Obstetrics & Gynecology Department

Morning Report (ward)

Tuesday, September 20th 2022

Coassistent :
Rahma Fauzia Al Erza

Departement of Obstetrics and Gynecology

RSU Haji Medan
2022
New Patient

Mrs. A, 22 y.o, G1P0A0

Diagnosis : Obs. Febris+G1P0A0 +IUP(24)wga
Supervisor : dr. A. Khuwalid Sp. OG
Planning : Observation
Mrs. A, 22y.o, G1P0A0, Moeslem, Senior High School, housewife,
Married with Mr. S, 24 y.o, Moeslem, Senior High School, Worker,
was admitted to RSU Haji Medan on September 19th 2022, 12.00
wib with:

CC : Fever and cough with phlegm

Review : The patient came with complaints of fever since three
days ago, and coughing up phlegm one week ago.
History of Previous illness : stomach acid
History of Medication : -
History of Surgery :-
LMP : 01 - 04 – 2022
EDD : 23- 12 – 2023
ANC : Obstetricians

History of pregnancy :
Present State

Sens : Composmentis Anemic : (-)

BP : 120/70 mmHg Icteric : (-)
HR : 110 bpm Cyanosis : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 39,4 °C Oedem : (-)

General Condition : Moderate

Nutrition State : Normal ( BB = 55kg, TB = 158cm)
Disease Condition : Moderate

Localized state
Head : Anemic palpebra conjuctiva (-), icteric (-)
Neck : within normal limits
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rales (-)/(-)
Abdomen : Hepar and Lien no abnormality
Genitalia : within normal limit
Ext Superior/Inferior: Oedem -/-, Cyanosis -/-
Obstetric State
• Abdomen : Asymmetrically enlarged
• Leopold 1 : Fundal Height : 3 fingers Below Processus Xyphoideus
• Leopold 2 : right: tension part, feels like board.
left: feels like hand foot
• Leopold 3 : head palpable
• Leopold 4 : head has not entered the pelvic
• Fetal movement : (+)
• Fetal Heart rate : 132 bpm, regular
• Uterine Contraction : (+)

Gynecological State
-
 Laboratory Findings
september 19th 2022

PEMERIKSAAN HASIL NILAI RUJUKAN

HEMATOLOGI
Darah Lengkap
- Hemoglobin 11.9 11.7 – 15.5 g/dL
- Hematokrit 35.4 37 – 45 %
- Leukosit 13.50 4 – 11 ribu/mm3
- Trombosit 191 150 – 440 ribu/mm3
- Eritrosit 3.94 4.00 – 5.00 juta/uL
- PDW 16.2 9.0 – 13.0 fL
- RDW-CV 13.3 11.5 – 14.5 %
- MPV 9 7.2 – 11.1 fL
- PCT 0.171 0.150 – 0.400 %

Indeks Eritrosit
- MCV 90 80 – 100 fL
- MCH 30 26 – 34 pg
- MCHC 34 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 0 1–3%
- Neutrofil Segmen 85 50 – 70 %
- Limfosit 11 20 – 45 %
- Monosit 4 4–8%
 Laboratory Findings
september 19th 2022
PEMERIKSAAN HASIL NILAI RUJUKAN
Total Sel
Total Limfosit 1.48 0.58-4.47
Total Basofil 0.00 0-0.1
Total Monosit 0.51 0.17-1.22
Total Eosinofil 0.05 0-0.61
Total Neutrofil 11.4 1.88-7.82
Diagnosis:
Obs. Febris+G1P0A0 +IUP(24)wga

Therapy:
IVFD RL 30 dpm
Cefixine 2x1 tab 200 mg
Paracetamol 3x1

Plan:
Observation
-measure vital signs
-monitoring fetal heart rate
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