LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

NO. DATE PATIENT DETAIL OF PATIENT TREATMENT RECOMMENDATION

1. 26/04/2021 Mrs. S Pre Treatment Diagnosis : - Spontaneous vertex - Exclusive Breastfeeding

28 years G3P2A0 39 weeks days of Gestational Age in active phase 1st delivery for 6 months
LMP : 28-07- of labor + IUD Acceptor Candidate - Early initiation of - Control for IUD Position
2020 breastfeeding
MR : 392105 Post Treatment Diagnosis : - IUD Insertion
Term delivery + IUD Acceptor

Outcome :
Female, BW : 2900 gr, BL : 47 cm, AS : 8/10

2. 27/04/2021 Mrs.SY Pre Treatment Diagnosis : - Spontaneous vertex - Exclusive Breastfeeding

30 years G4P3A0 40 weeks 2 days of Gestational age in 2nd stage of delivery for 6 months
LMP : 19-07- labor + IUD Acceptor Candidate - Early initiation of - Control for IUD Position
2020 breastfeeding
MR : 292081 Post Treatment Diagnosis : - IUD Insertion
Term delivery + IUD Acceptor

Outcome :
Female, BW : 3100 gr, BL : 49 cm, AS : 8/10 -

3. 28/04/2021 Mrs. L Pre Treatment Diagnosis : - Spontaneous vertex - Exclusive Breastfeeding

26 years G1P0A0 38 weeks 5 days of Gestational age in active phase delivery for 6 months
LMP : 30-07- 1st stage of labor - Early initiation of - Vaginal Hygiene
2020 breastfeeding - Family planning,
MR : 271287 Post Treatment Diagnosis : - Repair of perineal counseling and
Term delivery + 2nd degree perineal laceration laceration education: Implant
 LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

Outcome :
Female, BW : 2900 gr, BL : 47 cm, AS : 8/10
-
4. 28/04/2021 Mrs. E Pre Treatment Diagnosis : - Spontaneous vertex - Exclusive Breastfeeding
23 years G1P0A0 40 weeks 4 days of Gestational age in active phase delivery for 6 months
LMP : 18-07- 1st stage of labor - Early initiation of - Vaginal Hygiene
2020 breastfeeding - Family planning,
MR : 392274 Post Treatment Diagnosis : - Repair of perineal counseling and
Term delivery + 2nd degree perineal laceration laceration education: Progestin
Injection
Outcome :
Male, BW : 3300 gr, BL : 49 cm, AS : 8/10
-
5. 25/04/2021 Mrs. J G3P1A1 -Oxygen via NRM 10 lpm - Monitoring of general
27 years - Informed Consent condition, vital sign, and
Referred by Lamadukelleng Hospital with G3P1A1 35 weeks
LMP :23-08- - Consult to Cardiologist bleeding sign
of Gestational Age in Latent phase 1st stage of Labor + - Consult to -Educate the family about
2020
Congestive Heart Failure + IUGR suspected
MR : 392196 Neonatologist for NICU the patient and the baby
Dyspnea (+) admission condition
- Lower segment
Lower abdominal pain with bloody show (+) tranverse caesarean
History of heart disease since 4 years, the patient never got section
medication -Bilateral Pomeroy
Tubectoy Modification
History of dyspnea and fatique in daily physical activity - ICU Observation with
ventilatory support

BP: 100/70 mmHg

HR: 120 bpm
LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

RR: 36 bpm
SpO2: 78 % (with NRM support)
Clubbing fingers (+)

Laboratory Results (25/4/21):

HGB: 17.7 gr/dL
WBC: 7.590 /µL
PLT: 145.000 /µL
RBS: 70 mg/dL
GOT: 41 U/L
GPT: 24 U/L
Ureum : 18 mg/dL
Creatinin: 0.86 mg/dL
Blood Gas Analysis:: Partially Compensated Respiratory
Alkalosis

ECG:
Sinus tachycardia with Right Axis Deviation, P-Pulmonal,
Right Ventricle Hyperthrophy, CRBBB

Thorax x-ray: Cardiomegaly

USG: EFW: 1770 gr

SDP: 2.6 cm
LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

Pre Operative Diagnosis:

G3P1A1 35 weeks of Gestational Age in Latent phase 1 st stage
of Labor + Congestive Heart Failure NYHA III + IUGR
suspected + Female Sterilization Acceptor Candidate
Post Operative Diagnosis :
Congestive Heart Failure NYHA III + Term Delivery + IUGR
suspected + Preterm Delivery + Severe Asphyxia of Newborn
+ Female Sterilization Acceptor
Outcome:
Male, BW: 1750 gr, BL: 42 cm, AS: 1/6, NBS: 27 similar with
35 weeks Observation of general
condition and vital sign

Monday (27/4/21)
06.00 -Oxytocin 20 IU in Ringer Explain the family about
S: Lactate 500 cc 20 dpm patient condition
O: GCS : E2M4Vx (intubated) -Cefotaxime 1 gr/12
BP: 90/55 mmHg hours/ iv
HR: 101 bpm -Ketorolac 30 mg/ 8
Sp.O2: 67 % hours/ IV
Fundal Height: 2 fingers below umbilicus -Ranitidin 50 mg/ 8
Contraction: adequate hours/ IV
Active Vaginal bleeding : (-) -Tranexamid Acid 500
Urine production : 106 cc/hour mg/ 8 hours/iv
Hb post operative: 15.3 gr/dL
LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

Therapy from
A: Post operation day-1 + Congestive Heart Failure NYHA III + anesthesiologist::
IUGR + Preterm Delivery + Female Sterilization Acceptor - Fentanyl
30mcg/hour/SP
- Midazolam 2
mg/hour/SP

Therapy from
cardiologist:
- Dobutamin 5
mcg/kgBB/minute/SP
- Furosemide 40 mg/12
hours/IV
- Isosorbide dinitrate 2
mg/hours/SP
- Omeprazole 40 mg/24
hours/ iv

19.00 - Norepinephrine 0.5

S: (-) mcg/kgBB/minute/SP
GCS: E1M1Vx(intubated) - Dobutamin 5
BP: 53/42 mmHg mcg/kgBB/minute/SP
HR: 52 bpm
SpO2: 56 %

Post Treatment Diagnosis:

P2A1 + Cardiogenic Shock + Congestive Heart Failure + IUGR
+ Preterm delivery + Post Operation Day 1
 LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

19.45 - Cardiopulmonary
S: (-) rescucitation for 15
GCS: E1M1Vx(intubated) minutes
BP: Not measurable - The patient was
HR: Not palpated declared dead by
anesthesiologist at
Light Reflex: dilated pupil
20.00
Cornea Reflex: negative

Post Treatment Diagnosis:

P2A1 + Cardiac Arrest + Cardiogenic Shock ec Congestive
Heart Failure + IUGR + Preterm delivery + Post Operation
Day 1

Total Cases :5
Vaginal Delivery :4
Lower segment transverse cesarean section :1

Family planning
IUD :2
Implant :-
Female Sterilization :1
 LABUANG BAJI HOSPITAL / Dwicky Limbersia Aries

PERIOD OF APRIL 25th- 28th, 2021

Makassar, 29/04/2021
Known By:
Chief Resident :

TIM A TIM B

dr. Nur Amin Wahidji dr. Yuliati

Supervisor :

dr. A. Nursanty Padjalangi, Sp.OG (K)