MORNING REPORT

27TH OCTOBER, 2019

Supervisor: dr. Ratih Barirah, Sp.OG

Team in Charge: Annisa, Wahidah, Andre

 Case Resume
Normal Labor

Pathologies Labor -

Remain Patient 1. G3P2A0L2 GW 10-11 weeks with Complete Abortus

Case I
Name : Mrs. ZE
Age : 36 years old
Address : Monjok
Admitted : 28 October, 2019
MR Number : 048537
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
28-10-2019 Main complaint: Bloody discharge General Status: G3P2A0H2 GW 10-11
04.40 a.m from birth canal GC: well weeks with suspect
GCS: CM blight ovum + History
Patient came to the emergency room BP: 110/80 mmHg of SC 2 times 4,5 years
RSUD Provinsi NTB with bloody HR: 80 bpm ago
discharge came out from birth canal RR: 20 x/min
since 26-10-2019. Temp: 36,0oC
Patient felt the abdominal pain and SpO2: 99 % without O2
felt back pain since 05.00 (28-10- W: 50 kg
2019). Patient said that she had H: 154 cm
pregnant with gestational weeks is 10 IMT: 21,1 (N)
weeks. Patient felt dizziness (+).
Local Status:
There are not history about Eye : anemic -/-, icteric -/-
hypertension (-), diabetes melitus (-), Cor : S1S2 single reguler,
and other disease in patient, but murmur (-), gallop (-)
there are a history of her family had Pulmo : vesikuler (+/+),
DM (-) wheezing (-/-), ronkhi (-/-)
Abdomen : BU (+), scar (+)
Extremity : pitting edema (-/-),
warm acral (+/+), CRT < 2
second
TIME SUBJECTIVE OBJECTIVE ASSEMENT PLANNING
LMP : 17/08/2019 Obstetrical Status: G3P2A0H2 GW 10-11 Diagnostic:
EDD : 24/5/2020 Abdominal examination : weeks with suspect - Laboratorium
GW : 10-11 weeks Inspection : striae (-), scar (+) blight ovum + History (complete blood
Auscultation: BU (+) 8 times of SC 2 times 4,5 years count, HBsAg, HIV,
History of ANC: 1x at midwife, 2x permenit ago GDS, PT, APTT)
at Obstetrician Palpation: mass (-) , tenderness - USG
(-), fundus not palpable
History of USG: 1x at Obstetrician
(26-10-2019) the diagnose is suspect Genitalia examination : Co to SPV,
Blight Ovum. Inspection : active bleeding (-), SPV Advice:
blood (+), mass (-), - Observation
History of family planning: IUD for inflammation (-) subjective complain
4 years Inspeculo : ø (-), slippery and vital sign
portio, active bleeding (-), - Wait the doctor come
Next family planning: not decided bloody slime (+) to visit
yet VT : ø (-), soft portio (+),
cervical motion tenderness (-),
Obstetrical History:
1. 2013/female/SC/ BW 2400 grams/
Alive
2. 2015/male/SC/BW 2800
grams/Alive
3. This gestation
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Laboratorium: G3P2A0H2 GW 10-11 Diagnostic:
weeks with suspect - Laboratorium
1. Hematology blight ovum + History (complete blood
Hb 11,9 g/dl
Hct 35 %
of SC 2 times 4,5 years count, HBsAg, HIV,
WBC 8400 /uL ago GDS, PT, APTT)
RBC 4,33 x106/uL - USG
PLT 362000/uL

2. Hemostasis Co to SPV,
PT 12,8” SPV Advice:
APTT 29,7”
- Observation
3. Diabetes subjective complain
Blood Glucose Level: 56 mg/dl and vital sign
- Wait the doctor come
HbsAg Rapid (non reactive) to visit
HIV Rapid (non reactive)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
27-10-2019 No subjective complain GS : well G3P2A0H2 GW 10-11 Advice SPV:
10.30 a.m GCS : CM weeks with Abortus -Patient can to go home
SPV visite to the patient BP : 110/70 mmHg Imminens, susp Blight -If there are a emergency
HR : 86 bpm Ovum + History of SC signs patient can come to
RR : 20 bpm 2 times 4,5 years ago emergency room
Tempt : 36,4 C -Control tomorrow in poli
Obsgyn for planning to
Genitalia examination : curretage
Inspection : active bleeding (-),
blood (-), mass (-),
inflammation (-)
Inspeculo : ø (-), slippery
portio, active bleeding (-),
bloody slime (-)
VT : ø (-), soft portio (+),
cervical motion tenderness (-),

USG examination:
Uterus retroflexion, gestation
sac inrauterine irregular 4,05
cm, GW 9 weeks, Fetal
pulsation (-).
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
27-10-2019 Patient come to emergency room GS : moderate G3P2A0H2 GW 10-11 Planning therapy:
5.30 p.m with Severe abdominal pain and GCS : CM weeks with Abortus - Analgetic, ketrofen supp
patient said there are bloody BP : 110/80 mmHg incomplete, History of 2 tab
discharge from birth canal. HR : 80 bpm SC 2 times 4,5 years ago
RR : 20 bpm Advice SPV:
Tempt : 36,8 C - Co Anesthesia to
HIS: 3x/10’~15” planning curretage
-Planning Curretage at
Genitalia examination : 09.00 p.m
Inspection : active bleeding (+),
blood (+), mass (-),
inflammation (-)
Inspeculo : ø (-), slippery
portio, active bleeding (+),
fluxus (+), livid (+), bloody
portio (+), stolsel (+)
VT : ø (-), soft portio (+),
cervical motion tenderness (-),
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
27-10-2019 Abdominal pain (+) GS : moderate G3P2A0H2 GW 10-11 - Move to OK Cito for
9.00 p.m GCS : CM weeks with Abortus Curretage
BP : 110/70 mmHg incomplete, History of
HR : 88 bpm SC 2 times 4,5 years ago
RR : 20 bpm
Tempt : 36,7 C
HIS: 3x/10’~15”

27-10-2019 Dizziness GS : moderate G3P2A0H2 GW 10-11 Planning therapy post

10.00 p.m GCS : CM weeks with Abortus curretage:
BP : 112/68 mmHg incomplete, History of - Cefadroxil 2 x 500 mg
HR : 72 bpm SC 2 times 4,5 years ago - As mefenamat 3 x 500
RR : 20 bpm post curretage mg
Tempt : 36,8 C - Methylergometrine 3 x
200 mcg
- Observation vital sign,
bleeding
- Move to Segara Anak
USG
27-10-2019
THANK YOU ☺