Professional Documents
Culture Documents
Pagi Klinik 3 Mei 2018
Pagi Klinik 3 Mei 2018
Pagi Klinik 3 Mei 2018
Supervisors :
dr. Risman F. Kaban, M.Ked(OG), Sp.OG
Residents :
1. dr. T. Larry Arthit
2. dr. Fakhrurrazi
3. dr. Rina Sinta Dhanu
4. dr. Vivi Yovita
5. dr. Muhammad Iqsan
6. dr. Sofyan Andri
7. dr. Willy Kurnia Almon
`
Department of Obstetric and Gynecology
Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2018
NEW PATIENT : 2 PATIENTS
1. Mrs. N, 38 y.o, G8P6A1
Diagnose : Severe Oligohydramnion + GMG + IUP (29-30) wga + Head
Presentation + Alive Fetus
Planning : Expectant management
Sonography confirmation
Report to Supervisor on Duty dr. Risman F. Kaban, M.Ked(OG), Sp. OG
Approved
Conclusion:
Severe Oligohydramnion + IUP (29 - 30 ) wga + Head
presentation + Alive fetus
Laboratory Findings
May, 3rd 2018
Therapy :
- Bed Rest
- O2 2-4L/I via nasal canule
- IVFD RL 20 dpm
- Inj. Dexamethasone 15 mg IV
Plan :
- Expectant management
- Sonography confirmation tomorrow
- Monitoring vital sign and fetal well-being
CC : Abdominal pain
This has been experienced since 1 day before admitted to hospital. Pain
in the abdomen and waist. History of vaginal bleeding (-) and history of
palpable lumps in the abdomen (-). History of postcoital bleeding (-).
History of leukorrhea (+), itch (+), odor (+) since 1 year ago. History of
weight decreased (-). History of decreased appetite (-). Nausea and
vomiting (+). Micturition and defecation showed no abnormalities.
Previous illness :-
Previous medication :-
History of surgery :-
History of contraceptive use : -
History of menstruation : Menarche at 12 y.o, regular cycle,
duration 6-7 days, volume 2-3 times changing pads/day,
menstrual pain (-), last menstruation April 8th 2018
Localized State
Inspeculo :
Looks exophytic mass size 5 x 4 cm. fragile, bleed easily, cleaned not
active.
Rectal Examination :
Exophytic mass palpable size 5 x 4 cm. Both Adnexa no mass palpated.
Both parametrium laxed. Douglas cavity not protruded. Anal Sphincter
was tight. Ampula of recti fill with feces.
Laboratory Findings
May, 3rd 2018
Therapy :
• IVFD NaCl 0,9% 20 dpm
• Inj. Ketorolac 30 mg/8 hours IV
Planning :
General Improvement Care