Morning Report

09 May 2016
Supervisor : dr. Edi P. W. ,
SpOG
DM : Ayu, Brian, Ida, Liya,
Martina, Nabila, Sani

Case 1

Name : Miss J
Age : 13 years old
RM : 577980
Address : Pringgarata
Admitted : 09th May 2016

Time

Subject

09th May
2016

Patient referred from Pringgarata

PHC with ovarian cyst. Patient
confessed abdominal pain in the
lower abdomen (+) since 10
month ago, but the pain became
more severe since 2 day ago,
fever (+) since 2 days ago, vomit
and nausea (+) since 2 days ago,
bleeding intra vaginal (-), the
patient confessed difficulty in
bowel movement, urination (+).

15.45

History of DM (-), HT (-), asthma

(-), allergy (-).
History of menarche: (-)
History of USG : 1x at Sp.OG
Last time (12/04/2016)
Result: Ovarian cyst 10 cm.

Object
General status
GC : moderate
Consciousness: CM
BP : 100/70 mmHg
PR: 128 tpm
RR: 22 tpm
T: 37,9C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen :
Inspection: mass (+) at
umbilical region, scar (-).
Auscultation: abdominal
contraction (+) 8x/m.
Percussion: dullness in the
umbilical region. Tympanic
sound in the other region.
Palpation: mass (+) in
umbilical region 10 cm,
consistency hard solid,
tenderness (-), immobile.
Extremity : edema (-/-), warm
acral (+/+).

Assessment
Ovarian Cyst

Planning
DM Planning:
Diagnostic:
Repeat USG
Therapy:
Cefotaxime inj. 2 gr.
PCT tab 500 mg.
Pro-Laparatomy
DM co to GP, GP co to
SPV, SPV advice:
Repeat the USG
tomorrow morning.

Time

Subject

Object
Lab (09/05/2016):
HB:
RBC:
HCT:
WBC:
PLT:
HbsAg: (-)

Assessment

Planning

Time
09/05/
2016
08.00

Subject
Chronology at Peringgarata PHC
(07/05/2016):
S:
Patient confessed abdominal pain
(+), vomit and nausea (+).
O:
General status
Consciousness: CM
BP : 110/60 mmHg,
PR : 84 ppm,
RR : 22 rpm,
T : 36, 8 C.
A:
Ovarian Cyst
P:
-

IVFD: D5 % 3 fls
PCT tab 500 mg
Antacid tab 500 mg
Inj. Ranitidine 1 amp
Inj. Ketorolac 1 amp

Object

Assessment

Planning

Time
17.45

10/05/2016
06.00

Subjective

Objective

Assessment

Planning

Abdominal pain in the

lower abdomen (+),
fever (+).

General status
GC : moderate
Consciousness: CM
BP : 100/70 mmHg
PR: 128 tpm
RR: 22 tpm
T: 37,9C

Ovarian Cyst

Moved to Segara Anak

Abdominal pain in the

lower abdomen (+)
minimal

GC : well
GCS: CM (E4V5M6)
BP : 110/70mmHg
PR: 84 x/m
RR: 20 x/m
T: 37C

Ovarian Cyst

Diagnostic:
Repeat USG
Therapy:
Cefotaxime inj. 2 gr.
PCT tab 500 mg.
Pro-Laparatomy

Case 4

Name : Mrs. R
Age : 35 years old
RM : 12-80-76
Address : Babakan Timur, Sandubaya
Admitted : 10th May 2016

Time
10th May
2016
00.30

Subject
Patient came to NTB GH by her
own with G3P2A0L2 33-34
weeks S/L/IU head presentation
with PPI + Polihidramnion.
Patient confessed bloody slime
(+) since 16.00 (09/05/2016),
abdominal pain (+) since 21.00
(09/05/2016), water leaked from
her womb (-), FM (+).
History of DM (-), HT (-), asthma
(-), allergy (-).
Family history: DM (-), HT (+)
mother, asthma (-)
LMP : 15 / 09 / 2015
EDD : 22 / 06 / 2016
GW : 33-34 weeks
History ANC : 9x at PHC
Last ANC: 07-05-2016,
Result GW 34 weeks, BP :
120/80 mmHg, BW: 64 kg, head
presentation, UFH: 32cm, FHB
(+) 11-11-11, edema (-).
History of USG : 1x at Sp.OG
Last USG: 27/04/2016
Result: S/L/IU 28-29 weeks, EFW
1283 gr/ male, polihidramnion,
EDD 14/07/16.
History of family planning: inj 3
month
Next family planning: IUD

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on right side
L3 : head
L4 : 5/5
UFH : 34 cm
EFW : 3400 gr
FHB: 12-12-12
UC : 1 x 10 ~ 25
VT : 2cm, eff 25%, amnion
(+), head still high.

Assessment
G3P2A0L2 33-34
weeks S/L/IU head
presentation with
PPI +
Polihidramnion.

Planning
DM Planning:
Diagnostic:
CBC
Therapy:
Ceftriaxone inj. 2 gr.
Dexamethasone 6
mg/ 12 hours
Nifedipin
Monitoring:
Obs. Mother and
fetal well being.
DM co to GP, GP co to
SPV, SPV advice:
Obs. Mother and
fetal well being.
Antibiotic
Ceftriaxone 1 gr/12
hours
Dexamethasone 6
mg/ 12 hours
Bufadilon 3x10mg.

Time

Subject
Obstetric history:
1. Aterm/ Spontaneously/ 3100
gr/ female/ PHC/ 16 y.o./ Alive
2. Aterm/ Spontaneously/ 3300
gr/ male/ PHC/ 10 y.o./ Alive
3. This

Object
Lab (10/05/2016):
HB: 11,1
RBC: 3,78
HCT: 34.0
WBC: 14,0
PLT: 265
HbsAg: (-)

Assessment

Planning

Time

Subject

Object

02.00

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

02.30

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

03.00

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

03.30

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

Assessment

Planning

Time

Subject

Object

04.00

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

04.30

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

05.00

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

05.30

Confessed abdominal pain (+)

GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

Assessment

Planning

Time
06.00

Subject
Confessed abdominal pain (+)

Object
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,5C
FHB: 12-12-12
UC : 1 x 10 ~ 25

Assessment

Planning