MORNING REPORT

GENERAL HOSPITAL of WEST

NUSA TENGGARA PROVINCE
28 November 2020
Team in charge:
Alya, Inggita, Dwi
 PATIENT IN WARD

NO NAME AGE DIAGNOSE

Mrs. H 37 y.o G3P2A0H2 GA 39 weeks S/A/IU head presentation + Obesity + PEB
1.
susp. Covid-19
 CASE 1
IDENTITY
NAME: Mrs. H
AGE: 37 years old
ADRESS: Kayangan, North Lombok
ADMITTED: 25 November 2020
MR NUMBER: 149674
 SUBJECTIVE
27/11/2020 MAIN COMPLAINT: -
19.00 WITA PRESENT MEDICAL HISTORY:
Patient with G3P2A0H2, GA 37 weeks, S/A/IU from has an high blood pressure and proteinuria +3, the
VK Teratai
patient was delivered the baby by section caesaria at 26 November 2020,the patient has no complaint
about her pregnancy, patient’s got referred Central Hospital of west nusa tenggara because of the
proteinuria and high blood pressure. At central hospital patient was recommended to do the section
caesarian because of her condition At the moment there was no flu, cough, fever, nausea and vomitting
at the patient, for now patient feel there is a bloody discharge from her vagina but don’t feel the pain,
she told that she routinely did the antenatal care every month
This patient was labelled as suspect covid-19 because has a history of travelling and IgG test (+) for
covid-19 at 25 Nov. 2020 but for now (27 November 2020) the swab result of this patient was negative.

PAST MEDICAL HISTORY:

Hypertension (-), Obesity (+), DM (-), Asthma (-), TB (-), fever/cough (-), surgery (-),
HISTORY OF FAMILY DISEASE:
Hypertension (+) on her mother , DM (-), Asthma (-), TB (-), Allergic (-), fever/cough (-)
 SUBJECTIVE
27/11/2020 OBSTETRIC HISTORY:
19.00 WITA 1. 2012/female/4500 gr/aterm/pervaginam/Midwife
VK Teratai 2. 2017/female/3500 gr/aterm/pervaginam/Midwife
3. 2020/Male/3300 gr/aterm/SC/ Obstetrician

HISTORY OF CONTRACEPTION: used implant contraception after delivered the first

child, used of injection contraception after delivered the second child but stop used it
at the second month of using the injection contraception until this pregnancy.
NEXT FAMILY PLANNIG: have no decision yet

MENARCHE: 14 y.o
HISTORY OF MENSTRUATION CYCLE: 1 x every month, 28 days cycle, reguler, duration
6-7 days, usually light pain in suprapubic

FIRST DAY OF LAST MENSTRUATION: patient forgotten her first day of last
menstruation
DELIVERY DATE: 26-11-2020
 OBJECTIVE before delivered
25/11/2020 GENERAL STATUS: LOCAL STATUS:
22.00 WITA GC: good Eye : anemic -/-, icteric -/-
Public Health GCS: E4V5M6 Cor : S1 S2 single reguler, murmur (-), gallop (-)
Center BP: 150/90 mmHg Pulmo :Vesiculer (+/+), rhonki (-/-), wheezing (-/-)
HR: 96 bpm Abdomen: Enlargement abdomen (+), intestinal
RR: 20 x/minute sound(+) normal, pain on palpation (-), scar (-)
Temp: 36,5 C
SpO2: 98% at the free air Extremity: edema
- -
, warm acral (+/+)
+ +
Proteinuria +3
Body Weight: 106 Kg
Body Height: 155 cm
BMI at pregnancy: 44,5
(Obesity)
 OBJECTIVE (before delivered)
26/11/2020
08.00 WITA OBSTETRICAL STATUS :
Abdominal examination :
• Inspection: striae gravidarum (+), scar (-),
-Havent met the criteria for inpartu at
linea nigra (+)
this moment (there’s no HIS and the
• Palpation:
cervix dilation only 1 cm)
Fundus Height : 32 cm
- Both baby and mother condition
Leopold I: breech
were good at this moment
Leopold II: back on the left side
Leopold III: head
Leopold IV: entering pelvic inlet: 4/5
Contraction: (-)
• Auscultation:
Fetal Heart Beat: 12-12-11 (140 bpm,
reguler)
 OBJECTIVE (before delivered)
26/11/2020 Gentalia Examination :
08.52 WITA • Inspection: bloody slime
OK Covid • VT: -Havent met the criteria for inpartu at
this moment (there’s no HIS and the
-Cervix dilatation: 1 cm cervix dilation only 1 cm)
- Both baby and mother condition were
-Effacement: 10% good at this moment
-Amnion: (-)
-Lowest part: head
-Hodge: no data
 OBJECTIVE (after delivered)
27/11/2020 GENERAL STATUS: LOCAL STATUS:
19.00 WITA GC: good Eye : anemic -/-, icteric -/-
VK teratai GCS: E4V5M6 Cor : S1 S2 single reguler, murmur (-), gallop (-)
BP: 150/100 mmHg Pulmo :Vesiculer (+/+), rhonki (-/-), wheezing (-/-)
HR: 98 bpm Abdomen: Enlargement abdomen (-), intestinal sound(+)
RR: 20 x/minute normal, pain on palpation (-), scar (+)
Temp: 36,5 C
SpO2: 98% at the free air Extremity: edema
- -
, warm acral (+/+)
+ +

Body Weight: 100 Kg

Body Height: 155 cm
BMI at pregnancy: 41,6
(Obesity)
 OBJECTIVE (after delivered)
27/11/2020 Inspection: lokia rubra (+)
19.00 WITA • Fundus Height: 2 finger below the umbilical
VK Teratai • Utery contraction after delivered: adecuate
• Bleeding after delivered: minimal ( abt 50 cc)
• Abdominal pain after delivered: minimal
• Perineum: intact
• Early initiation of breastfeeding: No
• There’s no problem on defecation and urination
Laboratory (25-11-2020 at 22.11)
Parameter Nilai Nilai rujukan

HGB 110,6 11,5-16,5

WBC 10800 4000-10000
RBC 4.06 3,5-5,5
PLT 308000 150000-400000
HCT 32 36 – 48
MCV 77,8 80,0-100,0
MCH 26,1 26,0-34,0
MCHC 33,5 32,0-36,0
PT 15,4 11,5-15,5
APTT 26,8 28,0-38,0
Laboratory (25-11-2020 at 22.11)
Parameter Nilai Nilai rujukan
Serology
HIV Rapid Non reactive Non reactive
HBsAg Rapid Non reactive Non reactive
CRP quantitative 20 <6.00
Liver Function
SGOT 12 < 38
SGPT 9 < 41
Kidney Function
Ureum 19 10-50
Kreatinin 0.5 0.6-1.1
Blood Glucose
Random Blood Glucose 111 <160.00
Laboratory (25-11-2020 at 22.11)
Parameter Nilai Nilai rujukan
Electrolyte
Sodium 136 135-146
Potassium 4.0 3.4-5.4
Chloride 111 95-108
Laboratory (27-11-2020 at 09.55)
Parameter Nilai Nilai rujukan
Serology
PCR & Swab Covid 19 Negative Negative
Laboratory (25-11-2020 at 16.16)
Parameter Nilai Nilai rujukan
Urinalysis
BJ 1,015 1,005-1,035
PH 7 4,5-8
Leucocyte Negative Negative
Nitrit Negative Negative
Protein +1 Negative
Glucose Negative Negative
Ketones bodies +2 Negative
Urobilinogen Negative Negative
Bilirubin Negative Negative
Blood Negative Negative
CXR

There’s infiltrate patchs

CTG
 ASSESMENT (before delivered)
25/11/2020 • G3P2A0H2 GA 39 weeks S/A/IU head presentation + PEB
09.00 WITA
Emergency
departement
and

PLANNING (before delivered)

• IVFD RL 1 kolf in 20 dpm
• Inj Ceftriaxone 1 gr pre op
• MgSO4 40% 6 gr 28 tpm
• Pro SC
 ASSESMENT (second day after delivered)
27/11/2020 • Post SC day II P3A0H3 + PEB + Susp. Covid-19
19.00 WITA
VK Teratai

PLANNING (after delivered)

• Monitor Vital sign
• RL drip MgSO4 40%
• Levofloxacin 750 mg/24 jam for 5 days (Advice from Pulmonologist)
• Nifedipine 1x10 mg
• Paracetamol 3x500mg (if needed)
 Baby Born 24-11-2020(13.00 WITA)
Immediately cry, A-S : 7-9
Gender : Male
Birth weight : 3300 gram
Body length : 51 cm
Amnion fluid: meconeal
Manual Placenta (+)
Placental weight abt 500gr
Anus : +
FOLLOW UP
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
25/11/2020 Complain : No GENERAL STATUS: G3P2A0H2 GA 39 -Monitoring vital sign
21:51 WITA Complain GC: well GCS: E4V5M6 weeks+ PEB+ susp -IVFD RL 500ml drip MgSO4
Emergency Bleeding: (-) Covid-19 40% 28 tpm
departeme Urine: 200 cc --Pro SC e.c PEB+susp. Covid
nt BP: 134/72 mmHg
HR: 96x / min
RR: 20x / min
T: 36 C
SpO2: 98% in room air
Pain score: -
Proteinuria +3
CXR: Pneumonia
RDT: reactive IgG
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
26/11/2020 Complain: GENERAL STATUS: P3A0H3 post SC day -Monitoring vital sign
10:30 WITA No complain GC: well GCS: E4V5M6 I+ PEB + Susp Covid-19 - Nifedipine 10 mg
Pantai Pink Bleeding: (-) - -RL drip MgSO4 40% 15
BP: 138/96 mmHg tpm 24 hrs post SC
HR: 95x / min - Paracetamol 3x500mg
RR: 20x / min - RL drip Oxy 10 IU 20 tpm
T: 36.7 C
SpO2: 98% in room air
Pain score: 0
Swab Covid: Negative

27/11/2020 Complaint: GENERAL STATUS: P3A0H3 post SC day -Monitoring vital sign
19.00 WITA No Complain: GC: well GCS: E4V5M6 II+ PEB + Susp Covid 19 -Take care of wound
VK Teratai Bleeding: (-)
BP: 150/100 mmHg
HR: 98x / min
RR: 20x / min
T: 36.5 C
SpO2: 98% in room air
Pain score: 0
Swab Covid (Repeated):
Negative
REFERRING LETTER
KIA BOOK
USG
THANK
YOU