DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

DUTY REPORT
Saturday, December 24th 2022 07.00 PM – Sunday, December 25 th 2022 07.00 AM
Consultant on Duty : 
dr. Firmansyah Basir, Sp.OG. Subsp. Obginsos, MARS
dr. Hadrians Kesuma Putra, SpOG, Subsp. Urogin.RE
 
Chief on Duty : 
dr. Kartika Ikrama
dr. M Komarul Hakim 
Resident on Duty :
dr. Izza Aliya
dr. Dian Permata Rizda
dr. M Arief Rachman A.P
dr. M Satria Erlangga S
dr. Kms Afif Rahman
dr. Ahmad Ramadhanu
dr. Nurkulis
dr. M Fahri Hamas
dr. Gilang Amanda
Dr. Obby Saleh Siregar
dr. Nuria Junita
dr. Eadiva Putri P
dr. Afif Naufal A
 NEW PATIENT ON DUTY RECAPITULATION
(January 1st – December 25th 2022)

Obstetric patient
  Physiologic patient 179
  Pathologic patient 1421
Gynecology patient
  Gynecology patient 1611
  Oncology patient 951
  FER patient 46
  Urogynaecology patient 7
Total 4211

DAILY INPATIENT RECAPITULATION (December 25th 2022 )

No Patient Count

1 Physiology Obstetric Patients 0

2 Pathology Obstetric Patients 0

3 Gynecology Patients 1

4 Assessment 0

5 Passed Away 0

  Total 0
PATHOLOGIC OBSTETRIC PATIENTS
2 Patients
No Identity Analysis Diagnosis Procedure
1. Mrs. AMBA/ 1 Chief complaint : Preterm pregnancy with convulsion • G1P0A0 33 weeks • Observation of vital
9 YO/ 1307932 Primary survey gestational age not sign, seizure,
/ PALEMBAN A : GCS 13 inlabor (Z3A.33)
G/ FIF-DHA-I contraction and FHR
B : RR : 20x/m; SpO2 99% • Eclampsia
YA/ HD antepartum (V71.09)
C : BP : 180/130 mmhg;
 The patient was referred by obstetrician with diagnosis G1P0A0 33 weeks (O14.13) • Stabilization (84.82)
gestational age with antepartum eclampsia + single life fetus cephalic presentation. • Single life fetus • Anticonvulsant (Y46.6)
Addmision The patient had a history of seizure since 5 hours ago; 2x, > 5 min, awake after cephalic • Lung Maturation (Z36.
Time: seizure. Patient complained headache since 2 days ago. presentation 84)
24.12.2022 History of abdominal contraction radiates to the waist (-), bloody show (-), watery (Z37.0) • Neurology assessment
22.45 wib discharge (-). Post-coital (-), leukorrhea (-), trauma (-). • Fetal distress
• Internal medicine
History of hypertension before pregnancy (-), seizure before pregnancy (-). assessment
Patient complaint severe persistent headache before seizure (+), nausea and vomit
• Anesthesia assessment
(+), blurry eyes (+).
Physical Examination Recent diagnosis • LSCS (669.7)
BP 180/130 mmHg, Pulse : 82x/minute, T: 36,9oC, RR: 20x/minute • P1A0 post LSCS o.i
eclampsia Outcome
External obstetric examination : • 23.25 PM Life neonatus
Uterine fundal height in 3 fingers below prox- xyphoideus (28 cm), longitudinal antepartum
was born, male, weight
lie, right fetal spine, cephalic presentation, contraction (-), FHR : 161 bpm, EFW : 1840 gram, length 44
2480 g cm, HC 31 cm A/S 4/7
Speculum examination : PTSGA
Livide portio, closed OUE, flour (-), fluxus (-), E/L/P(-) •
Vaginal toucher: • 23.28 PM Placenta
Soft portio, posterior, Eff 0%, Ø 0 cm, Amniotic membrane and denominator can’t delivered completely,
be assessed yet. weight 460 gram,
US examination : 33 weeks gestational age, single life fetus cephalic presentation umbilical cord length 20
Lab Examination : cm, ϴ 17 x 19 cm.
Hb 8.6 g/dL; RBC 3060/mm3; WBC 24280/mm3; Ht 25%; PLT 185000/µL; MCV
83,0 fL; MCH 28 pg; MCHC 34 g/dL; RDW-CV 15,40%; D/C 0/0/91/3/6; PT
19.0; INR 1.36; APTT 30.5;D-dimer 12.84; Fibrinogen 773; HsCRP 337.5 mg/L
Albumin 2.9 g/dL; BSS 99 mg/dL; Na 144 mEg/L; K 3.5 mEg/L
No Identity Analysis Diagnosis Procedure
2. Mrs. SANT / 3 Chief complaint : Preterm pregnancy with fetal movement can’t be felt anymore • G1P0A0 19 weeks • Observation of vital
2 YO/ 0406517 The patient was referred by obstetrician with diagnosis G1P0A0 24 weeks gestational gestational age(Z3A.36) sign, contraction
/PALEMBAN age partial mola was suspected single death fetus intrauterine with hydrops fetalis. • Mild anemia (O31.0) • Laboratory
G/ AB/ FIF-D Since 1 days before admission, patient complained fetal movement can’t be felt Single dead fetus examination
HA-IYA •
anymore. history of abdominal contraction radiates to waist but irregular (+), history intrauterine (O32.1) • Vaginal Delivery
of bloody show (-), history of amniotic fluid leakage (-). • Multiple congenital
Patient than went to Obstetric Gynecologist and after that admitted to RSMH. disorder (Hygroma colli
History of abdominal massage (-), history of trauma (-), history of consume and Hydrops fetalis)
traditional medicine. (D18.1)
Patient admitted has preterm pregnancy with fetal movement can’t be felt anymore • Anhidramnion (O36.59)
Addmision since 1 days ago.
Time:
24.12.2022 External obstetric examination :
20.30 WIB Uterine fundal height at umbilicus (20 cm), FHR (-), tenderness (-), ass (-), free fluid
sign (-)
Genitalia
Speculum examination
Livide portio, opened OUE, there was tissue in OUE, fluor (-), fluxus (-), E/L/P (-)
Vaginal toucher
Portio unpalpable, effacement 0%, closed OUE , Amniotic membrane and
denominator can’t be assessed yet.
US Examination :
23 weeks gestational age, Single death fetus intrauterine

Lab Examination :
Hb 10,5 g/dL; RBC 4,46x106/mm3; WBC 11510/mm4; Ht 30%; PLT 253.000/µL
MCV 86.4 fL; MCH 29 pg; MCHC 34 g/dL; RDW-CV 13,10%; D/C 0/1/73/19/7; T3
1,47; FT4 1,17; TSH 1,5399, Ur 13; cr 0,61.
No Identity Analysis Diagnosis Procedure
3. Mrs. ANAN Chief complaint : Preterm pregnancy with abdominal pain  G1P0A0 30 weeks  Observation of vital
/ 23 YO/ 14 Since 6 hours before admission, patient complained abdominal pain, intermittent, gestational age not in signs, contractions,
05838/ PAL with vas score 2-3. labor (Z3A.31) and FHR
EMBANG/ History of abdominal contraction (-). History of bloody show (-), history of amniotic  Abruptio placentae  Stabilization
FIF-DHA-IY fluid leakage (-), history of leucorrhea (+) white colour, itch (-), odor (-) , history of (O45.003)  Laboratory
A/ NS fever (-). History of trauma (-), history of abdominal massage (-), history of post  Moderate Anemia examination
coital (-). History of hypertension before pregnancy (-) (O43.219)  Lung maturation
   Urinary tract  PRC transfusion
Patient admitted has preterm pregnancy with fetal movement still can be felt infection
Addmision asymptomatic
External obstetric examination : (N39.0)
Time: Uterine fundal height 3 fingers above umbilicus (24 cm), longitudinal lie, left fetal
25.12.2022  Single life fetus
spine, cephalic, U 5/5, contraction (-), FHR 155x/m, EFW 1705 grams cephalic presentation
03.05 WIB
(Z34.0)
Genitalia
Speculum
Livide portio, closed OUE, fluor (-), fluxus (-), erosion (-), laceration (-), polyp (-)

US Examination :
30 weeks gestational age, SLF Cephalic presentation
placental abruption

Lab Examination :
Hb 8,9 g/dL RBC 5030/mm3 WBC 11050/mm4 Ht 34% PLT 356000/µL MCV 68,4 f
MCH 21 pg MCHC 31 g/dL RDW-CV 16,10% D/C 0/0/81/12/7 HBsAg non
reactive; VDRL non reactive; TPHA non reactive; Anti HIV non reactive
GYNECOLOGY PATIENTS
1 Patient
No Identity Analysis Diagnosis Procedure
1. MRS. DEWI / Chief complaint : Preterm pregnancy with vaginal bleeding  G3P2A0 6 weeks  Observation of vital
31 TH/ PALE Since 1 days ago, patient complained has vaginal bleeding comes from vaginal, for gestational age sign, bleeding
MBANG / 2-3x changing wet cloth, fresh red color. History of tissue discharged (-). History of (Z3A.30)  Bed rest
6575791 bubble like appearance discharge (-). history of leuchorrhea (-) history of trauma (-),  Microgest 200 mcg/
/DHA-FIF-IY  Threatened abortion
history of consume traditional medicine (-), history of post coital (-), history of 12 hours
A/ (O20.0)
tensed breast (+).  Us confirmation
NS    Submucous
Patient admitted has late in menstruation for 2 months  leiomyoma of uterus
External examination (D25.0)
Flat abdomen, supple, uterine fundal height unpalpable, tenderness (-), ass (-), free
Addmision fluid sign (-)
Time:  
24.12.2022 Genitalia
21.00 WIB Speculum examination
Livide portio, opened OUE, there was tissue in OUE, fluor (-), fluxus (+) didn’t
active bleeding, E/L/P (-)

US Result :
6 weeks gestational age intrauterine
Submucous leiomyoma of uterus

Lab Examination :
Hb 12.5 g/dL RBC 3,18/mm3 WBC 7570/mm3 Ht 38% PLT 231000/µL MCV 88,1
fL MCH 31 pg MCHC 35 g/dL RDW-CV 12,60% D/C 0/0/93/5/2
 
PASSED AWAY PATIENT
0 Patient
THANK YOU