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MORNING REPORT

29 November 2017

Supervisor: dr. Gede Made Punarbawa, Sp.OG (K)

Medical Students:
Shiva, Dhini, Tika

CASE RESUME
NORMAL LABOR -

PATHOLOGIES CASE 1. G1P0A0L0 37-38 weeks, S/L/IU Head


presentation with PROM > 12 hours
2. G3P2A0L2 4-5 weeks with Ectopic Pregnancy
and anemia

REMAIN CASE
Tidak ada
pertanyaan yang
salah
Case I
• Name : Mrs. T
• Age : 23 yo
• Addrs : Ampenan, West Lombok
• Admitted : 13-12-2017
Time Subject Object Assessment Planning
13/12/ Patient reffered from Awet Muda General condition : moderate G3P2A0L2 4-5 -Obs. Mother well
2017 Hospital with abdominal pain GCS : CM (E4V5M6) weeks with being.
e.c susp. Ectopic Pregnancy. BP : 100/70 mmHg ectopic -Check Lab : DL,
19.40 Patient confessed lower PR : 106 x / m Pregnancy and blood glucose,
WITA abdominal pain since 12-12- RR : 24 x/m anemia HBsAg, pregnancy
2017, Lower abdominal pain Temp : 36,9 ◦C test
increases since 13-12-2017. -USG
Bloody spot (-), General Status
History of DM (-), HT (-), asthma Eye : an (+/+), ict (-/-) -CIE family about
(-). Pulmo: ves (+/+), rh (-/-), wh medical
(-/-) examination
LMP : 10/11/2017 Cor : S1S2 single regular M(-
EDD : 17/08/2018 ), G(-) DM co to GP to
Abd : impalpable mass on SPV:
Obstetrical History. the right side, distensi (-), - Obs. Mother
I. 2011/Hospital/Spotan linea nigra (-), scar (-), condition
pervaginam/Aterm/ Abdominal pain (+) -Injection
Midwife/Girl/ 3,3 kg/ Life UFH: impalpable Ceftriaxon 2gr
II. 2007/Hospital/Aterm/ Ext : edema (-/-) -Serial DL in 3
Spontan Pervaginam/ hours
Midwife/ Boy/3 kg/Life Gynecology status : -Prepare PRC 2
III. This -Inspection : cervix dilatation kolf
(-), vaginal bleeding (-), fluor
History of ANC : - albus (+)
History of USG : 1x, last USG - Inspeculo : fluksus (-), fluor
(13-12-17) (+), livide (-),
Result: - VT : slinger pain (+)
Gestation Intra Uterine (-),
intraabdominal bleeding (+)
Conclusion: Ectopic
Time Subject Object Assessment Planning
History of Family Lab :
planning : - Hb : 9,5 g/dl
Planing family : - RBC : 4,16
WBC : 24,67
PLT : 374
HCt : 28,8%
HbSAg : (-)
RBG : 92
Pregnancy test : (+)
Time Subject Object Assessment Planning

14/08/2 Abdominal pain General condition : moderate G3P2A0L2 4-5 weeks with -DM consul to GP,
017 increase GCS : CM (E4V5M6) ectopic Pregnancy and GP to SPV:
BP : 80/60 mmHg anemia -CIE mother
23.30 PR : 114 x / m condition to family
RR : 24 x/m -CIE family, patient
Temp : 36,7 ◦C will doing
laparotomy
Eye : an (+/+), ict (-/-) -Tranfuse 1 kolf
Pulmo: ves (+/+), rh (-/-), wh (-/-) PRC
Cor : S1S2 single regular M(-), -Insert DC
G(-)
Abd : palpable mass on the left
side, distensi (-), linea nigra (-),
scar (-), Abdominal pain (+)
UFH: impalpable
Ext : edema (-/-), cold (+/+)

00.30 Abdominal pain General status G3P2A0L2 4-5 weeks with -Laparotomy
increase General condition : moderate ectopic Pregnancy and Began
GCS : CM (E4V5M6) anemia
BP : 90/60 mmHg -Blood at cavum
PR : 102 x / m peritoneum ±1000
RR : 22 x/m cc
Temp : 36,7 ◦C -Rupture of tuba
Eye = an (+/+) fallopi dextra
Abd: abdominal pain (+) -Tuba fallopi and
Ext : cold ovarium sinistra is
well
Time Subject Object Assessment Planning
03.30 Feeling uneasy about General status 2 hours post -Obs. Patient
operation scar General condition : Laparotomy well being, Obs
moderate vital sign
-Transfution
GCS : CM (E4V5M6) PRC 1 kolft
BP : 100/60 mmHg -Inj tranexamat
PR : 98 x / m acid 3x50gr
RR : 20 x/m -RL 20 dpm
Temp : 36,4 ◦C -Obs active
Eye = an (-/-) bleeding
Abd: abdominal pain (-) -Monitoring
urine output by
Ext : warm DC
-Patient move
to Segara Anak
Reffered
Letter
Case 2
• Name : Mrs. L
• Age : 25 yo
• Address : Suranadi
• Admitted : Desember 13th 2017
• RM : 00 52 78
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
23/12/ Patient came with G2P1A0H1 38- General status G2P1A0L1 38-39 DM planning:
2017 39 weeks, S/L/IU head presentation GC: well weeks, S/L/IU Diagnostic:
14.30 with PROM > 12 hours. Patient GCS : E4V5M6 head presentation • Check HbsAg
confessed water leaked from her BP : 120/70 mmHg with PROM >12 • CTG
womb since yesterday (12/12/2017). HR: 96 tpm Hours
Abdominal pain (-), bloody slime (-), RR: 20 tpm Therapy:
FM (+). Tax: 36,4◦C • Injection
BW : 65 kg cefotaxime 1
History of DM (-), HT (-), asthma (-), BH : 156 cm gr/iv, for 1 day
allergic (-) • Obs mother and
History DM in family (-), HT (-), Local status fetal well bring
asthma (-), allergic (+) (food) Eye : an (-/-), ict (-/-)
Pulmo ves (+/+), rh (-/-), wh (-/-)
LMP: 13-03-2017 Cor : S1S2 single regular, murmur Spv, advice:
EDD: 20-12-2017 (-), gallop (-) observasion
GW : 38-39 weeks Abdomen:
Scar (-), striae gravidarum (+),
History of ANC: 6x at PHC linea nigra (+)
Last ANC: 13/12/2017 Extremity: oedema (-/-) warm
Result : BP 120/70 mmHg, GW 38- (+/+)
39 weeks, UFH 34 cm, head
presentation, FHB (+) 144bpm Obs status:
History of USG: 3x at PHC L1 : breech
Last USG (13/12/17) Result  L2 : back to the left side
S/L/IU, GW 38-39 weeks, EFW L3 : head
3100gr head presentation L4: 4/5
UFH: 32 cm
History of family planning: injection EFW : 3100 g
Next family planning: implant FHB : 12-12-12 (144 bpm)
UC :-
Obstetrical history: VT : Ø 2 cm, eff 25%, amnion (-),
1. 2011/ HI, head not palpable, denom
PHC/Aterm/midwife/girl/3,1kg/ unclear, not palpable small part &
50cm/ life. umbilical cord
2. This
Time Subjective Objective Assessment Planning

Pelvic examination
Spina ischiadica non prominent
Sacrum convex
Os coccygeus mobile
Arcus pubis >90o

Lab: (/11/2017)
HB 11,6 g/dl
RBC 4,37 x 10^6/uL
HCT 35,2%
WBC 8,45 x 10^3/uL
PLT 274 x 10^3/uL
HbSAg non reactive

14.55 No Complaint -Nacl + ceftriaxone 1 gr


-Obs. VS, UC, bleeding
-Obs mother and baby well
being
- CIE mother to mobilization,
eat and drink

16.30 No complaint -DS 2 + oxytocin 5 In 8 dpm

17.00 No complaint UC – DS 2 + oxytocin 5 In 12 dpm


FHB (+) 12 -11 -11

17.30 No complaint UC – DS 2 + oxytocin 5 In 16 dpm


FHB (+) 12 -11 -11

18.00 No complaint UC (-) DS 2 + oxytocin 5 In 20 dpm


FHB (+) 12 – 12 – 11
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
18.30 Abdominal pain - UC (-) G2P1A0L1 38-39 weeks, DS 2 + oxytocin 5 In
FHB (+) 12 – 12 – 11 S/L/IU head presentation 24 dpm
with PROM >12 Hours

19.00 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 28 dpm

19.30 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 12 32 dpm

20.00 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 36 dpm

20.30 Abdominal pain - UC (-) - DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 40 dpm

21.00 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 40 dpm

21.30 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 40 dpm

22.00 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 40 dpm

22.30 Abdominal pain - UC (-) DS 2 + oxytocin 5 In


FHB (+) 12 – 12 – 11 40 dpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
23/12/ General status G2P1A0L1 38-39 DM planning:
2017 GC: well weeks, S/L/IU Diagnostic:
14.30 GCS : E4V5M6 head presentation • Check HbsAg
BP : 120/70 mmHg with PROM >12 • CTG
HR: 96 tpm Hours
RR: 20 tpm Therapy:
Tax: 36,4◦C • Injection
BW : 65 kg cefotaxime 1
BH : 156 cm gr/iv, for 1 day
• Obs mother and
Local status fetal well bring
Eye : an (-/-), ict (-/-)
Pulmo ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, murmur Spv, advice:
(-), gallop (-) observasion
Abdomen:
Scar (-), striae gravidarum (+),
linea nigra (+)
Extremity: oedema (-/-) warm
(+/+)
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USG
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