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Ok 3 Obgin 12 March 2020

This document contains medical records for three patients. The first is a 25-year-old female, gravida 37 weeks, scheduled for cesarean section for no inpartu head presentation with SLE. Exam and labs are normal. The second is a 47-year-old female with adenomyosis and endometrial cyst scheduled for resection. Exam and labs are also normal. The third is a 59-year-old female with bilateral NOP scheduled for laparotomy. Exam shows enlarged abdomen and labs are normal except anemia. All three patients are classified ASA II and scheduled for general anesthesia.

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Rudy Siahaan
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27 views34 pages

Ok 3 Obgin 12 March 2020

This document contains medical records for three patients. The first is a 25-year-old female, gravida 37 weeks, scheduled for cesarean section for no inpartu head presentation with SLE. Exam and labs are normal. The second is a 47-year-old female with adenomyosis and endometrial cyst scheduled for resection. Exam and labs are also normal. The third is a 59-year-old female with bilateral NOP scheduled for laparotomy. Exam shows enlarged abdomen and labs are normal except anemia. All three patients are classified ASA II and scheduled for general anesthesia.

Uploaded by

Rudy Siahaan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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OBGYN

MARCH, 12ND 2020


RD/FB
I. IDENTIFICATION
 Name : Vera Sonia
 Age : 25 yo
 Sex : Female
 Med Rec :986016
 Diagnosis: G2P1A0 Gravida 37 weeks, No
inpartu head presentation with SLE
 Pro : Cesarean section
II. SUBJECTIVE
 Plan to labour with Cesarean section with indication
SLE, no sgin of labour yet, no vaginal sign of bleeding
 SLE since 2016, with simptoms pain on feet if cold
weather,no history headache, no chest pain, No sign
of dispnea,
 Routine Therapy: Azathiprine 50 mg once dailiy,
metilprednisolon 4 mg once daily
 History of surgery –
 History of DM –
 History of Hipertension -
 History of coex (-) allergy (-), acute
respiratory infection (-)
III. PHYSICAL EXAMINATION
 Sensibility : CM
 Blood Pressure :120/80mmHg
 HR :100x/minutes
 RR : 22x/minutes
 Temperature : 36,7°C
 SpO2 : 99 %
 Head : Eye : anemic (-) icterik (-)
 Neck : mass (-)
 Thorax: Cor : heart sound I & II reguler,
murmur (-) gallop (-)
Pulmo : vesicular (+) normal
rhonki (-) wheezing (-)
 Abdomen : Gravid, fetal heart beat 141 bpm
 Extremitas : deformity (-) edema (-)
IV. EXAMINATION
Laboratorium Result (23/2/2020) :
 Hb : 10,7
 HT : 35  BSS : 89
 Leucocyte : 7210
 Platelet : 358000
 Ur/Cr: 9/0,53
 Natrium: 142
 Potassium: 4.2
 Cloride: 113
 PT : 29.1(32.3)
 INR : 0,96
 APTT : 29,1(32.7)
 Consult PDL: Cor pulmo fungsional
compensata
 Echo 27/2/2020 Normal echo EF 64,1%
Chamber and septum normal
 ASA II
 RA Spinal
I. IDENTIFICATION
 Name : Aidah
 Age : 47 yo
 Sex : Female
 Med Rec :1161469
 Diagnosis: Adenomiosis uteri + endometrial
cyst
 Pro : resection adenomiosis +
cystectomi
II. SUBJECTIVE
 Pain every menstrual cyle, no bleeding on
vaginal,
 History of surgery (-)
 History of DM (-)
 History of Hipertension (-)
 History of coex (-) allergy (-), acute
respiratory infection (-)
III. PHYSICAL EXAMINATION
 Sensibility : CM
 Blood Pressure :120/80mmHg
 N : 70x/minutes
 RR : 18x/minutes
 Temperature : 36,7°C
 SpO2 : 99 %
 Head : Eye : anemic (-) icterik (-)
 Neck : mass (-)
 Thorax: Cor : heart sound I & II reguler,
murmur (-) gallop (-)
Pulmo : vesicular (+) normal
rhonki (-) wheezing (-)
 Abdomen : supel, BU+N
 Extremitas : deformity (-) edema (-)
IV. SUPPORTING EXAMINATION
Laboratorium Result (11/2/2020) :
 Hb : 11,8  OT/PT : 12/8
 HT : 35  Natrium: 147
 Leukocyte : 7390
 Kalium: 4,2
 Platelet : 342000
 Cl: 113
 Ur/Cr: 13/0,72

 RBG : 99 mg/dl
 USG abdomen 10/2/2020
Mass ovarium right 4x3 cm, left 3x2 cm,
larging uterus 19x8 cm
 ECG 12/2/2020 NSR
 Chest X ray 12/2/2020 Normal thorax
 ASA II
 GETA
IDENTITY
 Mrs. Yati Daryati
 59 y.o
 1116294
 Enim 1
 Dx: NOP Bilateral
 Pro laparatomi VC
 Abdomen enlarged 2 months
 bleeding from the genitals (-)
 dispnea(-)
 Sens compos mentis
 BP: 124/73 mmHg
 HR 91 bpm
 RR 18 bpm
 SpO2 99%
 Head: Anemic conjunctiva (-), icteric (-)
 Neck : Mass (-)
 Thorax: Cor : heart sound I/II normal,
gallop (-) murmur (-)
Pulmo: vesicular (+), wheezing (-)
rhonci (-)
 Abdomen : as high as 7 months gestation
 Extremity : normal extremities
 Lab 3/3/2020
 7,8/25/8.440/471,000 >>>> PRC 2 bag
 Na/K: 142/4.7
 Ur/Cr: 13/0,62

 11/3/2020

9.6/30/8210/543.000
USG Abdomen (21/1/2020): Mass on ovarium
right 11x 10 cm
ECG (21/1/2020) NSR
Chest x ray: normal thorax
 Physical status ASA I
 GETA
IDENTITY
 Mrs Masna
 57 y.o
 1154853
 Dx: pyometria suspect Ca Endometrium
 Pro : Laparatomy Histerectomi
Vaginal discharge since 3 months
ago , white discharge

 Pain (-), Cough (-), fever (-),


 History of coex (-), History of
diabetes mellitus (-), allergy (-),
Asthma (-), surgery (-)
 Sens CM
 BP: 112/58
 HR 94 bpm
 RR 18 rpm
 SpO2 99%
 Head: Anemic conjunctiva (-), icteric (-)
 Neck : Mass (-)
 Thorax: Cor : heart sound I/II normal, gallop
(-) murmur (-)
 Pulmo: vesicular (+), wheezing (-) rhonci (-)
 Abdomen : supel, peristaltic sound+ normal
 Extremity : pitting edema (-)
 Lab 03/2/2020
 11.2/33/12.740/374,000
 Na/K: 144/4,0
 Ur/Cr: 43/1,09
 Ca/8.0

 Ro thorax(4/2/20): infiltrate both lung bases


 ECG(27/11/19): NSR
 PDL: cor fungsional compensate, Pulmo
bronchitis chronic
 Physical status ASA II
 GETA
IDENTITY
 Mrs Yusniarsih
 45 y.o
 1155107
 Rambang 2.2
 Diagnosis: Sarcoma Uteri
 Pro laparotomy histerectomi
 stomach pain 3 months ,
 right stomach cramps, inactive
bleeding
 Pain (-), Cough (-), fever (-),
 History of coex (-) hypertension,
History of diabetes mellitus (-),
allergy (-), Asthma (-).
 Sens CM
 BP: 140/95
 HR 87 bpm
 RR 18 rpm
 SpO2 99%
 Head: Anemic conjunctiva (-), icteric (-)
 Neck : Mass (-)
 Thorax: Cor : heart sound I/II normal, gallop
(-) murmur (-)
 Pulmo: vesicular (+), wheezing (-) rhonci (-)
 Abdomen : pain (-) bowel sounds normal,
Mass (+) 3 cm above simphisis
 Extremity : mass (+) size orange , discharge
(+) pain (+)
 Lab 11/3/2020
 13,8/41/90300/356000
 Na/K/Cl: 145/4,5/116
 Ur/Cr: 26/0,76

 ECG(14/1/2020): NSR
Chest X ray 30/12/20 Normal Thorax
PDL: Cor pullmo compensata
USG : lage uterus 11x 8 cm cavum uterina masss +
 Physical status ASA II
 GETA

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