1. This document reports on the care of a 32-year-old female patient (Mrs. M) over 4 days at Adam Malik General Hospital. 2. Mrs. M was post-cesarean section for hepatitis B and had a previous cesarean delivery and sterilization. She was being treated for pain and monitored for bleeding and vital signs. 3. Over the 4 days, Mrs. M's condition was stable with normal vital signs and decreasing pain. Her lab results were monitored and she was discharged on the fourth day with a plan for oral therapy.

1. Duty Team :
1. dr. Rizky Fachriza Harahap
2. dr. Mashdarul Ma’arif
3. dr. Handri RV
Department of Obstetric and Gynecology
Faculty of Medicine University of Sumatera Utara
Adam Malik General Hospital
2015
Fetomaternal Ward Report
Thursday, October 8th 2015

2. Ward Patients : 1 patients

3. 1. Mrs. M, 32 years old, P4A0
Dx: Post C – Section dt Hep-B +Prev C-Section 1x + Post
Pommeroy Sterilization + PD 2
Plan : Oral Therapy
Check Anti HbsAg, HbsAb
Consult to Gastroentero Hepatology
Supervisor : dr.Iman Helmi Effendi, M.Ked (OG), SpOG.K
Resident : dr. Rizky
Length of stay : 5 days

4. Follow up Monday, 6th October 2015 8 am
Chief Complaint: -
Present state
Level of Cons : Alert Anemic : (-)/(-)
BP : 110/80 mmHg Icteric : (-)/(-)
HR : 82 times/minute Cyanosis : (-)
RR : 20 times/minute Dyspnea : (-)
Temperature : 36,5 0C Oedem : (-)
Generalized state
Head : Eye : Conjuctive Palpebra Inferior anemic -/-, icteric -/-
Nose : Within normal limit
Ear : Within normal limit
Mouth : Within normal limit
Neck : JVP R-2 cmH2O, enlargement of lymph node(-)

5. Thorax :
Breathing sound : Vesicular
Heart : Cor S1S2 (N)
Localized State :
Abdomen : asymmetrical enlargement
Fundal height : 3 finger below bpx
Tension : Left
Lowest art : Head
Movement : (+)
His : (-)
Fetal Heart rate : 148 x/I

6. Diagnosis : Hep B + Prev CS 1x + MG + IUP (38-40) wga + Head Presentation + Live
fetus
Therapy :
- IVFD RL  20 gtt/i
- Inj Cefazolin 2 gr prophylaxis  skin test
- Foley Catheter
Plan :
- C-section on October 6th 2015 in Emergency OT
- Consult to Anesthesiology
- Consult to Perinatology

7. Follow up Wednesday, October 7th 2015 8 am
Chief Complaint: Pain
Present state
Level of Cons : Alert Anemic : (-)/(-)
BP : 110/70mmHg Icteric : (-)/(-)
HR : 92 times/minute Cyanosis : (-)
RR : 20 times/minute Dyspnea : (-)
Temperature : 36,7 0C Oedem : (-)
Generalized state
Head : Eye : Conjuctive Palpebra Inferior anemic -/-, icteric -/-
Nose : Within normal limit
Ear : Within normal limit
Mouth : Within normal limit
Neck : JVP R-2 cmH2O, enlargement of lymph node(-)

8. Thorax :
Breathing sound : Vesicular
Heart : Cor S1S2 (N)
Localized State :
Abdomen : soeple, peristaltic (+) N
Fundal Height. : 1 finger below umbilicus, well contraction
Operation wound : covered with gauze, dry
Vaginal bleeding : (-), lochia (+)rubra
Micturition : (+) via catheter uop 70cc/ hr, clear
Defecation : (-), flatus (+)

9. Diagnosis : Post C-section d/t Hep B + Prev CS 1x + Pomeroy Sterilization + PD1
Therapy :
-IVFD RL 20 gtt/I
-Inj ceftriaxon 1 gr/12 hr
-Inj Ketorolac 30 mg/8 hr
-Inj Ranitidin 50 mg/12 hr
Plan :
- Observe vital sign, contraction, and bleeding
- Perform complete blood check post CS
- Consult to Gastroenterohepatology

10. Follow up Thursday, October 8th 2015 8 am
Chief Complaint: Pain
Present state
Level of Cons : Alert Anemic : (-)/(-)
BP : 120/70mmHg Icteric : (-)/(-)
HR : 84 times/minute Cyanosis : (-)
RR : 20 times/minute Dyspnea : (-)
Temperature : 36,7 0C Oedem : (-)
Generalized state
Head : Eye : Conjuctive Palpebra Inferior anemic -/-, icteric -/-
Nose : Within normal limit
Ear : Within normal limit
Mouth : Within normal limit
Neck : JVP R-2 cmH2O, enlargement of lymph node(-)

11. Thorax :
Breathing sound : Vesicular
Heart : Cor S1S2 (N)
Localized State :
Abdomen : soeple, peristaltic (+) N
Fundal Height. : 1 finger below umbilicus, well contraction
Operation wound : covered with gauze, dry
Vaginal bleeding : (-), lochia (+)rubra
Micturition : Spontaneus
Defecation : (-), flatus (+)

12. Diagnosis : Post C-section d/t Hep B + Prev CS 1x + Pomeroy Sterilization + PD2
Therapy :
-IVFD RL 20 gtt/I
-Inj ceftriaxon 1 gr/12 hr
-Inj Ketorolac 30 mg/8 hr
-Inj Ranitidin 50 mg/12 hr
Plan :
- Oral Therapy

13. 06/10/15 07/10/2015
Hb: 9.70
Ht: 29.4
L: 15.4400
PLT: 298.000
PT : 16.2 C: 14.10
INR : 1,18
aPTT : 26.8 C : 33,6
TT : 13,8 C : 17,2
Albumin : 3.5
BGL adr : 102
Ureum :20.10
Creatinin 0.47
Natrium 137
Kalium 3.9
Clorida 106
HBsAg Positif
Hb: 10.2
Ht: 29.4
L : 19.440
PLT: 278.000
PT : 16.5 C: 14.00
INR : 1,19
aPTT : 26.2 C : 34.0
TT : 12,8 C : 17,4
BGL adr : 75

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