MORNING REPORT

MATARAM UNIVERSITY HOSPITAL

30 SEPTEMBER 2020
TEAM IN CHARGE
Ranova and Tari
 PATIENT IN WARD

NO NAME AGE DIAGNOSE

1. Mrs. R 21 y.o. G1P0A0H0 Aterm S/L/IU Head Presentation + Severe Preeclampsia
G4P2A1H2 Aterm 39 – 40 weeks S/L/IU Uk. Head Presentation +
2. Mrs. BL 31 y.o.
Premature Rupture of Membrane
3. Mrs. RK 50 y.o STGO + Anemia + Cysta Bhartolini
4. Mrs. M 42 y.o STGO
IDENTITY
NAME
AGE
: Mrs. R
: 21 years old
ADRESS : Lingsar, West Lombok
CASE 1
ADMITTED : 28 September 2020
MR NUMBER : 147297
28-09-2020 Main Complaint: evaluate pregnancy with Severe Preeclampsia
22.43 WITA
VK IGD Present Medical History:
ROOM The patient came for a referral at Awet Muda Hospital with a diagnosis of G1P0A0 39 weeks pregnant
S / L / IU head presentation with impending eclampsia.
The patient said that she was 9 months pregnant, complained that she had not felt any abdominal pain
that came and went, had not yet released blood mucus, and had not yet released amniotic fluid.
movement of the fetus is still active. Subjective complaints of dizziness (-), nausea (-), blurred vision
(-), heartburn (-).
Covid19 Screening: Cough (-), Colds (-), Fever (-), Shortness (-), Contact with Covid (-)
Past Medical History :
Hypertension (-), DM (-), Asthma (-), TB (-), allergic (-), gastritis (-)

History of Family Disease :

Hypertension (-), DM (-) , Asthma (-), TB (-), allergic (-)
Time Subjective
28-09-2020 Obstetric History: First Pregnancy
22.43 WITA
VK IGD ROOM History of Contraseption : -

Menarche: 14 y.o
History of menstrual cycle: regular 28 days, 1 x every month, volume 50 – 80 cc / 24 hours
Married 1x

First Day of Last Menstruation: 26 - 12-2019

Estimated Delivery Date: 03- 10 -2020
Gestational Age : 39 weeks
Time Objective
28-09-2020 General Status: Local Status:
22.43 WITA GC: Well Eye : anemic -/-, icteric -/-
VK IGD GCS: E4V5M6
ROOM Cor : S1S2 single reguler, murmur (-),
BP: 130/70 mmHg
HR: 96 bpm gallop (-)
RR: 18 x/min Pulmo : vesikuler (+/+), wheezing (-/-),
Temp: 36.5oC ronkhi (-/-)
SpO2 : 99% Abdomen : pain (-), bowel sounds (+),
BW: 65 kg scar (-)
BH: 149,5 cm Extremity : edema (-/-), warm acral (+/+)
(-/-)
 OBJECTIVE
28-09-2020 OBSTETRICAL STATUS:
22.43 WITA Abdominal examination :
VK IGD
ROOM • Inspection: striae gravidarum (+), scar (-), linea nigra (+)
• Palpation:
Fundus Height : 31 cm
EFW: 3100 gram
Leopold I: palpable round, large soft (buttocks)
Leopold II: palpable lengthwise (left back) on one side and palpable small parts
(extremities) on the other
Leopold III: felt round, big, hard (head)
Leopold IV: PAP 4/5
Contraction: -
• Auscultation:
Fetal Heart Beat: 12-12-12 ( 136 bpm), reguler

Genitalia examination :
• Inspection : bloody slime (-)
• VT: not evaluated
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Had not any General Status: G1P0A0 Aterm GA 39 – • observation of maternal
22.43 WITA complain GC: Well Temp: 36.2oC 40 weeks S/L/IU Head and fetal well-being
(VK ER) GCS: E4V5M6. RR: 20 x/min Presentation + Severe • CTG, check lab (complete
HR: 96 bpm BP: 110/70 mmhg Preeclampsia blood, count type,
SpO2 : 99% hemostasis, renal + liver
Obstetrical Status: function, Glucose)
Abdominal examination : • Consul dr. Fadly Sp.OG,
• Inspection: striae gravidarum (+), scar (+), advice : Dx. Severe
linea nigra (+) Preeclampsia,
• Palpation: Termination misoprostol
fundus Height : 31 cm (umbilical level) 25 mcg/6 jam
EFW: 3100 gram (based on FH) • KIE Family, Move patient
Leopold I: palpable round, large soft to vk teratai
(buttocks)
Leopold II: palpable lengthwise (left back) History therapy of Awet
on one side and palpable small parts Muda Hospital :
(extremities) on the other Bolus MgSO4 4 gr, Drip
Leopold III: back MgSO4 6 gr, Nifedipin,
Leopold IV: felt round, big, hard (head) PCT infus Inj. Ranitidin,
Contraction: 4/5 PAP Inj. Ondansentron
• Auscultation:
Fetal Heart Beat: 12-11-11 (136 bpm), Monitoring:
reguler • Symptoms
Genitalia examination : • Vital signs
• Inspection : bloody slime (-),
• VT: not evaluated
Laboratory (28-09-2020, 23.31 wita)
Parameter value Reffered value

HGB 12,8 11,5-16,5

WBC 15000 4000-10000
RBC 4,23 3,5-5,5
PLT 376000 150000-400000
HCT 38 36 - 48
MCV 88,7 80,0-100,0
MCH 30,3 26,0-34,0
MCHC 34,1 32,0-36,0
PT 13,8 11,5-15,5
CPT 13,6
APTT 30,8 28 -38
CAPTT 31,7
Laboratory Count type (28-09-2020, 23.31
wita) Parameter value Referred value

Basofil 0.2 0.0 – 1.0

Eosinofil 2.8 1.0 -26.0
Neutrofil 74.9 50.0 – 70.0
Limfosit 18.4 20.0 – 40.0
Monosit 3.7 2.0 – 8.0
Basofil# 0.03 0.00 – 0.10
Eosinofil# 0.43 0.00 – 0.40
Neutrofil# 11.31 1.50 – 7.00
Limfosit# 2.78 1.00 – 3.70
Monosit# 0.56 0.00 – 0.70
Laboratory (28-09-2020, 23.31 wita)
Parameter Nilai Nilai rujukan

RFT

Ureum 21,6 10-50

Creatinin 0,6 0,6-1,1
LFT
SGOT 25 0-40
SGPT 10 0-41
N-FBG
GDS 111 <160
Serology
HIV Rapid Non reaktif Non reaktif
HBsAg Rapid Non reaktif Non reaktif
URINALISA
Protein ++ -
Berat jenis 1,030 1010-1030
PH 6.5 5,0-7,5
Nitric - -
Glucose - -
Keton - -
urobilinogen - -
bilirubin - -
darah +++ -
leukosit + -
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Had not any General Status: G1P0A0 Aterm GA 39 –
02.05 WITA complain GC: Well Temp: 36.6oC 40 weeks S/L/IU Head Therapy:
(VK Teratai) - Fetal GCS: E4V5M6. RR: 20 x/min Presentation + Severe • Misoprostol 25 mcg/6
movement HR: 94 bpm BP: 120/80 mmhg Preeclampsia hours
(+) SpO2 : 98% • MgSO4 flush II
• Observation His + DJJ
Obstetrical Status:
Abdominal examination :
• Contraction: - Monitoring:
• Auscultation: • Symptoms
Fetal Heart Beat: 12-12-12 (144 bpm), • Vital signs
reguler • Urine output
Genitalia examination :
• Inspection : bloody slime (-),
• VT: not evaluated
Urine output: 1000 cc since referred Awet
Muda Hospital
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Had not any General Status: G1P0A0 Aterm GA 39 –
06.00 WITA complain GC: Well Temp: 36,8oC 40 weeks S/L/IU Head Therapy:
(VK Teratai) - Fetal GCS: E4V5M6. RR: 20 x/min Presentation + Severe • Infus RL Drips MgSO4 fls
movement HR: 88 bpm BP: 130/80 mmhg Preeclampsia with III (28 tpm)
(+) SpO2 : 98% induction terminasi
misoprostol Monitoring:
Obstetrical Status: • Symptoms
Abdominal examination : • Vital signs
• Contraction: - • Urine output
• Auscultation:
Fetal Heart Beat: 12-12-12 (144 bpm),
reguler
Genitalia examination :
• Inspection : bloody slime (-),
• VT: not evaluated
Urine output:380 cc
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Had not any General Status: G1P0A0 Aterm GA 39 –
08.00 WITA complain GC: Well Temp: 36oC 40 weeks S/L/IU Head Therapy:
(VK Teratai) - Fetal GCS: E4V5M6. RR: 20 x/min Presentation + Severe • Infus RL Drips MgSO4 fls
movement HR: 88 bpm BP: 130/100 mmhg Preeclampsia with III (28 tpm)
(+) SpO2 : 98% induction terminasi
misoprostol Monitoring:
Obstetrical Status: • Symptoms
Abdominal examination : • Vital signs
• Contraction: - • Urine output
• Auscultation:
Fetal Heart Beat: 13-13-13 (156 bpm),
reguler
Genitalia examination :
• Inspection : bloody slime (-),
• VT: not evaluated
Urine output: 500 cc
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Had not any General Status: G1P0A0 Aterm GA 39 –
08.30 WITA complain GC: Well Temp: 36,6oC 40 weeks S/L/IU Head Consul : dr. Fadhly, Sp.OG,
(VK) - Fetal GCS: E4V5M6. RR: 19 x/min Presentation + Severe advice :
movement HR: 105 bpm BP: 130/90 mmhg Preeclampsia with if at 10 there is no
(+) SpO2 : 98% induction terminasi contraction, prepare sc cito
misoprostol
Obstetrical Status: Monitoring:
Abdominal examination : • contraction
• Contraction: - • Vital signs
• Auscultation:
Fetal Heart Beat: 13-13-13 (156 bpm),
reguler
Genitalia examination :
• Inspection : bloody slime (-),
• VT: not evaluated
Urine output: 500 cc
IDENTITY
NAME
AGE
: Mrs. BL
: 31 years old
ADRESS : Kediri, West Lombok
CASE 2
ADMITTED : 28 September 2020
MR NUMBER : 008598
28-09-2020
23.58 WITA
VK IGD Present Medical History:
ROOM The patient came with complaints of amniotic fluid discharge since 22.30 WITA. the patient is
currently 9 months pregnant. the patient also complained of abdominal pain that disappeared a little bit
since 8:00 p.m. blood slym (-). fetal movement is still felt active
Covid19 Screening: Cough (-), Colds (-), Fever (-), Shortness (-), Contact with Covid (-)
Past Medical History :
Hypertension (-), DM (-), Asthma (-), TB (-), allergic (-), gastritis (-)

History of Family Disease :

Hypertension (-), DM (-) , Asthma (-), TB (-), allergic (-)
Time Subjective
28-09-2020 Obstetric History:
23.58 WITA 1. 2011/Hospital/aterm/spontan/Dokter/Boy/2900
VK IGD ROOM 2. 2015//Hospital/aterm/spontan/Midwife/Boy/3100
3. 2012/Abortus (kuret)
4. This pregnancy

History of Contraseption : -

Menarche: 14 y.o
History of menstrual cycle: regular 28 days, 1 x every month, volume 100 cc / 24 hours
Married 1x

First Day of Last Menstruation: 22 - 12-2019

Estimated Delivery Date: 03- 10 -2020
Gestational Age : 39 weeks
Time Objective
28-09-2020 General Status: Local Status:
23.58 WITA GC: Well Eye : anemic -/-, icteric -/-
VK IGD GCS: E4V5M6
ROOM Cor : S1S2 single reguler, murmur (-),
BP: 130/70 mmHg
HR: 96 bpm gallop (-)
RR: 18 x/min Pulmo : vesikuler (+/+), wheezing (-/-),
Temp: 36.5oC ronkhi (-/-)
SpO2 : 99% Abdomen : pain (-), bowel sounds (+),
BW: 65 kg scar (-)
BH: 149,5 cm Extremity : edema (-/-), warm acral (+/+)
(-/-)
 OBJECTIVE
28-09-2020 OBSTETRICAL STATUS:
23.58 WITA Abdominal examination :
VK IGD • Inspection: striae gravidarum (+), scar (-), linea nigra (+)
ROOM • Palpation:
Fundus Height : 31 cm
EFW: 3100 gram
Leopold I: palpable round, large soft (buttocks)
Leopold II: palpable lengthwise (left back) on one side and palpable small parts
(extremities) on the other
Leopold III: felt round, big, hard (head)
Leopold IV: PAP 4/5
Contraction: + 1x10’ - 15”
• Auscultation:
Fetal Heart Beat: 12-12-12 ( 144 bpm), reguler

Genitalia examination :
• Inspection : bloody slime (-), discharge of amniotic fluid (+)
• VT: remaining amniotic fluid, fornix touch impression of the head, soft portio
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
28-09-2020 discharge of General Status: G4P2A1H2 Aterm 39 –
23.58 WITA amniotic fluid GC: Well Temp: 36.6oC 40 weeks S/L/IU Uk. Therapy:
VK IGD - Fetal GCS: E4V5M6. RR: 20 x/min Head Presentation + • Ceftriaxon 1 gr iv
ROOM movement HR: 94 bpm BP: 120/80 mmhg Premature Rupture of • Observtion his + djj
(+) SpO2 : 98% Membrane • Observation His + DJJ
• Move patient to vk
Obstetrical Status: teratai
Abdominal examination :
• Contraction: + 1x10’ - 15”
• Auscultation: Monitoring:
Fetal Heart Beat: 12-12-12 (144 bpm), • Symptoms
reguler • Vital signs
Genitalia examination :
• Inspection : bloody slime (-), discharge of
amniotic fluid (+)
• VT: remaining amniotic fluid, fornix touch
impression of the head, soft portio
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 discharge of General Status: G4P2A1H2 Aterm 39 – CTG
08.00 WITA amniotic fluid GC: Well Temp: 36,8oC 40 weeks S/L/IU Uk. Therapy:
(VK Teratai) - Fetal GCS: E4V5M6. RR: 20 x/min Head Presentation + • Infus RL Drip oksitosin 5
movement HR: 88 bpm BP: 120/80 mmhg Premature Rupture of unit untuk terminasi
(+) SpO2 : 98% Membrane kehamilan mulai 8 tpm
(max 40 tpm)
Obstetrical Status: diobservasi tiap 30
Abdominal examination : menit
• Contraction: + 1x10’ - 15”
• Auscultation: Monitoring:
Fetal Heart Beat: 12-12-12 (144 bpm), • Symptoms
reguler • Vital signs
Genitalia examination :
• Inspection : bloody slime (-), discharge of
amniotic fluid (+)
• VT: remaining amniotic fluid, fornix touch
impression of the head, soft portio
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 discharge of General Status: G4P2A1H2 Aterm 39 – CTG
14.00 WITA amniotic fluid GC: Well Temp: 36oC 40 weeks S/L/IU Uk. Therapy:continued drips
(VK Teratai) - Fetal GCS: E4V5M6. RR: 20 x/min Head Presentation + oxytocin at 32 tpm
movement HR: 88 bpm BP: 130/100 mmhg Premature Rupture of
(+) SpO2 : 98% Membrane with aktif Monitoring:
phase kala I • Symptoms
Obstetrical Status: • Vital signs
Abdominal examination :
• Contraction: + 4x10’ 40
• Auscultation:
Fetal Heart Beat: 13-13-13 (156 bpm),
reguler
Genitalia examination :
• Inspection : bloody slime (-), discharge of
amniotic fluid (+)
• VT: open 4cm, eff : 50%
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29-09-2020 - Patient want General Status: G4P2A1H2 Aterm 39 –
15.00 WITA impartu GC: Well Temp: 36,6oC 40 weeks S/L/IU Uk. Observation ttv
(VK) GCS: E4V5M6. RR: 19 x/min Head Presentation + Help to impartu
HR: 105 bpm BP: 120/90 mmhg Premature Rupture of
SpO2 : 98% Membrane with kala II Monitoring:
• contraction
Obstetrical Status: • Vital signs
Abdominal examination :
• Contraction: +4x10’ 45”
• Auscultation:
Fetal Heart Beat: 13-13-13 (156 bpm),
reguler
Genitalia examination :
• Inspection : bloody slime (-), discharge of
amniotic fluid (+)
• VT: remaining amniotic fluid, fornix touch
impression of the head, soft portio
TERIMA KASIH