MORNING REPORT MATARAM

UNIVERSITY HOSPITAL
15 July 2020

Coassistants : Aminah, Widaning, Chairul, Kadek

 Patient’s List
New Patient
No. Name Age Diagnosis
1. Mrs. RHD 19 G1P0A0H0 GA 40-41 weeks + active phase of the first stage of labor
+ severe anemia
2. Mrs. NM 33 G2P1A0H1 GA 36-37 weeks + eklampsia
3. Mrs. NJ 26 G3P2A0H2 GA 22 weeks + IUFD

Patient In Ward
No. Name Age Diagnosis
1. Mrs. Y 22 P1A0H1 post C-section day-2
 Case 1

Name : Mrs. RHD

Age : 19 y.o
Address : Sekarbela
Admitted : 14 July, 2020
MR Number : 01 90 47
Time Subjective
14/07/20 Main Complaint : abdominal pain
06.00 AM
Present Medical History :
This patient is referred from Karang Pule Primary Health Care with diagnosis
G1P0A0H0 GA 40-41 weeks + latent phase of the first stage of labor + anemia. The
patient felt abdominal pain since last night (00.00 AM), bloody slime (+), presence
of contractions (-), fetal movement (+), fluid leakage (-),nausea (-), vomiting (-),
blurred vision (-)

Past Medical History :

hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)

History of Family Disease :

hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)
Time Subjective
14/07/20 Obstetric History : -
06.00 AM
History of Family Planning : -
Next Family Planning : not yet decided

First Day of Last Menstruation : 21-09-2019

Estimated Delivery Date : 28-06-2020
Time Objective
14/07/20 General Status: Local Status:
06.00 AM GC: fine Eye : anemic -/-, icteric -/-
GCS: E4V5M6
BP: 100/60 mmHg Cor : S1S2 single reguler, murmur (-),
PR: 80 bpm gallop (-)
RR: 20 x/min Pulmo : vesikuler (+/+), wheezing (-/-),
Temp: 36,6 oC ronkhi (-/-)
SpO2 : 97%
BW: 51 kg Abdomen : pain (+), bowel sounds (+),
BH: 155 cm scar (-)
BMI: 21 kg/m² Extremity : edema (-/-), warm acral (+/+)
Time Objective
14/07/20 Obstetrical Status:
06.00 AM Abdominal examination :
Inspection : striae gravidarum (+), scar (-), linea nigra (+)
Fetal Heart Beat : 132x/minute
Fundus Height : 29 cm
Estimated Fetal Weight : 2635 gram
Contraction : 2 in 10 minutes @35 seconds

Leopold 1 : breech
Leopold 2 : back on the right side
Leopold 3 : head
Leopold 4 : divergent, 3/5
Genitalia examination :
Inspection : bloody slime (+)
VT : cervix dilatation 4 cm, eff 35%, amnion (+), denominator unclear, Hodge II
Time Assessment Planning
14/07/20 G1P0A0H0 GA 40-41 weeks + active Laboratory examination
06.00 AM phase of the first stage of labor + CXR
anemia VT evaluation on 10.00 AM
Time Assessment Planning
14/07/20 G1P0A0H0 GA 40-41 weeks + active Laboratory examination
06.00 AM phase of the first stage of labor + CXR
anemia VT evaluation on 10.00 AM

Time Objective
14/07/20 VT : cervix dilatation 5 cm, eff 75%, amnion (+), denominator unclear, Hodge II
10.00 AM

Assessment Planning
G1P0A0H0 GA 40-41 weeks + active Observation
phase of the first stage of labor + VT evaluation on 02.00 PM
anemia Planning for Oxytocin drips  rejected by
the patient
Time Objective
14/07/20 VT : cervix dilatation 7 cm, eff 75%, amnion (-), denominator occiput left anterior,
01.00 AM Hodge II

Assessment Planning
G1P0A0H0 GA 40-41 weeks + active Observation
phase of the first stage of labor + VT evaluation on 05.00 PM
anemia

Time Objective
14/07/20 VT : cervix dilatation 8 cm, eff 80%, amnion (-), denominator occiput left anterior,
05.00 AM Hodge III

Assessment Planning
G1P0A0H0 GA 40-41 weeks + prolong Pro emergency C-section
active phase of the first stage of labor Ceftriaxone 2 gr
+ anemia
 Laboratory (29/06/20)
Parameter Nilai Nilai rujukan
HGB 7,8 11,5-16,5
WBC 7010 4000-10000
RBC 3,71 3,5-5,5
PLT 271.000 150000-400000
HCT 25,6 25 - 42
MCV 69.0 80,0-100,0
MCH 21.0 26,0-34,0
MCHC 30,5 32,0-36,0
RDW-CV 24,6 11.5 – 14.5
 Laboratory (14/07/20)
Parameter Nilai Nilai rujukan

ANTI SARS COV-2

IgG Non Reaktif Non Reaktif
IgM Non Reaktif Non Reaktif
 Case 2

Name : Mrs. NM
Age : 33 y.o
Address : Selaparang
Admitted : 14 July, 2020
MR Number : 01 90 48
Time Subjective
14/07/20 Main Complaint : loss of consciousness
06.30 AM
Present Medical History :
This patient came to Mataram University Hospital’s Emergency Room with a loss of
consciousness since this morning. Before she lost her consciousness, the patient
had experienced a seizure for 30 minutes at her home. In the emergency room, the
patient had vomited 2x and seizure 7x. After seizure, the patient had experienced
desaturation.

Past Medical History :

hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)

History of Family Disease :

hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)
Time Subjective
14/07/20 Obstetric History :
06.30 AM 1. 2013/spontan labor/aterm

History of Family Planning : -

Next Family Planning : not yet decided
First Day of Last Menstruation : 16-10-2019

Estimated Delivery Date : 23-07-2020

Time Objective
14/07/20 General Status: Local Status:
06.30 AM GC: weak Eye : anemic +/+, icteric -/-
Awareness: somnolen
BP: 200/150 mmHg Cor : S1S2 single reguler, murmur (-),
PR: 113 bpm gallop (-)
RR: 26x/min Pulmo : vesikuler (+/+), wheezing (-/-),
Temp: 36 oC ronkhi (-/-)
SpO2 : 95%
BW : 86 kg Abdomen : bowel sounds (+),
BH : 158 cm scar (-)
BMI : 34,4 kg/m² Extremity : edema (-/-), warm acral (+/+)
Time Objective
14/07/20 Obstetrical Status:
06.30 AM Abdominal examination :
Inspection : striae gravidarum (+), scar (-), linea nigra (+)
Fetal Heart Beat : 130x/minute
Fundus Height : 26 cm
Estimated Fetal Weight : 2325 gram
Contraction : -

Leopold 1 : breech
Leopold 2 : back on the left side
Leopold 3 : head
Leopold 4 : divergent, 5/5
Genitalia examination :
Inspection : bloody slime (-)
VT : cervix dilatation (-)
Time Assessment Planning
14/07/20 G2P1A0H1 GA 36-37 weeks + IVFD Ringer Lactate
06.30 AM eklampsia Bolus MgSO4 4 gr/IV
Drip MgSo4 6 gr in RL 28 drips per minute
O2 10 lpm
Emergency C-section
Time
14/07/20 C-section performed
09.30 AM Baby :
Female
Apgar score : 2-4-8
BW : 2600 gr
Time Objective
14/07/20 GC: weak
10.30 AM Awareness: somnolen
BP: 136/84 mmHg
PR: 84 bpm
SpO2 : 96%

Assessment Planning
P2A0H2 post C-section with Refer to General Hospital of Nusa Tenggara
eklampsia Barat Province
 Laboratory (14/07/20)
Parameter Nilai Nilai rujukan
HGB 16,1 11,5-16,5
WBC 20130 4000-10000
RBC 6,08 3,5-5,5
PLT 269.000 150000-400000
HCT 48,4 25 - 42
MCV 79,6 80,0-100,0
MCH 26,5 26,0-34,0
MCHC 33,3 32,0-36,0
RDW-CV 15,4 11.5 – 14.5
 Laboratory (14/07/20)
Parameter Nilai Nilai rujukan

ANTI SARS COV-2

IgG Non Reaktif Non Reaktif
IgM Non Reaktif Non Reaktif
 Case 3

Name : Mrs. NJ
Age : 26 y.o
Address : Lembar
Admitted : 14 July, 2020
MR Number : 01 89 71
Time Subjective
14/07/20 Main Complaint : no fetal movement
11.30 AM
Present Medical History :
This patient came to the Pinere Covid-19 Outpatient Clinic of Mataram University
Hospital by herself, she complains that she can’t feel her fetal movement since 2
weeks ago. Other complaints : bloody slime (-), presence of contractions (-), fluid
leakage (-),nausea (-), vomiting (-), blurred vision (-)
Past Medical History :
hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)

History of Family Disease :

hypertension (-), DM (-), Asthma (-), TB (-), allergic (-)
Time Subjective
14/07/20 Obstetric History :
11.30 AM 1. 2013/Primary health care/aterm/spontan labor/midwife/female/2500 gr
2. 2018/primary health care/aterm/spontan labor/midwife/male/2700 gr
History of Family Planning :
3. IUD for 4 years
4. IUD for 1,5 years
Next Family Planning : not yet decided
First Day of Last Menstruation : January, 2020

Estimated Delivery Date : October, 2020

Time Objective
14/07/20 General Status: Local Status:
11.30 AM GC: fine Eye : anemic -/-, icteric -/-
GCS: E4V5M6
BP: 110/60 mmHg Cor : S1S2 single reguler, murmur (-),
PR: 82 bpm gallop (-)
RR: 20 x/min Pulmo : vesikuler (+/+), wheezing (-/-),
Temp: 36,5 oC ronkhi (-/-)
SpO2 : 97%
Abdomen : pain (+), bowel sounds (+),
scar (-)
Extremity : edema (-/-), warm acral (+/+)
Time Objective
14/07/20 Obstetrical Status:
11.30 AM Abdominal examination :
Inspection : striae gravidarum (+), scar (-), linea nigra (+)
Fundus Height : 20 cm
Estimated Fetal Weight : 1550 gram
Genitalia examination :
Inspection : bloody slime (-)
VT : not evaluated
Time Assessment Planning
14/07/20 G3P2A0H2 GA 22 weeks + IUFD Mesoprostol ¼ tab
11.30 AM
 Laboratory (14/07/20)
Parameter Nilai Nilai rujukan
HGB 11 11,5-16,5
WBC 12030 4000-10000
RBC 4,42 3,5-5,5
PLT 583.000 150000-400000
HCT 32,6 25 - 42
MCV 73,8 80,0-100,0
MCH 24,9 26,0-34,0
MCHC 33,7 32,0-36,0
RDW-CV 13,9 11.5 – 14.5
 Laboratory (10/07/20)
Parameter Nilai Nilai rujukan

rt-PCR Covid-19 Negatif Negatif

THANK
YOU