DM OBGYN G27

Bismillahirrahmanirrahim
Morning Report, 16-1-2018
List OB:
 Ny. F/ G1P0A0 UK 39-40 mgg + letsu/ dr. Eni, Sp.OG
 Ny. S / erosi cervix uteri / dr.Yanti, SpOG
 Ny. C / G1P0A0 UK 30-32 + PPI / dr.Yanti, SpOG
 Nn. N / massa abdomen / dr. Supratikto, SpOG (K)
 Ny. D/ G1P0A0 UK 40-41 / dr.Yanti, SpOG
Identity
 Name: Mrs. C
 Age: 29 yo
 Address: Lamongan
 Job: House wife
 Date examination: 15/01/2018
 Merried : 4 year ago
 Name: Mr. S
 Age: 30 yo
 Address: Lamongan
 Job : Swasta
Anamnesis
 Chief complain: Contraction of labour
 Present Illness History: Patients present with contraction of
labour at 04.00 WIB (4 hours before). Contraction of labour,
contiunously, bloody show and clear fluid flow (-). Nausea -,
vomit -, dizziness -, hardly to pee (anyang-anyangan) in
trimester III
 Previous Illness History: HT(-), DM(-), food allergy(+),
asthma(-)
 Familly Illness History: DM(-), HT(-)
 Social Illness History: smoking, alcohol(-), consumption drug
or herbal (-)
 HPHT: June 03 2017  UK: 30-32 mgg
 HPL: 11 April 2018
 ANC: 4 times, routine in midwife
 Menstruation History:
- Menarche 13 years old, regular, for 6-7 days, 27-30 days
cycles, disminorhea (+), flour albus (-)
 Obsetrics History:
- Female/2,5 kg/preterm/SpOG/SC
- This pregnancy
 Contraception (-)
 Operation: SC
Primary Survey
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh -/-, SaO2
100% without O2 support
 C: akral warm dry red, CRT <2”, PR 87 x/mnt, BP
118/67mmHg
 D: GCS 456, lateralisasi -, PBI 3mm/3mm
 E: temp 36 C
Secondary Survey
 GCS 456
 H/N: aicd –
 Tho: sim, ret -/-
P: ves/ves; rh -/-, wh -/-
C: S1S2 single, murmur -, gallop –
 Abd: gravid +
 Ext: aie -, akral warm dry red
Status gynekologi
 Genitalia eksterna: rambut pubis +, bloody show +,
perineum menonjol +
 Genitalia interna: Did not evaluated
 VT : pembukaan -, penipisan-, ketuban +, fluksus -, darah -
Status obstetric
 Leopold 1: TFU 25 cm, teraba bundar, lunak kesan bokong
 Leopold 2: puki, DJJ 124x/menit
 Leopold 3: teraba bulat keras kesan kepala, belum masuk PAP
 Leopold 4: 5/5 divergen
Planning Dx
 DL
 UL
Assesment
 G2 P1011 A000 UK 30-32 week T/H + PPI
Laboratory test
 GDA 102 mg/dl
 Leukosit 8.6 103/uL - Neutropil 82.7%
 Limposit 8.6 % - Monosit 3.8%
 Eosinopil 2.7 % - Basofil 2.2 %
 Eritrosit 3.88 106/uL - Hb 8.0 g/dL
 Hematokrit 26.0 % - MCV 68.6 fl
 MCH 20.60 pg - MCHC 30.10 g/dL
 RDW 16 % - Trombosit 277 103/uL
 MPV 4 fl - LED 1/2 jam 61/88
 HbsAg (-) - Metode 1 NR
Re-Assesment
 G2 P1011 A000 UK 30-32 week T/H + PPI

 Planning Dx : USG
Therapy
 IVFD RL 1500cc/24 hour
 Terbutalin drip 1 amp/500 cc  16 tpm
 Inj. Dexamethasone 3 amp IV/24 jam diulang lagi 3 amp
 C/ Sp.OG
Monitoring
 General state
 Vital sign
 Patients complaints
 Cek DL
Education
 Explain to patients and her family about : disease, therapy,
complication and prognosis
 Explain to patients and her family about side effects of
therapy and the consequences if such therapy is not done