Morning Report

th
June 29 , 2019

Supervisor: dr. I Made Putra Juliawan, SpOG

Team in Charge: Diana, Ira, Rusmin, Reza

Case Resume

Normal Labor -

Pathologies Labor -

Remain Patient 1. G4P2A1L2 GW 38-39 weeks S/L/IU head presentation

chronic hypertension + cardiomegaly + suspect
cardiomiopathy
Case I
Name : Mrs. RI
Age : 42 y.o.
Address : Tanjung, North Lombok
Admitted : June 28th, 2019
MR Number : 034918
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
28-06-2019 Main complaint: Weakness General Status: G4P2A1L2 GW 38-39 Diagnostic:
10.55 GC: Moderate weeks S/L/IU head • CTG
Patient came to emergency GCS: CM presentation chronic • Complete blood
room RSUP NTB refer from BP: 147/78 mmHg hypertension + count
RSUD KLU with G4P2A1L2 GW PR: 94 bpm cardiomegaly + suspect • Faal Haemostasis
37-38 weeks S/L/IU head RR: 24 x/min cardiomiopathy (PPT, APTT)
presentation chronic Temp: 36.6oC • Blood Glucose
hypertension + cardiomegaly + W: Profile
suspect cardiomiopathy. Patient H: 163 cm • Urinalisis
complaint feel weakness since IMT: 32,5 • ureum, creatinine
yesterday. Main complaint feel • SGOT, SGPT
suddenly when the patient Local Status: • Electrolyte
resting. Patient also complaint Eye: anemic -/-, icteric -/- • HBsAg Rapid
dyspnea since yesterday and Cor: S1S2 single reguler, • Anti HIV Rapid
heavier since 3 hours before murmur (-), gallop (-) Observation:
hospitalized. Then pasien was Pulmo: vesikuler (+/+), • Fetal and mother
refer to PHC. Dyspnea heavier wheezing (-/-), ronkhi (+/+) health
when patient doing activity. Abdomen: BU (+), scar (-) DM co to SPV (SpOG),
Patient still fetal movement. Extremity: edema (+/+), advice:
warm acral (+/+) • IVFD D5 12 tpm
Patient didn’t have history of • Rehidration RL 1
fainting, hypertension, asthma or flash
diabetes mellitus. Patient has • Co to cardiologist
history of abortus on 2014. and anasthesiologist
• Pro SC
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
Patient did curettage at Akasia Obstetrical Status: DM co to SPV (SpAn),
Clinic. L1: breech advice:
L2: back on the right side • Pro
LMP: - L3: head Echocardiography
EDD: - L4: 4/5 • Pro SC Elective at
GW: 38-39 weeks (UFH) UFH: 34 cm IBS
FHB: 11-11-12 (136x/min) DM co to SPV (SpJP),
History of ANC: - EFW : 3565gr advice:
His: (-) • Accept SC
History of USG: - VT: (-)
Lab: (28-06-2019)
History of family planning: HB 11.0 g/dL
Injection HCT 35%
WBC 9.220/uL
Next family planning: Implant PLT 245.000/uL
GDS 63 mg/dL
Obstetrical History : PT 12,8
1. 1997/RS Sanglah/9 month/ APTT 29,6
spontan/Female/2,6 kg Ureum 18
2. 2004/RS Sanglah/9 month/ Creatinin 0.6
spontan/Male/4 kg SGOT 15
3. 2014/Abortus/Curettage/Aka SGPT 12
sia Clinic Na 138
4. This K 3.9
Cl 107
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
HBsAg non reactive
Anti HIV Rapid non
reactive
Urinalysa:
pH: 6,5
Nitrit (-)
Protein (-)
Glucose (+2)
Keton (-)
Urobilinogen (-)
Bilirubin (-)
Blood (-)
Leukocyte (-)
 TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
16.15 There isn’t subjective complaint, GC: moderate G4P2A1L2 GW 38-39 Patient move to VK
mother still feel fetal movement GCS: CM weeks S/L/IU head Teratai
BP: 180/90 mmHg presentation chronic
PR: 88 bpm hypertension +
RR: 22 x/min cardiomegaly + suspect
Temp: 37,1oC cardiomiopathy
FHB: 12-12-11 (140 x/min)
His: (-)

16.45 There isn’t subjective complaint, GC: moderate G4P2A1L2 GW 38-39 DM co to SPV (SpAn),
mother still feel fetal movement GCS: CM weeks S/L/IU head advice:
BP: 150/90 mmHg presentation chronic • Lapor hasil echo
PR: 93 bpm hypertension + besok
RR: 20 x/min cardiomegaly + suspect • Booking ICU
Temp: 36,8oC cardiomiopathy DM co to SPV (SpOG),
FHB: 13-12-12 (148x/min) advice:
His: (-) • Pro SC tomorrow

20.00 There isn’t subjective complaint, GC: moderate G4P2A1L2 GW 38-39

mother still feel fetal movement GCS: CM weeks S/L/IU head
BP: 130/80 mmHg presentation chronic
PR: 82 bpm hypertension +
RR: 20 x/min cardiomegaly + suspect
Temp: 36,8oC cardiomiopathy
FHB: 12-12-12 (144x/min)
His: (-)
Child and Mother’s Health Book
USG
Referal Form
Referal Form
EKG
Case II
Name : Mrs. MH
Age : 16 y.o.
Address : Kayangan, North Lombok
Admitted : June 20th, 2019
MR Number : 033772
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
20-06-2019 Main complaint: Abdominal General Status: Mola hidatidosa + Diagnostic:
22.00 Pain GC: Well hypertiroid • Complete blood
GCS: CM count
Patient came to IGD RSUP NTB BP: 103/59 mmHg • Faal Haemostasis
refer from RS KLU with mola PR: 98 bpm (PPT, APTT)
hidatidosa. Patient complaint RR: 20x/min • Blood Glucose
abdominal pain on lower Temp: 36.6oC Profile
quadrant. Abdominal pain since W: 60 kg • HBsAg Rapid
2 days ago. Other complaint is H: 150 cm • Anti HIV Rapid
active bleeding since last night. IMT: 26,67
Active bleeding until 3 cloth. Observation:
Nausea (+), vomitting (-), Local Status: • Subjective, active
palpitation (-). Eye: anemic -/-, icteric -/- bleeding, vital sign
Cor: S1S2 single reguler,
Patient didn’t have history of murmur (-), gallop (-) DM co to GP, GP
hypertension, asthma or Pulmo: vesikuler (+/+), advice:
diabetes mellitus. wheezing (-/-), ronkhi (-/-) • Kaltrofen supp 2 per
Abdomen: BU (+), scar (-) rectal
Treatment from RSUD KLU: Extremity: edema (-/-), • Inj. Asam
IVFD RL 20 tpm warm acral (+/+) Tranexamat 1 Amp
Propanolol 10mg/8 hours iv
PTU 100mg/8 hours • Prepare for
Nifedipine 30 mg single dose transfusion 2 kolf
TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
LMP: 15-03-2019 Obstetrical Status: GP co to SPV, advice:
EDD: 22-12-2019 UFH: half umbilical - • Pro Curettage  co
GW: 14 weeks symphisis to morning shift SPV
History of ANC: - Inspeculo: Ø (-), active • If active bleeding (+)
History of USG: 1x on June 15th bleeding (-), flux (+), and patient condition
2019. Impression: mola erotion (-), livide (-) weaker  co to SPV
hidatidosa. VT: Ø (-), portio movement
pain (-)
History of family planning: -
Next family planning: - Lab: (21-06-2019)
Obstetrical History : HB 10.5 g/dL
1. This HCT 32%
WBC 13.250/uL
Lab from RSUD KLU: PLT 235.000/uL
HB 14.4 g/dL GDS 70 mg/dL
HCT 31,2% HBsAg non reactive
WBC 14.400/uL Anti HIV Rapid non
PLT 245.000/uL reactive
TSH <0,04
FT4 35.64
BT 2’
CT 7’
SGOT 24
SGPT 33
HBsAg negatif
 TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
21-06-2019 Abdominal Pain (+), Nausea (+), GC: well Mola hidatidosa + DM co to GP, GP
01.30 vomitting (-) GCS: CM hypertiroid advice:
BP: 100/60 mmHg • Inj. Ondannsentron
PR: 96 bpm 1 A / iv
RR: 20x/min
Temp: 36.6oC
Active bleeding: (-)
Referral form
Referral form
Chronology
Thank you 
Homework
• Pelvic evaluation!!!
• Mola Hidatidosa!!!