MORNING REPORT

Tuesday, December 29th, 2015 at 03.30 PM

Wednesday, December 30th, 2015 at 07.00 AM
Physiologic obstetrical patient
Pathologic obstetrical patient
Gynecological patient
Passed Away
Total patient

: -1 case
: cases
: - cases
: - cases
: cases

Obstetric ward patients

Gynecology and Oncology ward patients
ICU patient
Total Patients

: 17 patients
: 28 patients
: 2 patients
: 47 patients

OBSTETRICS
1 22.12.2015
.
07.30 PM

LSCS due to VSD + Pulmonary Hypertension

Mrs.FIT/30/UA/ AF-STR
D/ G1P0A0 32 weeeks gestational age not inlabor with severe
preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation
US ER (PUT) :
BS : 2
- SLF cephalic presentation
GI : 6
- Fetal biometry :
BPD : 88 mm
FL : 63 mm
HC : 300 mm
EFW : 1770 g
AC : 252 mm
- Placenta at corpus posterior
- Amniotic fluid was enough, SP : 2,8 cm
C/ 32 weeks gestational age SLF cephalic presentation
Hb 13.4 g/dL
M/ Expectative
WBC 7.83/mm3
Observed vital sign, FHR, contraction
3
PLt 156.10 /L
IVFD RL gttt x/m
Ureum 17
Nifedipine 10 mg/8hours
mg/dL
Dexamethasone injection 6mg/12 hours
Kreatinin 0.54
Laboratory examination

mg/Dl
LDH 628U/L
urine Protein ++
+

Urine catheter
Consult to Internal Medicine and Ophtalmology Department
Evaluated with gestosis task
Joint care with Cardiology division

22.12.15

Refferal reply from Internal Medicine :Department

Assesment : Ventrical Septal Defect + Pulmonal Hypertension
P/ Digoxine 1x tablet (morning)
Continued other therapy
Join care with Cardiology Division

23.12.15

D/ G1P0A0 32 weeeks gestational age not inlabor with severe

preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
US confirmation
Evaluated with gestosis task
Joint care with Cardiology division

23.12.15
09.00 AM
US

P/ US Confirmation (NS) :
- SLF cephalic presentation
- Fetal biometry :
BPD : 8,77 cm
FL : 5,8 cm
HC : 30,94 cm EFW : 1675 g
AC : 25,82 cm
CD : 4,86 cm ~ 36 w 1 d
RI MCA : 0,31
SDAU : 2,8
- Placenta at corpus posterior
- Amniotic fluid was enough, SP : 2,8 cm
- BPP : .FM: 2 FB: 2 FT: 2 ICA 2 NST: 2
C/ 36 weeks gestational age SLF cephalic presentation+ IUGR was
suspected + BPP 10

24.12.15
07.00 AM

24.12.15
11.20 AM

25.12.15
07.00 AM

25.12.15

Suggestion : abdominal delivery after lung maturation

Consult to consultant in charge :
Terminated pregnancy after assessment from Prof.Dr.Ali
Ghanie,Sp.PD;KKV (Joint conference)
D/ G1P0A0 36 weeks gestational age not inlabor with severe
preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation +
IUGR was suspected
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
Evaluated with gestosis task
Joint care with Cardiology Division
Internal Medicine Department
Assesment : Ventrical Septal Defect + Pulmonal Hypertension
G1P0A0 36 weeeks gestational SLF cephalic presentation + susp
IUGR
P/ Digoxin 1x tablet (morning)
Continued other therapy
D/ G1P0A0 36 weeks gestational age not inlabor with severe
preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation +
IUGR was suspected
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
Evaluated with gestosis task
Joint care with Cardiology Division
Visite Consultant in Charge :
Continue the lung maturation with dexametasone 6 mg/12 hours

26.12.15
07.00 AM

D/ G1P0A0 36 weeks gestational age not inlabor with severe

preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation +
IUGR was suspected
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
Evaluated with gestosis task
Joint care with Cardiology Division

27.12.15
07.00 AM

D/ G1P0A0 36 weeks gestational age not inlabor with severe

preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation +
IUGR was suspected
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
Evaluated with gestosis task
Joint care with Cardiology Division

27.12.15
07.00 AM

Internal Medicine Department

Assessment : Ventricular Septal Defect + Pulmonal Hypertension
GEA without dehydration
M/ : O2 1 2 L
Digoxin 1 x tab
Diatab 3 x 2 tab
Oralit 1 2 sachet
Continuous other therapy
D/ G1P0A0 36 weeks gestational age not inlabor with severe
preeclampsia +partial HELLP syndrome + ventricular septal

28.12.15
07.00 AM

defect + Pulmonary hypertension SLF cephalic presentation +

IUGR was suspected
M/ Expectative
Observed vital sign, FHR, contraction
IVFD RL gttt x/m
Nifedipine 10 mg/8hours
Dexamethasone injection 6mg/12 hours
Evaluated with gestosis task
Joint care with Cardiology Division
28.12.15
10.20 AM

Internal Medicine Department

Assesment : Ventricular Septal Defect + Pulmonal Hypertension
GEA without dehydration
M : Digoxin 1 x tab
Continuous other therapy
29.12.15
D/ G1P0A0 36 weeks gestational age not inlabor with severe
07.00 AM
preeclampsia +partial HELLP syndrome + ventricular septal
defect + Pulmonary hypertension SLF cephalic presentation +
IUGR was suspected
Hb 15.1 g/dL
M/ Expectative
3
3
WBC 13.2 /mm
Observed vital sign, FHR, contraction
3
PLt 139.10 /L
IVFD RL gttt x/m
Ureum 21
Nifedipine 10 mg/8hours
mg/dL
Dexamethasone injection 6mg/12 hours
Kreatinin 0.68
Evaluated with gestosis task
mg/Dl
Joint care with Cardiology Division
LDH 807 U/L
29.12.15
10.40 AM

10.30 PM
2 cm

Internal Medicine Department

Assessment : Ventricular Septal Defect + Pulmonal Hypertension
M : Digoxin 1 x tab
Continuous other therapy
D/ G1P0A0 36 weeeks gestational age inlabor 1st stage laten phase
with severe preeclampsia+partial HELLP syndrome + ventricular
septal defect + Pulmonary hypertension SLF cephalic

10.35 PM

02.30 AM
PIC
Lub curve
02.35 AM
PIC

2
.

30.12.15
06.00 AM
9 cm
Contraction:
4x/10/40

presentation + IUGR was suspected

Consult to consultan in Charge (Dr.H.Amir Fauzi,SpOG(K)
Suggest : Abdominal delivery
Consult to Anestesiology Department
Consult to Internal Medicine Department
Consult to ICU
Male live baby was born, BW 1650 g, BL 41 cm, AS 6/9 PT SGA
Placenta was delivered completely, PW 270 g, umbilical cord length
43 cm, 14 x15 cm.
The Mother is in ICU and the baby is in NICU
Plan for vaginal delivery
Mrs. NUR/30/RA/EDP
D/ G1P0A0 40 weeks gestational age inlabor 1st active phase with
history of ROM 1 days SLF cephalic presentation
M/ Observed FHR.Vital sign,contraction
IVFD RL gtt xx/mnt
Ceftriaxone inj 2x1gr/ IV
Laboratory examination
P/ Vaginal delivery

30.12.15
06.15 AM
IG: 7

Plan for abdominal delivery

Mrs. NIA/30/RA/EDP
D/ G2P1A0 40 weeks gestational age inlabor with prolonged 2nd stage
outside+ severe preeklampsia SLF vertex presentation
M/ Stabilization 1 hours
Observed FHR.Vital sign,contraction
IVFD RL gtt xx/mnt
Inj MgSO4 40% ~ protokol
Nifedipine 3 x 10 mg/8 hours
Poly catheter
Laboratory examination
Consult to internal+ophtalmology Departement

Consult Anastesi
P/ Abdominal Delivery
4

30.12.15
06.30 AM

GYNAECOLO
GY
29-12-15
07:00 PM

Hb : 8.g/dL

General condition improvment

Mrs SUR/40/RA/EDP
D/P1 A0 post LSCS 7 days outside with urinary retention and sub
ileus was suspected
M// Observed vital sign
IVFD RL xx drops/m
Laboratory examination
Consult to surgery departement

General condition improvement

Mrs. AWI/53/RA/ARU
D/ Cervical cancer stage IIIB was suspected +
moderate anemia
M/ Observed vital sign and bleeding
IVFD RL xxx drops/m
Laboratory examination
Ceftriaxone inj. 1 g /12 hours IV
Transamin inj 500 mg/8 hours IV
PRC transfusion until Hb > 10 g/dL
P/ Cervical biopsy
Thorax X ray
BNO-IVP
Abdominal US
Clinical staging