November 20th, 2018
    Residents:
    Dr. Eka Handayani O
    Dr. Ibnu Sina
    Dr. Terry Mutia - Dr. Asep Nurul Huda
    Dr. Aditya Rachman
    Dr. M. Ath Thaariq. P - Dr. Febi Stevi Aryani

    Supervisor:
    Dr. Hj. Putri Mirani, OBGYN(C)
    Recapitulation Obstetric Outpatient
    th
    Tuesday, November 22 , 2018
    Physiology Patient 0
    Pathology Patient 2
    Total 2
    Friday, November 16th 2018 – Thursday, November 22nd 2018

    Physiology Pathology Total

    Friday, Nov 16th 2018 0 1 1


    Monday, Nov 19th 2018 0 0 0
    Tuesday, Nov 20th 2018 1 0 1
    Wednesday, Nov 21st, 2018 0 0 0
    Thursday, Nov 22nd, 2018 0 2 2
    Total 1 3 4
    NO. IDENTITY DIAGNOSIS ICD-10 MANAGEMENT ICD-9
    1. Mrs. NYI/ 34 G4P3A0 13 weeks gestational O98.711 CIE V08
    y.o/ UA/ NS age with HIV, SLF intrauterine Ferrous sulfate tab 1 x 300 mg
    Calcium lactate tab 3 x 500 mg

    2 Mrs. APR/ 39 G6P2A3 38 weeks gestational O99.119 CIE 649.33


    y.o/ RA/ age with non in labor with APS, D68.61 Ferrous sulfate tab 1 x 300 mg
    SFL cephalic presentation Calcium lactate tab 3 x 500 mg
    Mrs. NYI/ 34 y.o/ UA/NS BACK

    Chief Complain Preterm pregnancy with HIV


    Anamnesis Patient come to RSMH Fetomaternal Polyclinic for antenatal care of pregnancy. History of vomitting (-
    ), history of abdominal contraction spread to waist and back (-), history of bloody show (-), history of
    amnionic leakage (-), hystory of post coital (-), urination and defecation was normal. Patient
    diagnosed HIV since 2012 and went to voluntary counselling and testing (VST) routinely, history of
    chronic diarrhea (-), history of chronic fever (-), history of oral candidiasis (-), history of recurrent oral
    thrush (-). Patient admitted that her pregnancy was preterm and fetal movement (+).

    Marital status 2x, First: 2002 – 2010, Second: 2017 – now


    Reproduction status Menarche 12 yo, regular cycle, lasts 7 days, LMP: August 12th, 2018
    Obstetric History 1. 2003, female, 3500 gr, vaginal delivery, Tiara Fatrin Hospital, health
    2. 2007, female, 3650 gr, vaginal delivery, Bunda Fatima Hospital, health
    3. 2009, male, 3400 gr, vaginal delivery, midwife, health
    4. Current pregnancy

    Past medicine history Neviral® since 2012


    Duviral® since 2012

    Past illness history HIV since 2012

    Family illness history History of HIV in family (-)


    Mrs. NYI/ 34 y.o/ UA/NS BACK

    Physical Examination Vital Signs


    Sens: Compos Mentis BP: 90/70 mmHg Pulse : 86 x/m T: 36,2 oC RR: 20 x/m BW 51 kg BH 168 cm
    Head: normocephal, screal icterus (-), anemic conjuctiva (-),
    Neck: JVP (5-2) cmH₂O
    Thorax pulmo: symmetric, fremitus dextra = sinistra, resonant percussion, vesicular breath sound
    Thorax cardio: ictus cordis not visible, ictus cordis not palpabled, normal first and secound heart
    sound, heart reate 84 x/m
    Extremities: CRT < 2 seconds, edema pretibial (-)

    Obstetric Palpation: Flat, suffle, uterine fundal unpalpabled, tenderness (-), free fluid sign (-), uterine
    Examination contraction (-), FHR 126 bpm

    Laboratory
    Mrs. NYI/ 34 y.o/ UA/NS BACK

    US examination

    Diagnosis G4P3A0 13 weeks gestational age with HIV, SLF intrauterine

    Therapy CIE
    Ferrous sulfate tab 1 x 300 mg
    Calcium lactate tab 3 x 500 mg
    Mrs. APR/ 39 y.o/ RA/ BACK

    Chief Complain Control preterm pregnancy


    Anamnesis Patient come to RSMH Fetomaternal Polyclinic complains nausea. History of vomitting (-), history of
    abdominal contraction spread to waist and back (-), history of bloody show (-), history of amnionic
    leakage (-), hystory of post coital (-), hystory post coital (-), hystory of fever (-), urination and
    defecation was normal. Patient sufferd for APS (Antiphospolipid Syndrome) since 2007, controlled,
    consumed Aspillet® routinely. Patient admitted that her pregnancy was preterm and fetal movement
    (+).

    Marital status 1x, 13 months


    Reproduction status Menarche 14 yo, regular cycle, lasts 10 days, LMP: forget
    Obstetric History 1. 2005, Abortus, 12 weeks gestational age, curettage (+) at Moh Hoesin Hospital
    2. 2006, Abortus, 8 weeks gestational age, curettage (+) at Moh Hoesin Hospital
    3. 2008, Abortus, 12 weeks gestational age, curettage (+) at Moh Hoesin Hospital
    4. 2008, male, 2600 gr, caesarian section indicated by APS and transveresed lie position at
    Muhammadiyah Hospital, health
    5. 2016, male, 2700 gr, caesarian section indicated by APS at Moh Hoesin Hospital, health
    6. Current pregnancy

    Medicine History Aspillet® since 2007


    Past illness history APS (Antipospholipid Syndrome) since 2007
    Family illness history None
    Mrs. APR/ 39 y.o/ RA/ BACK

    Physical Examination Vital Signs

    Sens: Compos Mentis BP: 120/80 mmHg Pulse : 80 x/m T: 36,5 oC RR: 20 x/m BW 56 kg BH 152 cm

    Obstetric Palpation: Uterine fundal 3 fingers below procesus xypoideus (34 cm), longitudinal lie, left back,
    Examination cephalic, floating, uterine contraction (-), FHR 145 bpm, EFW 3255 g

    Laboratory
    Mrs. APR/ 39 y.o/ RA/ BACK

    US Examination

    Diagnosis G6P2A3 38 weeks gestational age with non in labor with APS, SFL cephalic presentation

    Therapy CIE
    Ferrous sulfate tab 1 x 300 mg
    Calcium lactate tab 3 x 500 mg
    TERIMA KASIH

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