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Obstetric Outpatient: Monday, April 2 2018
Obstetric Outpatient: Monday, April 2 2018
REPORTnd
Monday, April 2 2018
Residents:
Dr. Raden Bagus Prakoso
Dr. Tomas Ediba
Dr. Riyan Wira Pratama
Dr. Terry Mutia
Dr. Ismail Hadyatma
Supervisor:
Dr. Peby Maulina Lestari, OBGYN(C)
Identity Diagnosis ICD- Management ICD-9
10
1 Mrs. RAT/ G3P1A1 30 weeks gestational Z34.0 IEC 88.78
. 28 yo/UA age single life fetus cephalic 0 US
presentation Ferrous Sulfate 1x300 mg
Calcium lactate 1x500 mg
2. Mrs. MAR/ G2P1A0 4 weeks gestational Z34.0 IEC 88.78
26 yo/ UA age intrauterine 0 US
Folic Acid 1x400mcg
3. Mrs. YOS/ G4P3A0 18 weeks Z34.0 IEC 88.78
38 yo/ UA gestasional age with prior CS 0 US
1x + History of ca Thyroid Ferrous Sulfate 1x300 mg
post Thyroidectomy single Calcium lactate 1x500 mg
life fetus intrauterine
US examination
In USG Examination was found:
Single life fetus cephalic presentation
Fetal Biometry:
BPD: 7.6 cm HC: 28.0 cm
AC: 24.8 cm FL : 5.6 cm EFW: 1424 g
Amniotic fluid is sufficient
Placenta at anterior corpus
/- 30 weeks gestasional age SLF cephalic presentation
2. MRS MAR/ 26 yo/ UA
Anamnesis Pregnant woman came to Fetomaternal outpatient to control her second
pregnancy. Uterine contraction (-), blood spotting (-), nausea and
vomiting (-) , Patient said Pregnancy test was positive (+)
Birth status 1.2017. Male. Aterm. Spontaneous , 2900 g, Moh. Hoesin Hospital
healthy
2.This pregnancy
Reproduction Menarche 12 years old, irregular menstrual period,
History LMP : 15-02-2018
Physical Vital Signs
Examination BP: 120/70 mmHg P: 86 bpm RR: 20 x/mnt
Height: 153 cm Weight: 60 kg
Obstetric Uterine fundal not palpable, Abdomen not distended, tenderness (-).
Examination
US Examinantion 4 weeks gestasional age Intrauterine
Diagnosis G2P1A0 4 weeks gestational age intrauterine
Management - IEC
- US
- Folic Acid 1 x 400 ug
US Examination
In USG Examination was found:
- Gestational sac intrauterine diameter: 1.3 cm ~ 4 weeks
- fetal echo (-) yolk sac (-)
• 4 weeks gestasional age intrauterine
3. MRS YOS/ 38 yo/ UA BACK
US examination
In USG Examination was found:
Single life fetus intrauterine
Fetal Biometry:
BPD: 4.4 cm HC: 16.2 cm
AC: 13.5 cm FL : 3.0 cm EFW: 277 g
Amniotic fluid is sufficient
Placenta at posterior corpus
/- 18 weeks gestasional age SLF intrauterine
4. MRS RIC/ 27 yo/ RA BACK
US examination
In USG Examination was found:
Single life fetus intrauterine
Fetal Biometry:
BPD: 3.03 cm HC: 11.2 cm
AC: 9.49 cm FL : 1.46 cm EFW: 130 g
Amniotic fluid is sufficient
Placenta at posterior corpus
/- 15 weeks gestasional age SLF intrauterine
THANK YOU