MORNING REPORT

11th January 2018

Supervisor: dr. Gede Made Punarbhawa,
Sp.OG(K)
Medical Students:
Tannia, Nita, Chandri, Sasya
CASE RESUME

NORMAL LABOR -

PATHOLOGIES CASE 1. G1A0P0H0 34-35 weeks S/L/IU

breech presentation+PPROM
2. G3P2A0H2 25-26 weeks S/L/IU
head presentation + PPROM
history of myomectomy
Remain Case -
 Tidak Ada
Pertanyaan Yang
Salah
 Name : Mrs. AU
 Age : 32 y.o
 Address : Selong, East Lombok
 Admitted : January, 11th 2018
 RM : 600929
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

11/01/ Patient came to NTB General General status G1A0P0H0 34- DM planning:
2018 Hospital confessed water leaked out GC: well 35 weeks Diagnostic:
20.30 from her womb since 10th January GCS : E4V5M6 S/L/IU • Check CBC,
pm 2018, at 20.00 pm. Patient BP : 140/100 mmHg breech • CTG
confessed that the water is clear at PR: 82 bpm presentation Therapy:
first, an now it turned out to be RR: 20 bpm +PPROM • Obs mother and
yellowish color. Patient confessed no Tax: 36.5◦ C fetal well being
abdominal pain and no bloody • Rehidration
slime, fetal movement (+). Localis status DM co to GP,
Eye : an (-), ict (-) advice:
History of DM (-), HT (-), asthma (-), Pulmo ves (+/+), rh (-/-), wh (-/-)
allergic (-) Cor : S1S2 single regular, murmur • injection ampicilin
History DM in family (-), HT (-), (-), gallop(-) 1 gr/6 hours IV,
asthma (-), allergic (-) Abdomen: next three days
Scar (-), striae gravidarum (+), linea amoxicillin 3x500
LMP: 7/05/2017 nigra (+) mg
EDD: 14/02/2018 Extremity: oedema (-/-) warm (+/+) • Dexamethasone
GW : 35-36 weeks injection 6 mg/12
Obs status: hrs
History of ANC: 8x at PHC L1 : head • Patient stay at ER
Last ANC: 3/1/2018 L2 : back to the left side for observation
Result: BP 120/80 mmHg, B: 55 kgs L3 : breech and tomorrow
36 weeks, UFH 24 cm, GW: 32 L4 : 5/5 have been
weeks head presentation, FHB (+). UFH: 26 cm scheduled for
EFW : 2325 g policlinic visit
History of USG: 1x at SpOG FHB : 12-11-11 (136x/menit)
Last result (12/12/2017): fetal UC : (-)
S/L/IU, head presentation, GW 29- VT : Ø 1 cm, eff 25%, amnion clear,
30 weeks, EDD 19/02/2018. breech palpable, ↓HI, not palpable
EFW: 1518 gram small part & umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
gina
m
History of family planning: (-) laboratory exam (11/01/2018):
Next family planning: injection 3 HGB: 11.9
months RBC: 3.7
HCT: 34 %
Obstetrical history: MCV: 91.9 fL
1. this MCH: 32.2 pg
MCHC: 35.0 g/dL
WBC: 20.280/uL
PLT: 249.000
24.00 Water still leaked out (+) abdominal General status G1A0P0H0 34-
pain (-) GC: well 35 weeks S/L/IU
GCS : E4V5M6 breech
BP : 110/70 mmHg presentation+PP
PR: 82 bpm ROM
RR: 24 bpm
Tax: 36.5◦ C

05.00 Water still leaked out (+) abdominal General status G1A0P0H0 34-
pain (-) GC: well 35 weeks S/L/IU
GCS : E4V5M6 breech
BP : 110/60 mmHg presentation+PP
PR: 80 bpm ROM
RR: 20 bpm
Tax: 36.6◦ C
 Name : Mrs. NL
 Age : 37 y.o
 Address :BTN Mavilla, Mataram
 Admitted : January, 11th 2018
 RM : 597544
TIME SUBJECTIVE OBJECTIVE ASSEST PLANNING
MENT
11/01/ Patient came to NTB General Hospital referred from General status G3P2A0H2 DM planning:
2018 obstetrician private clinic confessed water leaked out GC: well 25-26 Diagnostic:
20.40 from her womb since 6 days ago, the patient admitted GCS : E4V5M6 weeks • Check CBC,
pm that the fluid is clear, and now the patient confessed that BP : 110/70 mmHg S/L/IU • CTG
the water turned to yellow color. The amount of the fluid PR: 82 bpm head Therapy:
that leaked out was unmeasurable. Patient confessed no RR: 20 bpm presen • Obs mother and
abdominal pain,no fever, and no bloody slime, fetal Tax: 37.2◦ C tation fetal well being
movement (+). + • Rehidration
The patient has undergo a myomectomy operation on Localis status PPRO • injection ampicilin
October 2017, and she said that it was 17 cm myoma. At Eye : an (-), ict (-) M 1 gr/6 hours IV,
first 1 week of her pregnancy, she admitted a huge Pulmo ves (+/+), rh history next three days
amount of blood show, she undergo an USG examination (-/-), wh (-/-) of amoxicillin 3x500
and found that it was 10 cm myoma. The bloody show Cor : S1S2 single myome mg
was unbearable, she consult to obstetrician, and had an regular, murmur (-), ctomy DM co to GP,
operation on 10-11 weeks of her pregnancy. gallop(-) advice:
Abdomen: • Move to VK teratai
History of DM (-), HT (-), asthma (-), allergic (-) Scar (-), striae for observation
History DM in family (-), HT (-), asthma (-), allergic (-) gravidarum (+), linea • Drip duvadilan for
nigra (+) tocolitic
LMP: 20 July 2017 Extremity: oedema (-
EDD: 27 April 2018 /-) warm (+/+)
GW : 25-26 weeks
Obs status:
History of ANC: 4x at SpOG L1 : breech
Last ANC: 11/1/2018 L2 : back to the left
Result: BP 120/80 mmHg, B: 36 weeks, UFH 23 cm, side
GW: 25-26 weeks head presentation, FHB (+). L3 : head
L4 : 5/5
History of USG: 1x at SpOG UFH: 23 cm
Last result (11/1/2018): fetal S/L/IU, head presentation, EFW : g
GW 25-26 weeks, EDD 24/04/2018. FHB : 11-12-12
EFW: 798 gram (140x/m)
UC : (-)
VT : (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
gina
m
History of family planning: condom laboratory exam (11/01/2018):
Next family planning: injection 3 HGB: 10.1
months RBC: 4.03 juta/uL
HCT: 31 %
Obstetrical history: MCV: 77.4 fL
1. 9 years MCH: 25.1 pg
old/Female/Midwife/Hospital/life MCHC: 32.4 g/dL
2. 5 years WBC: 16.250/uL
old/Female/Midwife/Hosppital/Lif PLT: 285.000
e
3. This

24.00 Water still leaked out (+) abdominal General status G3P2A0H2 25- Patient move to VK
pain (-) GC: well 26 weeks Teratai for
GCS : E4V5M6 S/L/IU head observation
BP : 110/70 mmHg presentation
PR: 82 bpm + PPROM
RR: 24 bpm history of
Tax: 36.5◦ C myomectom
y

05.00 Water still leaked out (+) abdominal General status G3P2A0H2 25-
pain (-) GC: well 26 weeks -
GCS : E4V5M6 S/L/IU head
BP : 110/60 mmHg presentation
PR: 80 bpm + PPROM
RR: 20 bpm history of
Tax: 36.6◦ C myomectom
y