You are on page 1of 11

MORNING REPORT

22nd January 2018

Supervisor: dr. Ario Danianto, Sp.OG

Medical Students:
Citra, Alfian, Shiva, Ida
CASE RESUME
NORMAL LABOR -
PATHOLOGIES CASE • G1P0A0L0 GW 38-39 weeks S/L/IU head
presentation latent phase with PROM > 12 hours

REMAIN CASE -
Tidak ada
pertanyaan
yang salah
Case 1
• Name : Mrs. KA
• Age : 27 years old
• Address : Narmada
• Admitted : 22nd January 2018
• RM : 139528
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
22/01/ Patient reffered from Narmada Awet General status G1P0A0L0 GW DM planning:
2018 Muda Hospital to the ER with GC : well 38-39 weeks Diagnostic:
14.00 G1P0A0L0 GW 38-39 weeks S/L/IU GCS : E4V5M6 S/L/IU head • Check CBC
head presentation with PROM > 12 BP : 120/80 mmHg presentation latent • HbsAg
hours. Patient confessed water HR : 88 tpm phase with PROM • RBG
coming out from her womb since RR : 20 tpm > 12 hours • PPT, APTT
00.00 (22/1/2018). Patient also felt T : 36,7◦ C • CTG
lower abdominal pain migrating to the
back which sometimes disappears Localis status
since 04.00 in the morning. Blurry Eye : edema palpebra (-/-), an (-
vision (-), blood slime from her womb /-), icterus (-/-) Therapy: (from Awet
(+), fetal movement (+). Pulmo : ves (+/+), rh (-/-), wh (-/-) Muda Hospital)
Cor : S1S2 single regular, - IVFD RL 20 tpm
History of DM (-), HT (-), asthma (-), murmur (-), gallop(-) - Ampicilin inj. 1 gr
allergic (-) Abdomen: IV (12.00)
History DM in family (-), HT (-), Scar (-), striae gravidarum (-),
asthma (-), allergic (-) linea nigra (-) SPV advice :
Extremity: oedema (+/+), warm - Pro drip oxytocin
LMP : 30th April 2017 (+/+) - Ampicilin inj.
EDD : 5th February 2018 1gr/6 hours
GW : 38-39 weeks Obs status: - Observation for
L1 : breech signs of labour
History of ANC: L2 : back on the left side
Last ANC : 18-01-2018 L3 : head
Patient complaint was lower L4 : 4/5
abdominal pain, BP 120/80 mmHg,
GM 37-38 weeks, UFH 33 cm, head UFH: 30 cm
presentation, FHB (+) 136x/m. EFW : 2945 gr
FHB : 12-11-12 (140 bpm)
History of USG: 6x UC : 1x10’~15”
Last USG (18/01/2018) : VT : Ø 1 cm, eff.10%, amnion (-),
S/L/IU, head presentation, placenta at head palpable, ↓HI, not palpable
fundus posterior extends down until small part & umbilical cord.
lower segment of uterus, not covering
OUE
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

History of family planning: no use of Laboratory exam (22p/01/2018):


contraception before HGB : 12.9 g/dL
RBC : 4.29 10^6/uL
Next family planning: injection every HCT : 39 %
3 months WBC :10.21 10^3/uL
PLT : 220 10^3/uL
Obstetrical history:
1. This one RBG : 75
HbsAg : (-) non reactive
PPT : 12.7
APTT : 26.0
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16.00 Abdominal pain (+) GC: well G1P0A0L0 GW 38- • Observation for signs of labor
GCS : E4V5M6 39 weeks S/L/IU • Patient move to VK Teratai
BP : 120/70 mmHg head presentation (16.15)
PR: 88 bpm latent phase with
RR: 20 bpm PROM > 12 hours
Tax: 36.6◦ C
FHB: 12-12-11
UC: 2x10’~20”
ANC BOOK
USG
USG
CTG
REFERRAL LETTER