MORNING REPORT

29 November 2017
Supervisor:
dr. Doddy Ario K., Sp.OG
dr. Ario Danianto, Sp.OG
Medical Students:
Agung, Sasya, Shiva
CASE RESUME
NORMAL LABOR -

PATHOLOGIES CASE -

REMAIN CASE 1. G2P1A0L1 36 weeks /S/L/IU head presentation

with placenta previa
 Tidak ada
pertanyaan
yang salah
 Case I
• Name : Mrs. M
• Age : 31 years old
• Address : Bayan, North Lombok
• Admitted : November 28th 2017
• RM : 599323
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
28/11/ Patient referred from North lombok General Status : G2P1A0L1 36 weeks DM Planning:
2017 Hospital with G2P1A0L1 36 weeks GC : well S/L/IU head Diagnostic:
/S/L/IU head presentation with suspect GCS: CM presentation with ante Laboratorium,
12.20 placenta previa. Patient confessed BP : 110/70 mmHg partum bleeding CTG
blood leaked out from her womb since PR : 88 bpm suspect placenta USG
20.00 pm (27/11/2017), abdominal pain RR : 18 x/min previa
(-), bloody slime (+), FM (+). Temp : 37,1oC Therapy :
•RL : D5 = 2: 1
No history of DM, HT, asthma and heart Eye : anemic -/-, icteric -/- •CIE patient to eat
disease Cor : S1S2 single reguler, and drink
murmur (-), gallop (-).
LMP : March 2017 Pulmo : vesikuler (+/+),
EDD : December 2017 wheezing (-/-), DM co to GP, GP co
GW : 36 weeks ronkhi (-/-). to SPV, advice :
Abdomen : bu (+) •C-section
History of ANC : 8x at PHC Extremity : edema (-/-), •Prepare 4-6 kolf
Last ANC : 23-11-2017 warm acral (+/+). PRC
Result: BP 110/70, BW 51 kg, GW 33
weeks, UFH 30 cm, head presentation, Obstetrical Status :
FHB 140tpm L1 : breech
History of USG : 2x L2 : back on the right side
L3 : head
History of family planning: implant L4 : 5/5
Next family planning :- UFH : 30 cm
EFW : 2790 gr
FHB : 13-13-13 (156 bpm)
VT : (tidak dilakukan)
Inspekulo :
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetrical History : Lab: (19/9/2017)

HB 12,3 g/dl
1. Male/ 6 yo/ PHC/ 9 months /spontan/ RBC 4,54 x 10^6/uL
midwifes HCT 37,2%
2. this WBC 13,42 x 10^3/uL
PLT 297 x 10^3/uL
HbSAg non reactive

14.00 Bloody leaked stop GC : well G2P1A0L1 36 weeks Therapy :

GCS: CM S/L/IU head •RL : D5 = 2: 1
BP : 110/70 mmHg presentation with ante •Obs. Mother and
PR : 84 bpm partum bleeding Fetus
RR : 18 x/min suspect placenta
Temp : 37,0oC previa
Kronologis
Pasien
Buku KIA
USG
CTG
TERIMA KASIH