MORNING REPORT

22-23 MAY 2017

 LIST OB 22-23 May 2017
1. Ny. C/G4P1A2 UK 38 mgg + Varises of Vagina/Sakinah 8.2
2. Ny. S/AUB/Sakinah 9.2
3. Ny. R/Myoma Uteri/Sakinah 11.2
4. Ny. I/Hyperplasia of Endometrium/Sakinah 13.1
5. Ny. M/Abortus Imminent/Sakinah 8.2
6. Ny. S/Myoma Uteri + Anemia/VK Isolasi
7. Ny A/G1P0A0 A/T/H post date/VK 1.3
8. Ny I/G3P1A1 uk 40-41 mgg+BSC 4
th+CPD+Oligohydramnions
9. Ny A /G2P1A0 uk 35-36 mgg+BSC 2 th+ PLR/Sakiah 13.2
10.Ny F/G1P0A0 uk 38-39 mgg+Oligohydramnions/Obs UPPA
11.Ny E/G2P1A0 uk 38-39 mgg +KPD +HIV +/UPPA
12.Ny L/G1P0A0 uk 39-40 mgg + KPD+Oligohydramnions
/Multazam
13.Ny. N/ G1P0A0 uk 39-40 mgg in partu/ dr .Tito
 Identity
Name : Mrs. R
Age : 43 yo
Address : Lamongan
Date examination : May 22th, 2017
 Anamnesis
Chief complain: Bleeding from the birth canal

Present Illness History: The patient came with a

bleeding complaint from the birth canal since 2
months. Patients said they had checked into an
obstetrician with a diagnosis of myoma uteri. Patients
also complained of irregular menstruation during the
use of 3-month contraceptive injections. Patients also
complained about this 3 month leukhorea.

Previous Illness History:, HT (-) and DM (-)

Familly Illness History : HT (-), and DM (-)

Social Illness History: consumption drug or herbal (-)

Obstetrics History:
1. Male/aterm/spontan/3100 gr/20th
2. Male/aterm/SC/3100gr/12th

. Menstruation History:
Menarche 12 years old, reguler, for 7
days, disminorhea (+), replace the 2x
pads

.Contraception : contraception
injections
 Primary Survey
A: clear, gargling (-), snoring (-), speak
fluently (+), potential obstruction (-)
B: spontan, RR 20x/mnt, ves/ves, Rh -/-,
Wh -/-, SaO2 100% without O2 support
C: akral warm dry red, CRT <2, PR
79x/mnt, BP 112/80 mmHg
D: GCS 456, lateralisasi -, PBI 3mm/3mm
E: temp 36.3 C
Secondary Survey
GCS 456
H/N: a-/i-/c-/d -
Tho: sim, ret -/-
P: ves/ves; rh -/-, wh -/-
C: S1S2 single, murmur -, gallop
Abd: soefel, met (-), BU (+) N,
mass (-),
Ext: aie -, akral warm dry red
Planning Dx
USG
Complete Blood Count
 Laboratorium
Metode 1 : non- Trombosit : 274 (150-
reaktif 450)
Hbs Ag : negatif Limposit : 16,7 (25.0-
Hb: 13,1 (13.0-18.0) 33.0)
Hct: 39,9 (35-47) Monosit: 4,0 (3.0-7.0)
Leucocyte: 7,0 (4.0- Eosinofil: 3,7 (1.0-2.0)
11.0) Basofil: 1,1 (0.0-1.0)
Neutropil: 74,5 Eritrosit : 4,48 (3.80-
(49.0-67.0) 5.30)
GDA : 89 MCV : 89,1 (87.00-100)
PT : 11,80 (10.3- MCH : 29,20 (28.00-
Assesment
Myoma Uteri
Therapy
Inf. Assering 1500 cc/ 24 jam
Inj. Ceftriaxon 2 gr iv pre op
C/Sp.OG pro TAH BSO
Monitoring
Vital sign
Patients complaints
Education
Explain to patients and her family
about : disease, operation pro TAH BSO,
complication and prognosis
THANK YOU