Morning Report

03 April 2016
SPV : dr. , SpOG
DM : Amy, Bella, Brian, Martina, Vita
 Case 1
Name : Mrs. T
Age : 49 years old
RM : 57-68-62
Address : Narmada
Admitted : 14th April 2016
 Time Subject Object Assessment Planning
14th Patient referred from Narmada General status Severe anemia + Diagnostic:
April PHC with severe anemia. Patient GC : well Susp. AUB CBC
2016 confessed languid and cold sweat Consciousness: CM Pro-USG
since 11.00 (14-04-2016). She BP : 140/90 mmHg
13.50 also confessed that her menstrual PR: 96 tpm Monitoring:
had been going for a week, with a RR: 16 tpm Obs. bleeding
lots of blood coming out from her T: 36,8C
womb (+). Abdominal pain (-), Therapy:
headache (-). Local status Pro-PRC transfusion
Eye : anemic +/+, icteric -/-
History of DM (-), HT (-), asthma Cor : S1S2 single reguler,
(-), malignancy (+) Ca Mamae murmur (-), gallop (-).
Family history: DM (-), HT (-), Pulmo : vesicular (+/+),
asthma (-). wheezing (-/-),
rhonchi (-/-).
LMP : 08/ 04 / 2016 Abdomen : scar (-), mass (-).
Extremity : edema (-/-), warm
History of USG : - accrual (+/+).

History of family planning: - VT : (-), shaky pain on the

portio (-), mass palpable (+) on
Obstetric History: the adnexa parametrium
1. Male/9m/traditional midwife/ cavum Douglas, cant be
3000 gr/spontaneous/alive. evaluated.
2. Female/9m/traditional midwife/
3000 gr/spontaneous/alive Lab (14/04/16):
HGB: 5,2 ()
RBC: 4,00 ()
HCT: 22,2 ()
WBC: 8,36 (N)
PLT: 643 ()

Random Glucose test: 159 (N)

Time Subject Object Assessment Planning
Chronology at Narmada PHC
(14/04/2016):
S:
Patient confessed languid (+) and
cold sweat since a week ago,
headache (+).

O:
GC : moderate
Consciousness: CM
BP : 120/90 mmHg,
Eye : anemic +/+, icteric -/-
Cor : S1S2 single reguler, murmur (-),
gallop (-).
Pulmo : vesicular (+/+), wheezing (-/-
), rhonchi (-/-).
Abdomen : scar (-), mass (-).
Extremity : edema (-/-), warm accrual
(+/+).

A:
Severe anemia

P:
O2 nasal 2lpm
IVFD RL 20 dpm
 Time Subject Object Assessment Planning
17.30 Confessed (-) General status Obs. Bleeding
GC : well Pro-PRC transfusion
Consciousness: CM Pro-USG
BP : 130/90 mmHg
PR: 96 tpm Moved to Segara
RR: 20 tpm Anak
T: 36,5C

14/04/
2016

06.00
 Case 2
Name : Mrs. UH
Age : 17 years old
RM : 57-68-84
Address : Sedau
Admitted : 14th April 2016
 Time Subject Object Assessment Planning
14th Patient referred from Sedau PHC General status G1P0A0L0 38-39 Diagnostic:
April with G1P0A0L0 38 weeks S/L/IU GC : well weeks S/L/IU head CBC, HbsAg,
2016 head presentation with latent Consciousness: CM presentation with PTT/APTT, CTG
phase first stage of labor + BP : 120/80 mmHg latent phase first
23.45 edema vulva. Patient confessed PR: 120 tpm stage of labor + Therapy:
abdominal pain (+) since 13.00 RR: 20 tpm edema vulva Obs mother and fetal
(14/04/2016), water leaked from T: 37,6C well being
her womb (-), bloody slime (-), Obs. progress of
FM (+). Local status labor
Eye : anemic -/-, icteric -/- CIE mother to lay
History of DM (-), HT (-), asthma Cor : S1S2 single regular, down on the left side
(+). murmur (-), gallop (-).
Family history: DM (+), HT (+), Pulmo : vesicular (+/+), DM co to GP, GP co to
asthma (+) grandmother. wheezing (-/-), SPV, advice:
rhonchi (-/-). Pro-SC at 01.00 am
LMP : 28 / 07 / 2015 Abdomen : scar (-), striae (+), (15-04-2016)
EDD : 04 / 05 / 2016 linea nigra (+).
GW : 38-39 week Extremity : edema (-/-), warm
accrual (+/+).
History ANC : 8x at Posyandu
Last ANC: 01-04-2016, Obstetric status
Result GW 36 weeks, BP : L1 : breech
100/70 mmHg, BW: 66 kg, head L2 : back on left side
presentation, FHB (+). L3 : head
L4 : 4/5
History of USG : - UFH : 30 cm
EFW : 2945 gr
History of family planning: - FHB: 12-12-12
Next family planning: - UC : 2x10~25

Obstetric History: VT : 2 cm, eff 25%, amnion

1. This (+), head presentation,
denominator unclear, HI,
small part or umbilical cord
unpalpable.
Time Subject Object Assessment Planning
Pelvic Examination
Promontorium unpalpable
Spina ischiadica prominent
Os sacrum convex
Os coccygeus mobile
Arcus pubis > 90

Pelvic score : 3
Cervix dilatation 1
Cervix length 0
Hodge 0
Consistency 0
Position 1

Lab (05/04/2016):
HB: 9,8 ()
RBC: 4,26 ()
HCT: 32,2 ()
WBC: 18,6 ()
PLT: 450 ()
HbsAg: (-)
Time Subject Object Assessment Planning
Chronology at Sedau PHC
(14/04/2016):
S:
Patient confessed abdominal pain
(+) since 13.00 (14/04/2016),
water leaked from her womb (-),
bloody slime (-), edema cervix
(+).

O:
GC : well
Consciousness: CM
BP : 110/90 mmHg,
PR : 84 x/m
T : 36,2 C
RR : 20 x/m
UFH : 30cm
UC : 2x10~20
FHB: 140 x/m
VT : 1 cm, eff 10%, amnion (+),
head presentation, denominator
unclear, small part or umbilical
cord unpalpable.

A:
G1P0A0L0 38 weeks S/L/IU head
presentation with latent phase
first stage of labor + edema vulva

P:
IVFD RL 28 dpm
 Time Subject Object Assessment Planning
15/04/ Confessed abdominal pain (+++) GC : well G1P0A0L0 38 weeks Patient move to OK
2016 Consciousness: CM S/L/IU head CITO
BP : 120/80 mmHg presentation with
01.00 PR: 120 tpm latent phase first
RR: 20 tpm stage of labor +
T: 37,6C edema vulva

01.30 Confessed (-) GC : well The baby was born:

Consciousness: CM Male/A-S~7-9/3000gr/
BP : 120/80 mmHg 49cm
PR: 120 tpm
RR: 20 tpm The placenta was born
T: 37,6C completely.

Obs. Mother and

fetal well being.
04.00 Confessed (-) GC : well Obs. Mother and
Consciousness: CM baby well being
BP : 120/80 mmHg
PR: 120 tpm Moved to Segara
RR: 20 tpm Anak
T: 37,6C

Baby (in NICU)

HR : 144x/min
RR: 40 x/min
T: 36.6 C
06.00 Confessed (-) GC : well Mobilization
Consciousness: CM Eat and drink
BP : 120/80 mmHg CIE
PR: 120 tpm
RR: 20 tpm
T: 37,6C

Baby (in NICU)

HR : 144x/min
RR: 40 x/min
T: 36.6 C