MORNING

REPORT
Saturday, April 26th 2024
PONEK CASE

1. Pande Dedit Pramana (018.06.0057)

2. Ketut Yulina Pratiwi (018.06.0038)
3. Baiq Fahira Mentari (019.06.0015)
4. Putu Ardhyana Yogeswara (019.06.0076)
Supervisor: dr. I Nyoman Sayang, Sp. OG
 PATIENT IDENTITY
Name : RDU
Medical Record : 32.49.49
Date of birth : 1989/07/12th
Age : 34 year old
Sex : Female
Religion : Hindu
Marital Status : Married
Occupation : private employees
Education : High School
Address : Br. Suluhan Susut
Admitted Date : APril 26th 2024, 11.30 a.m.
 CASE
A 34-year-old female patient came to the emergency room at Bangli Regional Hospital
at 11.30 A.M. The patient was fully conscious when her husband brought her. The
patient also complained of abdominal pain since April 26th 2024 at 03.00 A.M.
Abdominal pain is said to be aggravated when the patient is active and slightly
reduced when the patient is resting. Other complaints such as amniotic fluid, blood
and mucus from the birth canal were denied . The baby movement is good (+).
 Menstrual History

The patient experienced her first menstruation when she was 14 year old with regular cycles every 28 days. Each
menstruation lasts about 4 days. Patient also complained about abdominal pain in the first and second days of
menstruation.

HPHT : September 11th 2023

TP : juny 18st 2024

Obstetric History

1. 2008 – Aterm – Male – 3.200 gr – Spontanous Birth - in the healthcare – Life

2. 2013 – Abortus – kuretase
3. 2014 – Aterm – Female – 3.100 gr – Spontaneous Birth – in the healthcare – Life
4. 2018 – Aterm – Female – 3.100 gr – Spontaneous Birth – in the healthcare – Life
5. This gestation
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 Marital History

The patient got married once in 2007 when the patient was 20 year old and her husband was 25 year old.
Marriage was done officially.

History of Contraceptive Use

There is no history of contraceptive

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 Past Medical History

History of obstetrics and gynaecology disease was denied. History of systemic diseases such as diabetes
mellitus, hypertension, anemia, heart disease, kidney disease were denied by the patient.

History of Transfusion

There is no history of blood transfusion

History of Surgery
There is no history of Surgery

History of Allergy
There is no history of Allergy

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 Family History
History of systemic diseases in the family such as diabetes mellitus, asthma, anemia, heart disease,
kidney disease were denied by the patient. Family history of obstetrics and gynaecology disease was
denied

Personal, social and environmental history

Personal,
The patient lives withsocial and and
her family environmental history
their relationship is harmonious. The patient denied habits of
smoking and drinking alcohol.

History of Medicine

No medical history

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 Physical examination
Present Status
Consciousness : Compos Mentis
GCS : E4 V5 M6
Blood Pressure : 110/81 mmHg
Pulse Rate : 89 x/min, regular
Respiration Rate : 20 x/min
Axillary temperature : 36°C
SpO2 : 99% on RA
VAS : 3/10
FHR :-
Height : 156 cm
Weight
Before : 57 kg
After : 66 kg
BMI
Before : 23.4 kg/m2
After : 27.1 kg/m2
HPHT : September 11th 2023
TP : 18th Juny 2024
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 Physical examination
General Status

Head : Normocephalic
Eye : Anemic conjunctiva (-/-), icteric sclera (-/-)
ENT : Discharge (-), hyperemic pharyngeal (-)
Mouth : cyanosis (-)
Neck : Thyroid enlargement (-), lymph node enlargement (-)
Thorax : Symmetrical, rash (-)
Cor : S1 S2 single, regular, murmur (-)
Pulmo : Ves +/+, wh -/-, rh -/-
Mammae : obstetric status
Abdomen : obstetric status
Genital : obstetric status
Extremities: Warm + | + pitting edema - | - CRT <2 sec
+|+ -|-

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 Physical examination
Obstetric Status

Mammae : Symmetrical, hyperpigmentation (+/+), protruded nipples (-/-), good hygiene,

palpable mass (-/-), discharge (-/-),
Abdomen:
Inspection: Symmetrical, linea nigra (+), striae gravidarum (+), surgical scar (-)
Auscultation: Peristaltic sounds (+) normal
Palpation :
 Leopold I : Palpable two soft round –shaped part, impression of two buttocks
 Leopold II : palpable small hard part on the right side and palpable flat hard part on the left side. Left
back impression
 Leopold III : Palpable two hard round –shaped part, impression of head
 Leopold IV : konvergent, indicating the head has not descened into the upper pelvic inlet
 TFU : 3 fingers below processus xyphoideus (McD 25 cm)
 FW I : 2.015 gram
 His : 1x/10 minutes ~ 10-15 detik
 DJJ I : 134x/minutes 1
0
 Physical examination
Obstetric Status

Vagina :
Inspecsion : normal vulva, active bleeding (-), fluor (-)

VT : v/v normal, soft portio, effacement 25%, cervical dilatation 0 cm, intact amnion (+),
head desscen at hodge I, vaginal bleeding (-), blood slym (-), discharge (-), Chandelier sign (-)

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Laboratory Examination (26/04/2024)
Laboratory Examination - CBC (26/04/2024)
 ASSEMENT
G5P3013 UK 32
Minggu 4 Hari, T/H
Preskep + PPI
 MANAGEMENT
Planning
- Sectio Caesarea

Therapy
- IVFD RL 20 tpm
- Dexamethazone 2x12.5 mg (IM)
- Nifedipine 60mg

MONITORING
1. Vital signs
2. Subjective complaints
 FOLLOW-UP
April 12th 2024

S: surgical wound pain (+), flatus (+)

O: Status Present
General condition: E4 V5 M6
Cosnciousness: Compos Mentis
BP: mmHg
HR : x/min
RR: x/min
T:
SpO2: % on RA

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 Physical examination
General Status

Head : Normocephalic
Eye : Anemic conjunctiva (-/-), icteric sclera (-/-)
ENT : Discharge (-), hyperemic pharyngeal (-)
Mouth : cyanosis (-)
Neck : Thyroid enlargement (-), lymph node enlargement (-)
Thorax : Symmetrical, rash (-)
Cor : S1 S2 single, regular, murmur (-)
Pulmo : Ves +/+, wh -/-, rh -/-
Mammae : Symmetrical, hyperpigmentation (+/+), protruded nipples (-/-), good hygiene,
palpable mass (-/-), discharge (-/-),
Abdomen : obstetric status
Genital : obstetric status
Extremities: Warm + | + pitting edema - | - CRT <2 sec
+|+ -|-
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 FOLLOW-UP
O : Obstetric Status
A: P1002 Post SC day 1
Abdomen :
P:
TFU : 2 fingers below of umbilicus
IVFD RL 20 tpm
Uterus contraction (+)

Vagina :
Lochea (+) rubra

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THANKYOU