MORNING REPORT

06-06-2017

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

Medical Students:
Ros, Elmy, Dian, Ika
CASE RESUME

NORMAL LABOR -

PATHOLOGIES CASE -

REMAIN CASE
 Tidak ada
pertanyaan
yang salah
 Case 1
Name : Mrs. R
Age : 26 yo
Address : Narmada
Admitted : 5 June 2017
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

05/06/ Patient referred from Lingsar PHC General status G2P1A0H1 31-32 DM planning:
2017 with G2P1A0H1, aterm S/L/IU head GC: well weeks S/L/IU head
16.30 presentation with mother and fetal GCS : E4V5M6 presentation, Therapy:
good condition with active phase of BP : 140/90 mmHg active phase of
labor + mild pre-eclampsia. Mother HR: 84 tpm labor, with mild Obs mother and
confessed abdominal pain since RR: 20 tpm pre-eclampsia fetal well being
07.00 (05/06/2017). Patient Tax: 36.6 C Conduct mother to
confessed bloody slime since 07.00 bearing down
(05/06/2017), Water leaked from her Localis status
womb (+) since 15.30 (05/06/2017). Eye : an (-/-), ict (-/-) DM co to GP, GP co
fetal movement (+). Pulmo ves (+/+), rh (-/-), wh (-/-) to Spv, advice:
Cor : S1S2 single regular, murmur - Conduct mother to
History of DM (-), HT (-), asthma (-), (-), gallop(-) bearing down
allergic (-) Abdomen: Scar (-), striae
History DM in family (-), HT (-), gravidarum (+), linea nigra (+)
asthma (-), allergic (-) Extremity: oedema (-/-), warm
(+/+)
LMP: 18-10-2016 (forgot)
EDD: 25-7-2017 Obs status:
GW : 31-32 weeks L1 : breech
L2 : back to the left side
History of ANC: 2x at Lingsar PHC L3 : head
Last ANC (23/4/2017) : Patient L4: 1/5
complain nausea (+), vomiting (+) UFH: 34 cm
BP 110/70 mmHg, GW 27-28 weeks, EFW : 3565 g
breech presentation, FHB (+) FHB : 12-12-12
UC : 4x10~45
History of USG: - VT: complete, eff 100%, amnion
(-), head persentation, denom
unclear, HIV, small parts and
umbilical unpalpable
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

History of family planning: inplant Laboratory exam (18:36

Next family planning: inplant 05/06/2017):
HGB: 10,3
Obstetrical history: RBC: 4,59
1. male/aterm/spontan/midwife/3300 HCT: 32,1
gram/7 y.o MCV: 69,9
2. this MCH: 22,4
MCHC: 32,1
WBC: 26,04
PLT: 134

Proteinuria +2
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

5/6/17 Chronology: GC: well G2P1A0H1 aterm Obs mother and

11.00 S/ BP : 120/80 mmHg S/L/IU head fetal well being
Patient 9 month pregnant confessed HR: 80 tpm presentation with Obs progress of
abdominal pain, mother want to RR: 20 tpm mother and fetal labor
bearing down since 05/06/2017 at t: 36.5 C good condition with
07.00 am. FM (+) UFH : 33 cm active phase of
Head Presentation, back on the labor + mild pre-
left side, L4: 4/5 eclampsia
UC : 3x10~35
FHB: 136x/mnt
VT : 5 cm, eff 50%, amnion
(+), head palpable, HI, small
parts and umbilical unpalpable
Proteinuria (+1)

15.00 Abdominal pain (+) BP: 140/100

HR: 84 tpm
RR: 18 tpm
t: 36,6
UC: 4x10~40
FHB: 144 x/mnt
VT : 9 cm, eff 75%, amnion
(+), head palpable, HII, small
parts and umbilical unpalpable
Proteinuria (+1)
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

5/6/17 Mother want to bearing down BP : 140/90 mmHg 2nd phase of labor + Conduct mother to bearing down
16.40 HR: 88 tpm mild pre-eclampsia
RR: 20 tpm
Tax: 36.7 C
UC : 4x10~45
FHB : 12-12-12
16.55 Baby was born
Male/3480 gram/A-S 5-
7/anomaly congenital
(-)

17.05 Placenta was born

complete, blood
250cc,
19.00 Abdominal pain (-) BP: 140/90 mmHg P2A0H2 with mild pre- - PCT tab
HR: 82 tpm eclampsia - Drip ceftriaxon 2 gr
RR: 20 tpm
Tax: 38,00
ANC
Surat Rujukan
Kronologi
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