Obstetrics & Gynecology Department

Morning Report (ward)

Thursday, August 24th 2022

Coassistent :
Ni Ketut Novita Yani

Departement of Obstetrics and Gynecology

RSU Haji Medan
2022
New Patient

Mrs. E, 30 y.o, G3P2A0

Diagnosis : Previous Sc 2x + MG + KDR (39-40 minggu) + PK + CPD + AH
Supervisor : dr. Muslich P. Sp.OG
Planning : C-Section
Mrs. E, 30 y.o, G3P2A0, Moeslem, Senior High School, housewife,
Married with Mr. Moeslem, Senior High School, Worker, was
admitted to RSU Haji Medan on August 24th 2022, 07.20 wib
with:

CC : Abdominal Pain wants to give birth since one days ago

Review: The patient came with complaints of abdominal pain
and mucus,. His has been experienced since one days ago. The
patient’s pregnant for the third time,
first child and second child gave bithh by C-Section
History of Previous illness : -
History of Medication : -
History of Surgery :
LMP : ?? - 11 – 2021
EDD : ??- 08 - 2022
ANC : Midwife 9x
History of pregnancy :
1. Baby Boy, Aterm, SC, doctor, 5 years old, healthy
2. Baby Boy, Aterm, SC, doctor, 4 years old, healthy
Present State

Sens : Composmentis Anemic : (-)

BP : 117/68 mmHg Icteric : (-)
HR : 87 bpm Cyanosis : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36.7 °C Oedem : (-)

General Condition : Moderate

Nutrition State : Overoweight ( BB = 65kg, TB = 155)
Disease Condition : -

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 : 140 bpm, regular
• Uterine Contraction : (+)

Gynecological State
-
 Laboratory Findings
August 17 th 2022

PEMERIKSAAN HASIL NILAI RUJUKAN

HEMATOLOGI
Darah Lengkap
- Hemoglobin 11,4 11.7 – 15.5 g/dL
- Hematokrit 33,9 37 – 45 %
- Leukosit 8,80 4 – 11 ribu/mm3
- Trombosit 199 150 – 440 ribu/mm3
- Eritrosit 3,83 4.00 – 5.00 juta/uL
- PDW 16,3 9.0 – 13.0 fL
- RDW-CV 13.5 11.5 – 14.5 %
- MPV 11,2 7.2 – 11.1 fL
- PCT 0.222 0.150 – 0.400 %

Indeks Eritrosit
- MCV 88 80 – 100 fL
- MCH 30 26 – 34 pg
- MCHC 34 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 1 1–3%
- Neutrofil Segmen 71 50 – 70 %
- Limfosit 12 20 – 45 %
- Monosit 7 4–8%
 Laboratory Findings
August 17th 2022
PEMERIKSAAN HASIL NILAI RUJUKAN
Total Sel
Total Limfosit 1,91 0.58-4.47
Total Basofil 0.00 0-0.1
Total Monosit 0.59 0.17-1.22
Total Eosinofil 0.09 0-0.61
Total Neutrofil 6,2 1.88-7.82
Diagnosis:
Previous Sc 2x + MG + KDR (39-40 minggu) + PK + CPD + AH
Therapy:
Ivfd rl 20 gtt
Ceftriaxone 1 amp/8 jam
Amikasin 1 apm /12 jam
Asmet 1 apm /8 jam
Ketotolac 1 apm / 12 jam

Plan:
- C-Section
THANK YOU