Morning Report

May 11
th
2012
Supervisor : dr. Rusdy, SpOG
Medical Students:
Fahmi, Nisia, Ira, Nana, Heri, Hasaniah, Rani, Fadil, Zihni


Cases Resume
Normal labor 1
Pathologic cases 1. G4P2A1H2 41weeks/S/IUFD

Name : Ny. H
Age : 40 yo
Address : Gunung Sari
Came : 10 May 2012

Time Subject Object Assesment Planning
10/05
2012
12.30
Patient from Pregnancy Policlinic
of NTB GH, with G4P2A1L2 41
weeks S with IUFD. Patient
confessed hadnt feel fetal
movement since yesterday
(09/05/12). History of HT (+)
since , History of DM (+) since

LMP : 27-7-2011
EDD : 4-5-2012

History of ANC :
History of family planning :
Next family planning :
Obstetrical history :
1. Aterm, female, spontaneous,
TBA, alive, 17yo
2. Aterm, female, spontaneous,
TBA, alive, 11yo
3. 2 months, Abortus
4. This

Chronologis: 10/05/12
S : pasien came to policlinic
confessed hadnt feel fetal
movement since yesterday
morning. Abdominal pain (-),
bloody slim (-), history
rupture of membran (-)

GC : Well GCS ; E4V5M6
BP : 130/90mmHg ; PR : 88 bpm
T : 36,8C ; RR : 20 bpm
General status :
Eye : an (-/-), icteric (-/-)
Thorax :
Cor : S1/S2 single reguler, murmur (-),
gallop (-).
P ulmo :ves (+/+), wh (-), rh (-)
Abdomen : scar (-), striae (+)
Extremity : edema -/-

Obstetrical Status :
L1 : breech UFH : 29 cm.
L2 : back on right side
L3 : head
L4 : 5/5
EFW : 2790gram
UC : -
FHR : -
VE (-) fornices head impresion

Lab :
WBC : 7,7
RBC : 4,45
HCT : 40
PLT : 303
HGB 12.0
HbsAg : (-)
Blood Sugar (GDS): 241
Protein urine : +1


G4P2A1L2 41weeks
single with IUFD
Co SPV, adv:
- Check UL, DL, Blood
sugar, BUN
- Termination with
misoprostol
50mcg/SL/6hours



Time Subject Object Assesment Planning




O :
GC: well
BP: 150/90 mmHg

TFU: 29cm
Head presentation, L4 3/5
UC: (-)
FHB: (-)

A: G4P2A1H2 41weeks with IUFD
P: check DL, Blood Sugar, UL, BUN
Termination with misoprostol 50mcg SL/6hours
13.30 M