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    Morning Report Obs Febris

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    Jessica
    Rahma Fauzia Al Erza

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    Morning Report Obs Febris

    Uploaded by

    Jessica
    42 views10 pages
    Rahma Fauzia Al Erza

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    Morning Report obs febris

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    Rahma Fauzia Al Erza

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    Download as pptx, pdf, or txt
    42 views10 pages

    Morning Report Obs Febris

    Uploaded by

    Jessica
    Rahma Fauzia Al Erza

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 10

    Obstetrics & Gynecology Department

    Morning Report (ward)


    Tuesday, September 20th 2022

    Coassistent :
    Rahma Fauzia Al Erza

    Departement of Obstetrics and Gynecology


    RSU Haji Medan
    2022
    New Patient

    Mrs. A, 22 y.o, G1P0A0


    Diagnosis : Obs. Febris+G1P0A0 +IUP(24)wga
    Supervisor : dr. A. Khuwalid Sp. OG
    Planning : Observation
    Mrs. A, 22y.o, G1P0A0, Moeslem, Senior High School, housewife,
    Married with Mr. S, 24 y.o, Moeslem, Senior High School, Worker,
    was admitted to RSU Haji Medan on September 19th 2022, 12.00
    wib with:

    CC : Fever and cough with phlegm


    Review : The patient came with complaints of fever since three
    days ago, and coughing up phlegm one week ago.
    History of Previous illness : stomach acid
    History of Medication : -
    History of Surgery :-
    LMP : 01 - 04 – 2022
    EDD : 23- 12 – 2023
    ANC : Obstetricians

    History of pregnancy :
    Present State

    Sens : Composmentis Anemic : (-)


    BP : 120/70 mmHg Icteric : (-)
    HR : 110 bpm Cyanosis : (-)
    RR : 20 times/min Dispnoe : (-)
    Temp : 39,4 °C Oedem : (-)

    General Condition : Moderate


    Nutrition State : Normal ( BB = 55kg, TB = 158cm)
    Disease Condition : Moderate

    Localized state
    Head : Anemic palpebra conjuctiva (-), icteric (-)
    Neck : within normal limits
    Thorax : Respiratory sound : Vesicular
    Additional sound : Wheezing(-)/(-), Rales (-)/(-)
    Abdomen : Hepar and Lien no abnormality
    Genitalia : within normal limit
    Ext Superior/Inferior: Oedem -/-, Cyanosis -/-
    Obstetric State
    • Abdomen : Asymmetrically enlarged
    • Leopold 1 : Fundal Height : 3 fingers Below Processus Xyphoideus
    • Leopold 2 : right: tension part, feels like board.
    left: feels like hand foot
    • Leopold 3 : head palpable
    • Leopold 4 : head has not entered the pelvic
    • Fetal movement : (+)
    • Fetal Heart rate : 132 bpm, regular
    • Uterine Contraction : (+)

    Gynecological State
    -
    Laboratory Findings
    september 19th 2022

    PEMERIKSAAN HASIL NILAI RUJUKAN


    HEMATOLOGI
    Darah Lengkap
    - Hemoglobin 11.9 11.7 – 15.5 g/dL
    - Hematokrit 35.4 37 – 45 %
    - Leukosit 13.50 4 – 11 ribu/mm3
    - Trombosit 191 150 – 440 ribu/mm3
    - Eritrosit 3.94 4.00 – 5.00 juta/uL
    - PDW 16.2 9.0 – 13.0 fL
    - RDW-CV 13.3 11.5 – 14.5 %
    - MPV 9 7.2 – 11.1 fL
    - PCT 0.171 0.150 – 0.400 %

    Indeks Eritrosit
    - MCV 90 80 – 100 fL
    - MCH 30 26 – 34 pg
    - MCHC 34 32 – 36 g/dL
    Hitung Jenis Lekosit
    - Basofil 0 0–1%
    - Eosinofil 0 1–3%
    - Neutrofil Segmen 85 50 – 70 %
    - Limfosit 11 20 – 45 %
    - Monosit 4 4–8%
    Laboratory Findings
    september 19th 2022
    PEMERIKSAAN HASIL NILAI RUJUKAN
    Total Sel
    Total Limfosit 1.48 0.58-4.47
    Total Basofil 0.00 0-0.1
    Total Monosit 0.51 0.17-1.22
    Total Eosinofil 0.05 0-0.61
    Total Neutrofil 11.4 1.88-7.82
    Diagnosis:
    Obs. Febris+G1P0A0 +IUP(24)wga

    Therapy:
    IVFD RL 30 dpm
    Cefixine 2x1 tab 200 mg
    Paracetamol 3x1

    Plan:
    Observation
    -measure vital signs
    -monitoring fetal heart rate
    THANK YOU

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