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Morning Report

June 6, 2013

Patient Identity
Date of Admition Time Origin Name Age Education Occupation Religion Tribe Address : 6 June 2013 : 21. 43 WIB : UGD : Mrs. B : 35 years old : Senior High School : Housewife : Christian : Batak : Jl. Asyafiliah RT 03 RW 03 Kel. Cilangkap

I. Subjektif
1. Chief Complain :
Bleeding from vagina

2. Additional Complain
Abdominal pain

3. Chronology of Complain / Recent Illness :


Patient come with complaints bleeding from her vagina since 5 hours before admission, the blood less than 1 teaspoon, red and accompanied by mucus, sometimes with blood clots. The patient also complained pain in the lower abdomen. She felt intermittent and felt like squeezed. Day of last menstrual period was 15 April 2013. Patient did test pack and the result is positive, the patient never control her pregnancy to a gynecologist.

Menstruation History
a. First Period b. Circulation of menstrual Cycle Length Amount Period Pain (dismenorrhea) Having drug : 14 years old : Regular : 4 days : 2 changes / 80 cc : none : none

Marital History
a. Marital Status b. Last Marriage : Married : 3 years

Pregnancy, Labor, Parturition History


a. Previous Pregnancy b. Number of children living c. Age of youngest child :1P0A : 1 child : 1 years old

Previous illnesses

: dust allergy

History in disease family


Surgery history Family planning method

: denied
: denied : denied

Others Data
None

General Examination
Vital sign
Height Weight Body mass index General condition Consciousness Blood pressure Pulse Temperature Respiratory rate : 150 cm : 57 kg : 25, 3 : seem moderate illness : compos mentis : 100 / 80 mmHg : 72 x / minutes : 36,8 o C : 19 x / minutes

Head
Eyes :
Anemic conjunctiva Icteric sclera :-/: - /-

Teeth Ear
CAE Cerumen

: complete, caries (-)


: wide / wide :-/-

Nose
Cavum nasal Fluid

:
: wide /wide : - /: T1 - T1, red : red

Throat
Tonsil Faring

Neck
Enlarged lymph nodes Tenderness :-/:-/-

Thorax
Heart : Heart sounds 1 and 2 normal, regular, murmurs (-), gallops (-) Lungs : chest wall movement symetric, percussion : resonant / resonant, base breath sounds : vesicular , ronkhi - / -, wheezing /-

Abdomen
Inspection : looks flat Palpation : soft, tenderness (-), muscular defense (-), liver and spleen not palpable enlarged Percussion : tymphany Auscultation : bowel sounds (+) 4 x / minutes

Extrimities
Superior Inferior : warm akral, cap refill time < 2, edema -/: warm akral, cap refill time < 2, edema -/-

Outer Examination
Face Mammae : round shape :
Mass : -/ Retraction : -/ Pain : -/-

Abdomen
looks flat, soft, tenderness (-), muscular defense (-), liver and spleen not palpable enlarged, tymphany, bowel sounds (+) 4 x / minutes

External genitalia
Pubic hair distribution Fluksus : (+), not active fluor : none Vulva : mass (-), pink : distributed equally

Inspeculo (not performed) Vaginal Toucher


Vulva Vagina Portio Uterus Adnexa
: tenderness : -/-

: pink, fluksus (-) : rugae (+), mass (-) : round shape, chewy consistency : anteflexion position, shaky pain (-)

Douglas cavity

: not prominent, fluid (-)

Rectal toucher : not performed


Valsava test : not performed

Labolatory examination and next examination


Lab : Hemoglobin, Hematocrit, Leukocyt, Trombocyt Clotting time, Protrombin time, Bleeding time HbsAg Plano test USG

Assesment
Working diagnose
G2P1A0, 7 weeks pregnant + Abortus incomplete

Differential diagnose
Abortus imminens

Prognosis
Ad vitam Ad functionum Ad sanationum : bonam : bonam : dubia ad bonam

Problem list
Active Passive : Bleeding from vagina, Abdominal pain :-

Planning
1. Diagnostic planning
Lab : Hemoglobin, Hematocrit, Leukocyt, Trombocyt USG

2.

Management planning
Inpatient Vital sign observation, and bleeding observation Lab and USG examination Curettage planning Diet : fasting IVFD : RL 20 drops /minutes MM : Kedacillin 3 x 1 gr (IV) Methergin 3 x 0,125 mg (IV) Kaltrofen supp 2x1

3.

Education planning
Explain to the patient about her pregnancy and plans will be performed, Motivation patient for KB