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    Morning Report Departement of Obstetric and Gynecology: April 10 2017

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    Deasy Arindi Putri
    Ms. A, a 26-year-old woman, presented to the hospital with lower abdominal contractions every 5 minutes and clear fluid discharge from her vagina for 6.5 hours. On examination, she was found to be 36 weeks pregnant with ruptured membranes and a urinary tract infection. She was given intravenous fluids and misoprostol vaginally to induce labor and monitored for her vital signs, complaints and progression of labor.

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    Morning Report Departement of Obstetric and Gynecology: April 10 2017

    Uploaded by

    Deasy Arindi Putri
    42 views14 pages
    Ms. A, a 26-year-old woman, presented to the hospital with lower abdominal contractions every 5 minutes and clear fluid discharge from her vagina for 6.5 hours. On examination, she was found to be 36 weeks pregnant with ruptured membranes and a urinary tract infection. She was given intravenous fluids and misoprostol vaginally to induce labor and monitored for her vital signs, complaints and progression of labor.

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    Ms. A, a 26-year-old woman, presented to the hospital with lower abdominal contractions every 5 minutes and clear fluid discharge from her vagina for 6.5 hours. On examination, she was found to be 36 weeks pregnant with ruptured membranes and a urinary tract infection. She was given intravenous fluids and misoprostol vaginally to induce labor and monitored for her vital signs, complaints and progression of labor.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    42 views14 pages

    Morning Report Departement of Obstetric and Gynecology: April 10 2017

    Uploaded by

    Deasy Arindi Putri
    Ms. A, a 26-year-old woman, presented to the hospital with lower abdominal contractions every 5 minutes and clear fluid discharge from her vagina for 6.5 hours. On examination, she was found to be 36 weeks pregnant with ruptured membranes and a urinary tract infection. She was given intravenous fluids and misoprostol vaginally to induce labor and monitored for her vital signs, complaints and progression of labor.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 14

    MORNING REPORT

    Departement of Obstetric and


    Gynecology

    April 10th 2017


    Identity
    Name: Ms. A
    Age: 26 years old
    Address: Lamongan
    Date examination: April 10th 2017
    Anamnesis
    Chief complain: abdominal contraction
    Present Illness History: patient came with lower
    abdominal contraction since yesterday, the time
    between every contractions is 5 minutes. Patient also
    complained clear fluid came out from her vagina
    since 6.5 hours before admission. nausea and
    vomiting (-). watering and defecation within normal
    limit. Appetite within normal limit.

    HPHT:
    Patient forgot her first day of last period (but she just
    remember the months (july 2016)/
    Menarche 15th years old/Cycle 28
    days/7days/dismenorhea (+)
    Previous Illness History: allergy (-), asthma (-),
    DM (-), HT (-)
    Familly Illness History: allergy (-), asthma (-),
    DM (-), HT (-)
    Social Illness History: smoking (-), alcohol (-),
    consumption drug or herbal medicine (-)

    Gynecology history: menarche : 15 years old,


    usually 7 days), Dismenorhea (+)
    Primary Survey
    A: clear, gargling (-), snoring (-), speak
    fluently (+), potential obstruction (-)
    B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh
    -/-, SaO2 98 % without O2 support
    C: akral warm dry red, CRT <2, PR 104
    x/mnt, BP 131/82 mmHg
    D: GCS 456, lateralisasi -, PBI 3mm/3mm
    E: temp 36,7 C
    Secondary Survey
    GCS 456
    H/N: aicd
    Tho: sim, ret -/-
    P: ves/ves; rh -/-, wh -/-
    C: S1S2 single, murmur -, gallop
    Abd:flat, soepel, H/L not palpable,
    meteorismus (-), BU (+) N, mc burney sign
    (-), rovsing sign (-), psoas sign (-), blumberg
    sign (-)
    Ext: aie -, acral warm dry red
    Pmx obs
    Leopold:
    L1: TFU 39cm, rounded, puffy, appearance
    like gluteus
    L2: DJJ: 127x/m, right back
    L3: Rounded and hard,app like head, not
    yet insert in to PAP
    L4: 5/5 convergen
    VT obs : 1cm
    Planning Dx
    DL
    UL
    NST
    Laboratory Findings
    GDA MCV 83.3
    79
    Metode 1 non reactive MCH 26
    HbsAg (-) MCHC 32
    PT 10,30 Trombosit
    APTT 29,40 279
    Leukosit 12.1 LED 1 77
    Neutrofil 57 LED 2 94
    Limfosit 19
    Monosit 8.9
    Eritrosit 4.42
    Hb 11.9
    UL
    Glukosa (-) Eritrosit urine
    Bilirubin (-) (+2)
    Keton urin (++) Leukosit urine
    Darah (+) (+2)
    PH 6.5 Parasit urne
    Protein (-) (-)
    Bakteri (+)
    Cylinder eritrosit
    (-)
    Epitel (+ 5)
    Assesment
    G1P1A0 36weaks with primary rupture
    membranes
    UTI
    Therapy
    Inf RL 1500cc/24 hour
    Misoprostol 1/8 tab (250 mikrogram) per
    vaginam
    Monitoring
    General state
    Vital sign
    Patients complaints
    Development of labour
    Laboratory findings: leukosit
    Education
    Explain to patients and her family about :
    pregnancy, therapy to make delivery
    faster, complication and prognosis
    Explain to patients and her family about
    side effects of therapy

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