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 with

chronic hypertension + cardiomegaly + suspect
cardiomiopathy
2. G3P1A1H1 33-34 weeks S/L/IU breech presentation with
severe pre eclampsia and diastolic dysfunction grade II
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 • Report echo result
PR: 93 bpm hypertension + tomorrow
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
CTG
Referal Form
Referal Form
EKG
Ro
Thorax
Case II
Name : Mrs. IY
Age : 32 years old
Address : Sira, KLU
Admitted : 28th June, 2019
MR Number : 033470
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
28-06-2019 Main complaint: Shortness of breath General Status: G3P1A1H1 33-34 weeks Diagnostic:
22.40 wita GC: well S/L/IU breech - Laboratorium
Patient refered from RSUD KLU to the GCS: CM presentation with severe (complete blood
emergency room RSUD Provinsi NTB BP: 148/84 mmHg pre eclampsia and count, HBsAg)
with G3P1A1H1 33-34 weeks S/L/IU HR: 72 bpm diastolic dysfunction
breech presentation with severe pre RR: 22 x/min grade II Observation:
eclampsia and diastolic dysfunction Temp: 36.6 oC
- Observation
grade II. The patient felt shortness of SpO2: 97% with O2 2 lpm
subjective complaint
breath since 5 months of pregnancy, Weight : 58 kg
this complaint heavier when patient Height : 155 cm and vital sign
go to sleep. She also felt pain in lower IMT : 24
part of abdomen. Headache (-), blurry GP co to SPV advice :
vision (-), out of the amniotic fluid and Local Status: - Observation
blood (-), and fetal movement is still Eye : anemic -/-, icteric -/-
felt active (+) Cor : S1S2 single reguler, murmur
(-), gallop (-)
Patient was hospitalize with same Pulmo : vesikuler (+/+), wheezing
complaint at June 18th until 20th. (-/-), ronkhi (-/-)
There are not history about Abdomen : BU (+), scar (-),
hypertension (-), diabetes melitus (-), tenderness (-)
asthma (-), allergic (-). Extremity : pitting edema (-/-),
warm acral (+/+)
In the family, there are not history
about hypertension (-), diabetes
melitus (-), asthma (-), allergic (-).
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
LMP : 8-11-2018 Obstetrical Status: G3P1A1H1 33-34 weeks Diagnostic:
EDD : 15-08-2019 Abdominal examination : S/L/IU breech - Laboratorium
GW : 33-34 weeks Inspection : striae gravidarum (- presentation with severe (complete blood count,
), scar (-), linea nigra (+) pre eclampsia and HBsAg)
History of ANC: 10x at posyandu. diastolic dysfunction
Palpation: UFH 27 cm, grade II Observation:
L1: head - Observation subjective
History of USG: 1x at Sp.OG.
L2: back on the left side complaint and vital sign
L3: breech
History of family planning: injection L4: 5/5 GP co to SPV advice :
FHB: 11-10-10 (124x/m) - Observation
Next family planning: haven’t EFW: 2325 gr
decided yet VT and inspeculo: not performed

Obstetrical History: Lab examination :

1. 2008/ male/ 2900 gr /per HB 11.6 g/dl
vaginam/midwife/39-40 WBC 13570/uL
weeks/life RBC 4.55 x 10-6/uL
2. 2018/abortus PLT 240000/uL
3. This HCT 36 %
PT 13.1 second
APTT 28.5 second
HBsAg Rapid nonreactive
Protein urine +2
Child and Mother’s Health Book
USG
CTG
ECG
Echocardiography
Referred form
Thank you 