Tidak ada pertanyaan

yang salah
 MORNING REPORT
January, 02nd 2017
Supervisor: dr. Ario Danianto, Sp.OG

DM: Tannia, Fitri, Maya, Agung

Cases resume :
Normal Labor -
Pathologic Labor 1. G2P0A1L0 38-39 weeks S/L/IU+PROM+Uterine
Myoma with the history of failed induction
Remain patients -
 PATIENT IDENTITY

Name : Mrs. S
Age : 38 yo
Address : Bima
Admitted : December, 31st 2017
RM : 60053
TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

31/12/ Patient referred from Bima General status: G2P0A1L0 38-39 DM planing :
2017 General Hospital with G2P0A1L0 GC: well weeks Diagnostic planning
(06.15 36 weeks head presentation GCS : E4V5M6 S/L/IU+PROM+U • CTG
am) S/L/IU+PROM+Anemia+ Uterine BP: 110/70mmHg terine Myoma • DL
Myoma with the history of failed PR: 88 bpm with the history of
induction. Patient confessed water RR: 20 x/minutes failed induction Therapeutic planning :
leaked from her womb first at 4 T: 36,7oC • Inj. Ceftriaxone 2x1 gr
days ago which is 27/12/17. The
amount of water was only a few. Localized Status
The biggest volume leaked out at Eye : anemis (+/+), icteric (-/-)
24 hours ago. Abdominal pain (-), Thorax : CIE planning
Bloody slime (-), FM (+). Cor : S1/S2 single reguler (murmur - • CIE mother and
), (gallop -) family about
History of systemic diseases (-) Pulmo : vesikuler (+/+), wheezing (- diagnostic planning
/-), Ronkhi (-/-). and therapeutic
LMP: 04-04-2017 Abdomen : scar (+), striae (+), linea planning
EDD: 11-01-2018 nigra (+) • Obs. Mother and
Extremity : edema (-/-), warm acral fetal well being
History of ANC: (+/+)
Last ANC: DM co to GP, GP
BP: 100/60; GW: 38-39 weeks; Obstetrical status: advice: CTG,
UFH: 22 cm; head presentation; L1: breech Laboratory test
FHB + L2: back to the left side GP co to SPV, SPV
L3: head advice: USG
History of USG: + L4: 1/5
History of family planning: - UFH: 28 cm
Next family planning: refused EFW: 2635 g
famyly planning UC: there is no uterine contraction
FHB: 11-12-11 ( 136 x/min)
Obstetrical history: VT: Ø 0cm, eff 0%, amnion (-), portio
I. The patient has the history of still thick.
abortus 1 year ago at the age
4 weeks of her pregnancy
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
Chronologist at Bima Public hospital Lab (31-12-2017) G2P0A1L0 38-39 - SPV planning:
(27/01/2017) HB : 8.9 g/dl weeks Transfusion of PRC (2
WBC : 12.45 103/µl S/L/IU+PROM+U packs)
09.50 S : Patient 9 months gestation confessed RBC : 3,94 106/µl terine Myoma Sectio cesarean
pm water leaked out from her womb (27-12- PLT : 411 103/µl with the history of operation
2017). Abdominal pain(-), Bloody slime (-), HBsAg : (-) failed induction
FM (+).
Pateint was then stay at the hospital for 3
days until 30 Dec 2017

O : GC: well,
GCS: E4V5M6,
BP: 120/70 mmHg,
HR: 80 x/minutes,
RR: 20x/minutes,
T: 36,5OC
UC : there is no uterine contraction
UFH: 27 cm
FHB:+ 140 bpm
VT: Ø 0cm, eff 0%, amnion (-)

A : G2P0A1L0 36 weeks head

presentation S/L/IU+PROM+Anemia+
Uterine Myoma with the history of failed
induction

P : referred to NTB GH
 Time Subjective Objective Assessment Planning
12.00 Am Patient came to O : GC: well, Conduct the SC
operation room GCS: E4V5M6, At 12.30 pm
BP: 120/80 mmHg, The baby was born male, BW
HR: 92 x/minutes, 2950 gram, BL 51 cm, HC 34
RR: 20x/minutes, cm, AS 7-9, anus (+),
T: 36,5OC congenital anomaly (-)
UC : there is no uterine
contraction
UFH: 27 cm
FHB:+ 140 bpm
VT: Ø 0cm, eff 0%, amnion (-)
12.15 pm

14.00 pm General status 2 hours post partum •Obs. Mother and baby well
GC : well being.
GCS: E4V5M6 • CIE mother to mobilization,
BP : 120/80 mmHg eat and drink and breast
HR: 88 bpm feeding
RR: 20 bpm
T: 36,5 °C
UO : 100 cc/hour
UC : (+) well
UFH : 2 fingers bellow umbilical
Bleeding : ± 5 cc
01/02/16 GC : well 1st day post partum •Obs. Mother and baby well
07.00 BP : 120/80mmHg being.
HR : 86 bpm • CIE mother to mobilization,
RR : 18 bpm eat and drink and breast
Temp : 36,2°C feeding
UC : (+) well
UFH : 2 finger below umbilicus.
Lochea: (+)
Surat rujukan
4

19
3

3
21
Terima kasih