MORNING REPORT

WEST NUSA TENGGARA HOSPITAL

4th February 2021
TEAM IN CHARGE
Nada, Muara, Bagus
 PATIENT IN WARD

NO NAME AGE DIAGNOSE

1. Mrs. WA 24 y.o Introitus vaginal cicatrix
2. Mrs. H 53 y.o G2P1A0H1 (38 – 39 weeks) + Placenta Previa
IDENTITY
NAME: Mrs. WA
AGE: 24 years old
CASE 1
ADRESS: Batu Layar
ADMITTED: 4th February 2021
MR NUMBER: 167315
 SUBJECTIVE
04/02/2021 MAIN COMPLAINT : can’t have a sexual intercourse
12.00 am PRESENT MEDICAL HISTORY:
WITA
Patient came to obstetric and gynecological clinic with complaints of not being able to have sexual
VK intercourse with her partner because of narrowing of the vagina. This complaint causes the penis to
be unable to enter the vagina at all. This condition was realized by the patient since 6 months ago,
when the patient was about to have sex with her husband. About 8 months ago, the patient gave
birth to her first child normally at the RSAD with the help of a midwife and received suture in the
birth canal which causes vaginal narrowing in the patient.
The other complaint such as a pain (-), vaginal discharge (-), bleeding (-). Urination and defecate was
normal.
PAST MEDICAL HISTORY:
Similar complaint (-). Allergy history (+) to specific food.
Trauma (-), hypertension (-), DM (-), cancer (-), surgery (-).
HISTORY OF FAMILY DISEASE:
Similar complaint (-). Hypertension (+) in her grandfather. Cancer (-), DM (-).
 SUBJECTIVE
02/02/2021 OBSTETRIC HISTORY:
10.00 WITA 1. 2018/abortus
VK 2. 2019/aterm/pervaginam/male/hospital/midwife/3600 gram

HISTORY OF CONTRACEPTION: injection contraception (3 month) since 6 month ago

NEXT FAMILY PLANNING: injection

MENARCHE: 14 y.o
HISTORY OF MENSTRUATION CYCLE: 1 x every month, 28 days cycle, reguler,
duration 7 days, no complaints

FIRST DAY OF LAST MENSTRUATION: nowadays

26/01/2021 OBJECTIVE
02/02/2021 GENERAL STATUS: LOCAL STATUS:
10.00 WITA GC: good Eye: anemic -/-, icteric -/-
VK GCS: E4V5M6 Cor: S1 S2 single reguler, murmur (-), gallop (-)
BP: 110/70 mmHg Pulmo :Vesiculer (+/+), rhonki (-/-), wheezing (-/-)
HR: 80 bpm Abdomen: enlargement (-), scar (-)
RR: 22 x/minute Extremity: edema - ,- warm acral (+/+)
Temp: 36,4 C - -
SpO2: 98% O2 3 lpm

Body Weight: 48
Body Height: 154 cm
BMI: 20,5 kg/m2
 OBJECTIVE
01/02/2021
10.00 WITA OBSTETRICAL STATUS:
VK Abdominal examination :
• Inspection: distention (-), striae gravidarum (-), scar (+) vertical line,
linea nigra (-)
• Palpation: mass (-), tenderness (-)
• Percussion : typmhany in all quadrant
• Auscultation:
bowel sound (+) 10x/minutes, Metalic sound (-)
 OBJECTIVE
02/02/2021 OBSTETRICAL STATUS:
10.00 WITA Genitalia Examination:
VK Inspection :
• Pubic area : growth hair pubic normal, excoriasi (-), inflamation (-)
• Vulva area : Lesion (-), mass (-), inflamation (-)
• OUE : normal
• Mayor and minor labia : inflamation (-), gland bartholin swelling (-)
• Perineum : lesion (-), scar (-)
• Vaginal introitus : cicatrix at 6 o’clock (+), examiner finger can only enter up to
the tip of the little finger (± 1 cm) bleeding (-).

Inspeculo : not evaluated

VT : not evaluated
Laboratory (20/01/2021)
Parameter Nilai Nilai rujukan

Hematology
HGB 11.6 11,5-16,5
WBC 10.210 4000-10000
RBC 4,29 3,5-5,5
PLT 405000 150000-400000
HCT 36 36 - 48
MCV 84.4 80,0-100,0
MCH 27 26,0-34,0
MCHC 32 32,0-36,0
Hemostatic
PT 14.4 11.5 – 15.5
APTT 31.7 28.0 – 38.0
Laboratory (23/01/2021)
Parameter Nilai Nilai rujukan

Blood Glucose
GDS 86 70-140
Renal Function
Ureum 15 10 - 50
Creatinin 0.7 0.6 – 1.1
Liver Function
SGOT 12 0 – 40
SGPT 13 0 - 41
Albumin 4.3 3.8 – 5.5
Laboratory (20/01/2021)
Parameter Nilai Nilai rujukan

Electrolite
Natrium 142 135-146
Kalium 3.2 3,5-5,1
Klorida 107 95 – 108
Laboratory (20/01/2021)
Parameter Nilai Nilai rujukan

Imuno- serology
HIV Rapid Non reactive -
Hepatitis
HBsAg Non Reactive -
 ASSESMENT
02/02/2021 • Introitus vaginal cicatrix
10.00 WITA
VK

PLANNING
Planning Therapy:
Pro Vaginal Reparation
IDENTITY
NAME: Mrs. HM
AGE: 28 years old
ADRESS: Gondang, KLU
CASE 2
ADMITTED: 4th February 2021
MR NUMBER: 169105
 SUBJECTIVE
04/02/2021 MAIN COMPLAINT: Vaginal Bleeding
13.00 WITA PRESENT MEDICAL HISTORY:
Patient G2P1A0H1 came to Obstetric and Gynecological Clinic in West Nusa Tenggara Hospital
VK
with vaginal bleeding since 3 weeks ago. The characteristic of bleeding was Spontaneous, Redish,
and watery with the volume was about ± 80 cc (2 bandage). Patient didn’t experience any pain
when bleeding occurs.
Previously the patient checked his complaint at the Tanjung KLU Hospital and received a blood
supplement tablet.
The other complaint such as vaginal discharge (-), fever (-), malaise (-),

PAST MEDICAL HISTORY:

Similar complaint (-). Trauma (-), Surgery (+) SC 7 years ago, Hypertension (-),DM (-), Allergy (-)

HISTORY OF FAMILY DISEASE:

Hypertension (-) , DM (-), Asthma (-), TB (-), Allergic (-), same complaint (-)
 SUBJECTIVE
04/02/2021 OBSTETRIC HISTORY:
13.00 WITA 1. 2013/premature/SC/hospital/Doctors/2300 grams
VK 2. This pregnancy

HISTORY OF CONTRACEPTION: injection (3 months)

NEXT FAMILY PLANNING: injection contraception

MENARCHE: 12 y.o
HISTORY OF MENSTRUATION CYCLE: 1 x every month, 28 days cycle, reguler,
duration 8 days, no complaints

FIRST DAY OF LAST MENSTRUATION : 5th May 2020

 OBJECTIVE
04/02/2021 GENERAL STATUS: LOCAL STATUS:
13.00 WITA GC: good Eye: anemic -/-, icteric -/-
VK GCS: E4V5M6 Cor: S1 S2 single reguler, murmur (-), gallop (-)
BP: 110/70 mmHg Pulmo :Vesiculer (+/+), rhonki (-/-), wheezing (-/-)
HR: 82 bpm Abdomen: Enlargement (+), intestinal sound(+) normal,
RR: 18 x/minute pain on palpation (-), scar (+)
Temp: 36,6 C
_ _
SpO2: 99% Room Air Extremity: edema ,_warm acral + +
_ +
+
Body Weight: 85 Kg
Body Height: 143 cm
BMI: 42,4 kg/cm²
 OBJECTIVE
04/02/2021
13.00 WITA OBSTETRICAL STATUS:
VK Abdominal examination :
• Inspection: distention (+), striae gravidarum (+), scar (+) linier, linea
nigra (+)
• Palpation:
Fundus height: 34 cm
Leopold I: Breech
Leopold II: Back on the right side
Leopold III: Head
Leopold IV: hasn't entered the pelvis yet (5/5)
• Auscultation:
Fetal Heart Beat: 12-12-11 (140 bpm)
• EFW: 3.255 grams
 OBJECTIVE
04/02/2021 OBSTETRICAL STATUS:
13.00 WITA Genitalia Examination:
VK Inspection :
• Pubic area : growth hair pubic normal, excoriasi (-), inflamation (-)
• Vulva area : Lesion (-), mass (-), inflamation (-)
• OUE : normal
• Mayor and minor labia : inflamation (-), gland bartholin swelling (-)
• Perineum : lesion (-), scar (-)
• Vaginal introitus : bleeding (-)

Inspeculo : the surface of the portion and the vaginal canal is smooth, dilated
cervix (-), vaginal discharge and bleeding (-)
VT : not evaluated
Laboratory (03/02/2021)
Parameter Nilai Nilai rujukan

Hematology
HGB 11.9 11,5-16,5
WBC 9460 4000-10000
RBC 4,13 3,5-5,5
PLT 428000 150000-400000
HCT 38 36 - 48
MCV 91.5 80,0-100,0
MCH 28.9 26,0-34,0
MCHC 31.6 32,0-36,0
Hemostatic
PT 12.9 11.5 – 15.3
APTT 28.3 28.0 – 38.0
Laboratory (03/02/2021)
Parameter Nilai Nilai rujukan

Blood Glucose
GDS 95 70-140
Renal Function
Ureum 15 10 – 50
Creatinin 0.6 0.6 – 1.1
Liver Function
SGOT 20 0 – 0.40
SGPT 12 0 – 0.41
Laboratory (03/02/2021)
Elektrolit
Natrium 142 135-146
Kalium 4,6 3,4-5,4
Chloride 106 95-108
Laboratory (19/12/2020)
Parameter Nilai Nilai rujukan

Imuno-serology
HBsAg Non reactive -
USG (8/12/2021)
USG (30/01/2021)
USG (16/01/2021)
USG
CTG
 ASSESMENT
04/02/2021 • G2P1A0H1 (38 – 39 weeks) with placenta previa + obesity
13.40 WITA
VK

PLANNING
Planning Therapy: Planning Observation:
Pro Sectio Caesarean • Monitoring vital sign
• Monitoring of bleeding
KIA
DISCUSSION
THANK YOU