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  • Morning Report 03 April 2016: SPV: DR., Spog DM: Amy, Bella, Brian, Martina, Vita

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    pitaloka yuniartiningtyas
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    1. Mrs. T, a 49-year-old woman, was admitted to the hospital with severe anemia and suspected abnormal uterine bleeding. She reported heavy menstrual bleeding for a week. 2. Initial examination found her to be anemic with a hemoglobin level of 5.2. She was given a blood transfusion and monitoring for her bleeding. 3. Over the next day, her condition was stable with no new complaints as she continued receiving a transfusion and monitoring. She was then transferred to another hospital for further evaluation and treatment.

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    1. Mrs. T, a 49-year-old woman, was admitted to the hospital with severe anemia and suspected abnormal uterine bleeding. She reported heavy menstrual bleeding for a week. 2. Initial examination found her to be anemic with a hemoglobin level of 5.2. She was given a blood transfusion and monitoring for her bleeding. 3. Over the next day, her condition was stable with no new complaints as she continued receiving a transfusion and monitoring. She was then transferred to another hospital for further evaluation and treatment.

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    8 views6 pages

    Morning Report 03 April 2016: SPV: DR., Spog DM: Amy, Bella, Brian, Martina, Vita

    Uploaded by

    pitaloka yuniartiningtyas
    1. Mrs. T, a 49-year-old woman, was admitted to the hospital with severe anemia and suspected abnormal uterine bleeding. She reported heavy menstrual bleeding for a week. 2. Initial examination found her to be anemic with a hemoglobin level of 5.2. She was given a blood transfusion and monitoring for her bleeding. 3. Over the next day, her condition was stable with no new complaints as she continued receiving a transfusion and monitoring. She was then transferred to another hospital for further evaluation and treatment.

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    © All Rights Reserved
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    of 6

    Morning Report

    03 April 2016
    SPV : dr. , SpOG
    DM : Amy, Bella, Brian, Martina, Vita
    Case 1
    • Name : Mrs. T
    • Age : 49 years old
    • RM : 57-68-62
    • Address : Narmada
    • Admitted : 14th April 2016
    Time Subject Object Assessment Planning
    14th Patient referred from Narmada General status Severe anemia + • Diagnostic:
    April PHC with severe anemia. Patient GC : well Susp. AUB • CBC
    2016 confessed languid and cold Consciousness: CM • Pro-USG
    sweat since 11.00 (14-04-2016). BP : 140/90 mmHg
    13.50 She also confessed that her PR: 96 tpm • Monitoring:
    menstrual had been going for a RR: 16 tpm • Obs. bleeding
    week, with a lots of blood coming T: 36,8°C
    out from her womb (+). • Therapy:
    Abdominal pain (-), headache (-). Local status • Pro-PRC transfusion
    Eye : anemic +/+, icteric -/-
    History of DM (-), HT (-), asthma Cor : S1S2 single reguler,
    (-), malignancy (+) Ca Mamae murmur (-), gallop (-).
    Family history: DM (-), HT (-), Pulmo : vesicular (+/+),
    asthma (-). wheezing (-/-),
    rhonchi (-/-).
    LMP : 08/ 04 / 2016 Abdomen : scar (-), mass (-).
    Extremity : edema (-/-), warm
    History of USG : - accrual (+/+).

    History of family planning: - VT : Ø (-), shaky pain on the


    portio (-), mass palpable (+) on
    Obstetric History: the adnexa parametrium
    1. Male/9m/traditional midwife/ cavum Douglas, can’t be
    3000 gr/spontaneous/alive. evaluated.
    2. Female/9m/traditional
    midwife/ 3000 Lab (14/04/16):
    gr/spontaneous/alive HGB: 5,2 (↓)
    RBC: 4,00 (↓)
    HCT: 22,2 (↓)
    WBC: 8,36 (N)
    PLT: 643 (↑)

    Random Glucose test: 159 (N)


    Time Subject Object Assessment Planning
    Chronology at Narmada PHC
    (14/04/2016):
    S:
    Patient confessed languid (+) and
    cold sweat since a week ago,
    headache (+).

    O:
    GC : moderate
    Consciousness: CM
    BP : 120/90 mmHg,
    Eye : anemic +/+, icteric -/-
    Cor : S1S2 single reguler, murmur (-),
    gallop (-).
    Pulmo : vesicular (+/+), wheezing
    (-/-), rhonchi (-/-).
    Abdomen : scar (-), mass (-).
    Extremity : edema (-/-), warm
    accrual (+/+).

    A:
    Severe anemia

    P:
    O2 nasal 2lpm
    IVFD RL 20 dpm
    Time Subject Object Assessment Planning
    17.30 Confessed (-) General status • Obs. Bleeding
    GC : well • Pro-PRC transfusion
    Consciousness: CM • Pro-USG
    BP : 130/90 mmHg
    PR: 96 tpm • Moved to Segara
    RR: 20 tpm Anak
    T: 36,5°C
    14/04/ Confessed (-) General status • Obs. Bleeding
    2016 GC : well • Pro-PRC transfusion
    Consciousness: CM • Pro-USG
    06.00 BP : 130/90 mmHg
    PR: 96 tpm
    RR: 20 tpm
    T: 36,5°C

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