Obstetrics & Gynecology Department

Morning Report (ward)

Thursday, September 08th 2022

Coassistent :
Intan Novi Rachmadani

Departement of Obstetrics and Gynecology

RSU Haji Medan
2022
New Patient

Mrs. T, 39 y.o, G3P2A0

Diagnosis : G3P2A0 + IUP (41) wga + Post date
Supervisor : dr. Putri Aini Daulay, Sp. OG
Planning : PSP
Mrs. T, 39 y.o, G3P2A0, Moeslem, Senior High School, housewife,
Married with Mr. T, 40 y.o, Moeslem, Senior High School, Worker,
was admitted to RSU Haji Medan on August 08th 2022, 22.30 wib
with:

CC : Stomach pain, bleeding and mucus

Review: The patient came with complaints of Stomach pain. the
patient also complained of bleeding and mucus. The patient’s
pregnant for the third time with gestational age (41) wga
History of Previous illness : -
History of Medication : -
History of Surgery :-
LMP : 23-11-2021
EDD : 30-08-2022
ANC : obstetricians 9x
History of pregnancy :
1. Baby Girl, Aterm, SVD, Midwife, 15 years old, healthy
2. Baby Girl, Aterm, SVD, Midwife, 9 years old, healthy
Present State

Sens : Composmentis Anemic : (-)

BP : 130/81 mmHg Icteric : (-)
HR : 88 bpm Cyanosis : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36 °C Oedem : (-)

General Condition : Moderate

Nutrition State : Overoweight ( BB = 71kg, TB = 160cm)
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 entered the pelvic
• Fetal movement : (+)
• Fetal Heart rate : 140 bpm, regular
• Uterine Contraction : (+)

Gynecological State
-
 Laboratory Findings
September 08 th 2022

PEMERIKSAAN HASIL NILAI RUJUKAN

HEMATOLOGI
Darah Lengkap
- Hemoglobin 9,2 11.7 – 15.5 g/dL
- Hematokrit 27,9 37 – 45 %
- Leukosit 7,50 4 – 11 ribu/mm3
- Trombosit 22,3 150 – 440 ribu/mm3
- Eritrosit 3,26 4.00 – 5.00 juta/uL
- PDW 16,6 9.0 – 13.0 fL
- RDW-CV 16,6 11.5 – 14.5 %
- MPV 11,1 7.2 – 11.1 fL
- PCT 0,247 0.150 – 0.400 %

Indeks Eritrosit
- MCV 86 80 – 100 fL
- MCH 28 26 – 34 pg
- MCHC 33 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 1 1–3%
- Neutrofil Segmen 67 50 – 70 %
- Limfosit 25 20 – 45 %
- Monosit 7 4–8%
Diagnosis:
G3P2A0 + IUP 41() wga + Post date

Therapy:
IVFD RL 20 dpm

Plan:
- PSP
THANK YOU