Morning Report

September, 10th 2015

Supervisor:
Dr. Agus Thoriq, SpOG
DM Jaga:
Rian

Morning Report
th
september 10 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES
LABOR

1.

G1P0A0L0 39-40 weeks S/L/IU head presentation with

Mild Preeclampsia + Condyloma Acuminata

Case 1
Name : Mrs. I
Age : 22 years old
Address : Gunung Sari
Admitted : 09-09-2015
No. RM : 56-65-50
G1P0A0L0 39-40 weeks S/L/IU head
presentation with Mild Preeclampsia +
Condyloma Acuminata

TIME

SUBJECTIVE

09/09/201
5
12.12 wita

Patient reffered from Gunung

Sari PHC with G1P0AL0 39-40
weeks S/L/IU head presentation
mother and fetal well being with
1st stage latent phase + severe
preeclampsia. Patient
confessed about abdominal
pain since 22.00 (08/09/2015)
history of water leaked out from
her womb (-) History of bloody
slim (-), FM (+).
History of DM (-), HT in
pregnancy (-), asthma (-) and
allergy (-).
LMP : 07/12/2014
EDD : 14/09/2015
History of ANC : 6x at PHC
Last result: (20/08/2015)
BP 110/70 mmHg, BW 57 kg,
GW 36-37 w UFH 30 cm, head
presentation, FHB (+)
History of USG : 1x, at SpOG
Last : 28/07/2015
S/L/IU head presentation, male,
GW 36-37 weeks, placenta at
corpus posterior, amnion clear,
EFW 2459 g
EDD 01/09/2015
History of family planning:
injection 3 month
Next family planning : IUD

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 140/10 mmHg
PR: 72 bpm
RR: 20 bpm
T: 36.7C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 31 cm
EFW : 3100 g
UC : 1x10~20
FHB : 12-12-12
VT : 2 cm, eff 25%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
mild preeclampsia +
condyloma
acuminata

DM planning:
Diagnostic : CTG
Therapy :
Pro termination per CS
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
advice :
C-Section

TIME

SUBJECTIVE
Obstetric History:
I. This

OBJECTIVE
Pelvic Examination
Promontorium unpalpable
Spina ishiadica non prominem
Arcus pubis >90o
Os. Coccygeus mobile
Pelvic score = 5
Dilatation of cervix : 1
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1
Laboratory (09/09/2015
12.04):
HB: 11.1 g/dl
RBC: 4.31
HCT: 33.8 %
WBC: 10.98
PLT: 427
HbsAg: non reactive
BT : 300
CT : 610
Cr : 0.4
Ur : 12
SGOT : 16
SGPT : 7

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronology at Gunung Sari
PHC (09/09/2015)
10.00
S:
Patient 9 months of pregnancy
come to PHC confessed
abdominal pain nsince 22.00
(08/09/2015) water leaked out
from the womb (-) fetal
movement (+)
O:
GC : well
consciousness: CM
BP : 140/90 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.2C
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 29 cm
EFW : 2790 g
UC : 1x10~20
FHB : 12-11-11
VT : 2 cm, eff 25%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Oedema -/Protein urin +3
A:
G1P0A0L0 39-40 weeks /S/L/IU
head presentation mother and
fetal well being with 1st stage
latent phase + severe
preeclampsia
P:
CIE mother about examination
result
Co to GP advice
Nifedipine 10 mg po
Drip MgSO4
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
13.00

SUBJECTIVE
Patient transffered to OR

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,7C
UC : 1x10 ~20
FHB : 12-12-13

ASSESSMENT

PLANNING

G1P0A0L0 39-40
weeks S/L/IU head
presentation with
mild preeclampsia
+
condyloma
acuminata

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, FHB
CIE : suggest mother
to bearing down
C Section begin at
9/9/2015 13.30
At 13.37 Baby was
born, female, BW 3000
g, BL 49 cm, A-S 7-9
Placenta was born
completely at 13.40
Do the management of
4th stage of labor

TIME

SUBJECTIVE

16.00

OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C

ASSESSMENT

PLANNING

2 hours post CS

DM planning:
Diagnostic : Therapy :
Amoxicillin 3x500 mg
Mefenamic Acid 3 x
500 mg
Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

1 day post CS

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink

UC : well
UFH : 1 fingers below umbilical
UO : 200cc/2 hours
Active bleeding (-)
Baby in NICU :
HR : 152x/minute
RR : 54x/minute
T : 36,3oC
10/09/201
5
07.00

Patient confessed about

abdominal wound pain

GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 2 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU :
HR : 148x/minute
RR : 50x/minute
T : 36,5oC

.. Thank
You ..