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 Object Assessment Planning
09th May Patient referred from Pringgarata General status Ovarian Cyst DM Planning:
2016 PHC with ovarian cyst. Patient GC : moderate Diagnostic:
confessed abdominal pain in the Consciousness: CM Repeat USG
15.45 lower abdomen (+) since 10 BP : 100/70 mmHg
month ago, but the pain became PR: 128 tpm Therapy:
more severe since 2 day ago, RR: 22 tpm Cefotaxime inj. 2 gr.
fever (+) since 2 days ago, vomit T: 37,9C PCT tab 500 mg.
and nausea (+) since 2 days ago, Pro-Laparatomy
bleeding intra vaginal (-), the Local status
patient confessed difficulty in Eye : anemic -/-, icteric -/- DM co to GP, GP co to
bowel movement, urination (+). Cor : S1S2 single regular, SPV, SPV advice:
murmur (-), gallop (-). Repeat the USG
History of DM (-), HT (-), asthma Pulmo : vesicular (+/+), tomorrow morning.
(-), allergy (-). wheezing (-/-),
rhonchi (-/-).
History of menarche: (-) Abdomen :
Inspection: mass (+) at
History of USG : 1x at Sp.OG umbilical region, scar (-).
Last time (12/04/2016) Auscultation: abdominal
Result: Ovarian cyst 10 cm. 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 (+/+).
Time Subject Object Assessment Planning
Lab (09/05/2016):
HB:
RBC:
HCT:
WBC:
PLT:
HbsAg: (-)
 Time Subject Object Assessment Planning
09/05/ Chronology at Peringgarata PHC
2016
(07/05/2016):
08.00 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
 Time Subjective Objective Assessment Planning
17.45 Abdominal pain in the General status Ovarian Cyst Moved to Segara Anak
lower abdomen (+), GC : moderate
fever (+). Consciousness: CM
BP : 100/70 mmHg
PR: 128 tpm
RR: 22 tpm
T: 37,9C

10/05/2016 Abdominal pain in the GC : well Ovarian Cyst Diagnostic:

06.00 lower abdomen (+) GCS: CM (E4V5M6) Repeat USG
minimal BP : 110/70mmHg
PR: 84 x/m Therapy:
RR: 20 x/m Cefotaxime inj. 2 gr.
T: 37C 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 Subject Object Assessment Planning
10th May Patient came to NTB GH by her General status G3P2A0L2 33-34 DM Planning:
2016 own with G3P2A0L2 33-34 GC : well weeks S/L/IU head Diagnostic:
weeks S/L/IU head presentation Consciousness: CM presentation with CBC
00.30 with PPI + Polihidramnion. BP : 120/80 mmHg PPI +
Patient confessed bloody slime PR: 84 tpm Polihidramnion. Therapy:
(+) since 16.00 (09/05/2016), RR: 20 tpm Ceftriaxone inj. 2 gr.
abdominal pain (+) since 21.00 T: 36,5C Dexamethasone 6
(09/05/2016), water leaked from mg/ 12 hours
her womb (-), FM (+). Local status Nifedipin
History of DM (-), HT (-), asthma Eye : anemic -/-, icteric -/-
(-), allergy (-). Cor : S1S2 single regular, Monitoring:
Family history: DM (-), HT (+) murmur (-), gallop (-). Obs. Mother and
mother, asthma (-) Pulmo : vesicular (+/+), fetal well being.
wheezing (-/-),
LMP : 15 / 09 / 2015 rhonchi (-/-). DM co to GP, GP co to
EDD : 22 / 06 / 2016 Abdomen : scar (-), striae (+), SPV, SPV advice:
GW : 33-34 weeks linea nigra (+). Obs. Mother and
Extremity : edema (-/-), warm fetal well being.
History ANC : 9x at PHC acral (+/+). Antibiotic
Last ANC: 07-05-2016, Ceftriaxone 1 gr/12
Result GW 34 weeks, BP : Obstetric status hours
120/80 mmHg, BW: 64 kg, head L1 : breech Dexamethasone 6
presentation, UFH: 32cm, FHB L2 : back on right side mg/ 12 hours
(+) 11-11-11, edema (-). L3 : head Bufadilon 3x10mg.
L4 : 5/5
History of USG : 1x at Sp.OG UFH : 34 cm
Last USG: 27/04/2016 EFW : 3400 gr
Result: S/L/IU 28-29 weeks, EFW FHB: 12-12-12
1283 gr/ male, polihidramnion, UC : 1 x 10 ~ 25
EDD 14/07/16.
VT : 2cm, eff 25%, amnion
History of family planning: inj 3 (+), head still high.
month
Next family planning: IUD
Time Subject Object Assessment Planning
Obstetric history: Lab (10/05/2016):
1. Aterm/ Spontaneously/ 3100 HB: 11,1
gr/ female/ PHC/ 16 y.o./ Alive RBC: 3,78
2. Aterm/ Spontaneously/ 3300 HCT: 34.0
gr/ male/ PHC/ 10 y.o./ Alive WBC: 14,0
3. This PLT: 265
HbsAg: (-)
 Time Subject Object Assessment Planning
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
 Time Subject Object Assessment Planning
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
 Time Subject Object Assessment Planning
06.00 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