Obstetrics & Gynecology Department

Morning Report (ward)

tuesday, September 19th 2022

Coassistent :
R Tri kurnia putri

Departement of Obstetrics and Gynecology

RSU Haji Medan
2022
New Patient

Mrs. H, 31 y.o, G1P0A0

Diagnosis : KPD + PG + KDR (37-38) wga + PK + AH + Oligohidramnion
Supervisor : dr. Ahmad Khuwalid Sp. OG
Planning : C-Section
Mrs. H, 31 y.o, G1P0A0, Moeslem, Master degree, PNS, Married
with Mr. R, 25 y.o, Moeslem, Bachelor degree, Honorary
employee, was admitted to RSU Haji Medan on September 12th
2022, 08.15 am with:

CC : Water coming out of the vagina

Review: The patient came with complaints of water coming out
of the vagina experienced since one days SMRS. The patient’s
pregnant for the first time.
History of Previous illness : -
History of Medication : -
History of Surgery :-
LMP : 28- 12 – 2021
EDD : 21- 09 - 2022
ANC : obstetricians 3x
History of pregnancy :-
Present State

Cons : Composmentis Anemic : (-)

BP : 147/101 mmHg Icteric : (-)
HR : 96x/i Cyanosis : (-)
RR : 20x/i Dispnoe : (-)
Temp : 36.5 °C Oedem : (-)

General State : Good

Nutrition State : Overweight ( BB = 85kg, TB = 150cm)
Illnes Condition : Moderate

Generelize 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 -/- within normal limits
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 : (+)
• EFW : 2900 gr

Gynecological State
-
Laboratory Findings
September 01th 2022

PEMERIKSAAN HASIL NILAI RUJUKAN

HEMATOLOGI
Darah Lengkap
- Hemoglobin 12.4 11.7 – 15.5 g/dL
- Hematokrit 37 37 – 45 %
- Leukosit 13.333 4 – 11 ribu/mm3
- Trombosit 228 150 – 440 ribu/mm3
- Eritrosit 4,28 4.00 – 5.00 juta/uL
- PDW 15.7 9.0 – 13.0 fL
- RDW-CV 14,1 11.5 – 14.5 %
- MPV 8.8 7.2 – 11.1 fL
- PCT 0.294 0.150 – 0.400 %

Indeks Eritrosit
- MCV 86 80 – 100 fL
- MCH 29 26 – 34 pg
- MCHC 33 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 4 1–3%
- Neutrofil Segmen 70 50 – 70 %
- Limfosit 19 20 – 45 %
- Monosit 7 4–8%
Laboratory Findings
September 01th 2022
PEMERIKSAAN HASIL NILAI RUJUKAN

Total Sel
Total Limfosit 2.02 0.58-4.47
Total Basofil 0.01 0-0.1
Total Monosit 0.66 0.17-1.22
0-0.61
Total Eosinofil 1.06 1.88-7.82
Total Neutrofil 9.9
Diagnosis:
KPD + PG + KDR (37-38) wga + PK + AH + Oligohidramnion

Therapy:
IVFD RL 20 gtt/i
Inj Ceftriaxone 1gr/8 hours
Inj Ketorolac 30 mg/8 hours
Misoprostol 3x1
Tramal sup 1/8 hours

Plan:
• Sectio Caesarea
THANK YOU