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MORNING REPORT

26st February 2018

Supervisor: dr. Ratih Barirah, Sp.OG

Medical Students:
Arsy, Maya, Ida
CASE RESUME
NORMAL LABOR -
PATHOLOGIES CASE 1. G4P3A0L3 35-36 weeks S/L/IU head
presentation with impending eclampsia

REMAIN CASE -
Tidak ada
pertanyaan
yang salah
Case 1
• Name : Mrs. M
• Age : 44 yo
• Address : Tanjung
• Admitted : 26th February 2018
• RM : 602410
TIME SUBJECTIVE OBJECTIVE SESSMENT PLANNING
26/02/ Patient referred from Tanjung PHC General status G2P1A0L1 31-32 DM planning:
2018 with G4P3A0L3 S/L/IU GW 34-35 GC: well weeks S/L/IU head Diagnostic:
20.00 weeks head presentation with GCS: E4V5M6 presentation with • CTG
impending eclampsia. Headache (+) BP: 200/130 mmHg chronic • Check CBC,
since 5 days ago and getting severe HR: 98 tpm hypertention • HbsAg
since this afternoon (17.00), blurry RR: 20 tpm superimposed • Urinalysis (protein)
vision (+) since 5 days ago, epigastric T: 36.5◦ C preeclampsia, • SGOT/SGPT
and abdominal pain (-) bloody slime (- oedem pulmo(?) • Cretainin serum
), water leaked from her womb (-), Local status • Albumin serum
fetal movement (+). Eye : an (-/-), ict (-/-) • ECG
Pulmo ves (+/+), rh (-/-), wh (-/-) • USG
History of DM (-), HT (+) while third Cor : S1S2 single regular,
pregnancy, asthma (-), allergic (-) murmur (-), gallop(-) Therapy:
History DM in family (-), HT (+), Abdomen: • Oxygen 3 lpm
asthma (-), allergic (-) Scar (-), striae gravidarum (-), • IUVD NS 500
linea nigra (+) ml/24 hours
LMP : 30/06/2017 Extremity: oedema (-/-), warm • Nifedipine 3x10
EDD : 07/04/2018 (+/+) mg PO
GW : 34-35 weeks • Furosemide 3x1
Obs status: amp
History of ANC: 6x L1 : breech • Chana albumin
Last ANC (06/02/2018): L2 : back on the right side 3x1 tab
L3 : head • Albumin
History of USG: 1x L4 : 5/5 transfusion
Last USG (20/12/2017) : no
documented UFH: 26 cm SPV advice :
EFW : 2170 gr - Observation the
FHB : 11-11-11 tpm condition of
UC : (-) mother and fetus.
VT : (-) - Observation fluid
input and output
- High Protein Diet
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

History of family planning: before the Laboratory exam (21/12/2017): G2P1A0L1 31-32
pregnancy, patient used IUD, one HGB : 14,6 weeks S/L/IU
and three months injection RBC : 5,47 head presentation
HCT : 43,4 with severe
Next family planning : three months WBC : 9,02 preeclampsia
injection PLT : 102
PPT : 11,4
Obstetrical history: APTT : 28,7
1. Aterm/ Male/ Midwife/ BW:3500gr/ GDS : 82
BL: 50cm//5yo HbsAg : non reactive
2. This one SGOT :-
SGPT :-
Na : 129
K : 4,4
Cl : 109
Albumin : 2,3

Urinalysis
Protein : +4
Blood : +4
REFERENCE NOTE
RONTGEN
ECG
CTG
CHRONOLOGY
Case 2
• Name : Mrs. SR
• Age : 29 yo
• Address : Kayangan
• Admitted : 21st December 2017
• RM : 600176
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
21/12/ Patient referred from Tanjung Hospital General status G2P1A0H1 32-33 DM planning:
2017 with G2P1A0L1 GW 33 weeks S/L/IU GC: well weeks S/L/IU head Diagnostic:
22.30 head presentation, patient said that GCS : E4V5M6 presentation with • Check CBC
she had headache and epigastric BP : 180/110mmHg severe • HbsAg
pain since 1 month ago. Since two HR: 90 tpm preeclampsia and • Urinalysis (protein)
months ago, she had higher blood RR: 20 tpm suspect IUGR • SGOT/SGPT
pressure than before. Patient also T: 36.4◦ C • Creatinin serum
had fever, cough and cold since three • Electrolyte
days ago. Abdominal pain (-), water Localis status • ECG
and blood slime from her womb (-), Eye : edema palpebra (-/-), an (-
fetal movement (+). /-), ict (-/-) Therapy:
Pulmo ves (+/+), rh (-/-), wh (-/-) • Nifedipin 3x10mg
History of DM (-), HT (-), asthma (-), Cor : S1S2 single regular, PO
allergic (-) murmur (-), gallop(-) • Dexametason
History DM in family (-), HT (+), Abdomen: 2x6mg PO
asthma (-), allergic (-) Scar (-), striae gravidarum (-), • Methyldopa
LMP : 4th Mei 2017 linea nigra (+) 3x250 mg PO
EDD : 11th Feb 2018 Extremity: oedema (+/+), warm
GW : 32-33 weeks (+/+) SPV advice:
• Observation the
History of ANC: Obs status: condition of
Last ANC : 4-12-2017 L1 : breech mother and fetus.
Extremity swelling, BP 170/110 L2 : back on the left side • Observation fluid
mmHg, body weight 70 kg, GW 30-31 L3 : head input and output
weeks, UFC 20 cm, head L4: 5/5 • Pro USG in the
presentation, FHB (+), Hb 12 g/dl. morning
She did urinalysis: Proteinuria +3, UFH: 20 cm
Leukocyte (-). EFW : 1240 gr
FHB : 12-12-11
History of USG: 2x UC : (-)
Last USG (19/12/2017) : VT : (-)
S/L/IU head presentation, EFW 1190
gr, GW 27-28 weeks, placenta at
corpus posterior grade II, suspect
IUGR.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

22.30 History of family planning: before Laboratory exam (21/12/2017):


pregnancy, patient used injection HGB : 13,5
contraception for 1 year. RBC : 4,58
HCT : 38,4
Next family planning : patient WBC : 10,42
planning to used injection PLT : 187
contraception, and she is not PPT : 13,1
planning to have another child. APTT : 29,7
GDS : 80
Obstetrical history: Kreatinin : 1,2
1. Aterm/female/3200 Ureum : 30
gr/pervaginam/midwife/ PHC/ 10 SGOT : 30
yo SGPT : 20
2. This HbsAg : non reactive
Na : 135
K :4
Cl :108

Urinalysis
Protein : +3
Blood : +1
KIA
USG
ECG
Case 3
• Name : Mrs. S
• Age : 34 yo
• Address : Batu Layar
• Admitted : 21st December 2017
• RM : 600171
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
21/12/ Patient referred from Meninting PHC General status G6P5A0L4 GW DM planning:
2017 with G6P5A0L4 GW 39-40 weeks GC : well 39-40 weeks Diagnostic:
23.00 S/L/IU head presentation with PROM GCS : E4V5M6 S/L/IU head • Check CBC,
<12 hours. Patient confessed water BP : 120/70mmHg presentation with • HbsAg
leak from her womb since 15.30 HR : 80 tpm PROM <12 hours • GDS
WITA. Abdominal pain (-), blood slime RR : 20 tpm
from her womb (-), fetal movement T : 36.8◦ C Therapy:
(+). - IVFD RL
Localis status - Cefotaxime 1gr
History of DM (-), HT (-), asthma (-), Eye : edema palpebra (-/-), an (- IV
allergic (-) /-), ict (-/-)
History DM in family (-), HT (+), Pulmo ves (+/+), rh (-/-), wh (-/-) SPV advice :
asthma (-), allergic (-) Cor : S1S2 single regular, - Oxytocin
murmur (-), gallop(-) induction for labor
LMP : March 2017 Abdomen:
EDD : 27th Dec 2017 (based on USG) Scar (-), striae gravidarum (-),
GW : can’t be evaluated linea nigra (+)
Extremity: oedema (-/-), warm
History of ANC: (+/+)
Last ANC : 4-12-2017
No complaint, BP 110/70 mmHg, Obs status:
body weight 57,7 kg, GW 35-36 L1 : breech
weeks, UFC 31 cm, head L2 : back on the left side
presentation, FHB (+). L3 : head
L4 : 4/5
History of USG: 1x
Last USG (9/08/2017) : UFH: 31 cm
S/L/IU transverse lie, EFW 310 gr, EFW : 3100 gr
GW 20 weeks, placenta at fundus. FHB : 13-13-13
UC : 1x/10’-15”
VT : Ø 1 cm, eff.15%, amnion (-),
head palpable, ↓H1
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

History of family planning: three Laboratory exam (22/12/2017):


months injection for 8 years HGB : 11,4
RBC : 3,91
Next family planning: she’s planning HCT : 34,91
this is the last pregnancy, and WBC : 10,07
choose IUD for next contraception PLT : 343
PPT : 14,2
Obstetrical history: APTT : 28,9
1. 20 HbsAg : non reactive
yo/female/aterm/pervaginam/sha GDS : 112
man/life
2. 18
yo/male/aterm/pervaginam/sham
an/dead
3. 16
yo/male/aterm/pervaginam/midwi
fe/life
4. 15
yo/male/aterm/pervaginam/midwi
fe/life
5. 13
yo/male/aterm/pervaginam/midwi
fe/life
6. This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
22/12/ No complaint General status G6P5A0L4 GW Oxytocin induction
2017 GC : well 39-40 weeks started at 8 dpm
03.00 GCS : E4V5M6 S/L/IU head
BP : 120/70mmHg presentation with
HR : 82 tpm PROM <12 hours
RR : 18 tpm
T : 36.5◦ C
UC : (-)
FHB : 140x/m
03.30 UC : (-) Oxytocin induction
FHB : 144x/m 12 dpm

04.00 UC : (-) Oxytocin induction


FHB : 148x/m 16 dpm

05.00 UC : (+) 1x/10’ – 20” Oxytocin induction


FHB : 140x/m 20 dpm

05.30 UC : (+) 1x/10’ – 20” Oxytocin induction


FHB : 144x/m 24 dpm

06.00 UC : (+) 2x/10’ – 40” Oxytocin induction


FHB : 144x/m 28 dpm
KIA
USG
CTG