MORNING REPORT COASS

MAY, 19TH 2017

Case : Placenta Previa

Totalis
Supervisor : Dr. dr. Edy Mustofa,
Sp.OG(K)

Coass :
Bisma Dewanto
Khoirul Hakiem
Yuan Laura
Tiara Amalia
 PATIENT IDENTITY :
Register number : 11342337
Name : Mrs. Paini
Age : 40 y.o
Occupation : -
Husband : Mr. M Zaini
Age : 45 y.o
Occupation : kuli bangunan
Address : kampung Anyar RT 07/01 Malang
Arrive at ER : 12-05-2017 23.00
 SUBJECTIVE
Mrs. Paina / 40 y.o / G4P3002Ab000 / Married 1x, 23 years / AT
17 y.o / HPHT 17-9-2016 / gr 34-36 weeks S/L
Chief complaint :
 Bloody discharge from birth canal
Patient referred to RSSA from permata bunda Hospital with
suspect placenta previa totalis and chronic hypertension
12-5-2017
07.00
Patient complaining about bloody discharge from birth
canal, patient stayed at home
21.30
Patient complaining about bloody discharge from birth
canal getting worse. Patient decided to go to Permata
Bunda Hospital. From examination, bp : 160/90 &
protein dipstick (-). Patient advised to be referred to
RSSA, patient family discuss.
23.00
Patient arrived at ER RSSA.
PATIENT HISTORY
o Hypertension since 5 years ago, patient never take
any medication
oHistory of nausea, vomiting, dizziness, blurry vision(-),
epigastric pain (-)
oHistory of coitus (+) 2 days ago
oHistory of traditional massage(-)
 OBJECTIVE
General condition good
Bp : 140/90 mmHg
Hr : 80x/mnt reguler
RR : 18x/mnt GE : Flux (+) minimum.
Head/neck : normocephaly, Insp : flux (+) minimum, POMP
anemic conjungtiva (-/-), icteric closed slippery/glossy/smooth.
sclera -/- Birth canal laceration(-), Varices
(-)
Tho : c/ S1 S2 single, murmur
(-) VT : not performed
L/ Rh(-) wh(-)
Abd : TFU : 27 cm, longitudinal
position U, TBJ : 2170 g, DJJ :
150x/mnt, His (+) rare.
LABORATORY
Examination Result Normal value
Hemoglobin (Hb) 9,4 g/dL 11.4-15.1
Eritrosit (RBC) 3,17 x 106/µL 4.0-5.0
Leukosit (WBC) 10.98 x 106/µl 4.7-11.3
Hematokrit 27.90 % 38-42
Trombosit (PLT) 225 x 103/µl 142-424
MCV 88.00 fL 80-93
MCH 29.70 pg 27-31
MCHC 33.70 g/dL 32-36
RDW 14.60 % 11.5-14.5
PDW 11.4 fL 9-13
Examination Result Normal value
MPV 10.4 fL 7.2-11.1
P-LCR 28.4 % 15.0-25.0
PCT 0.23 % 0.150-0.400
Blood count
Eosinophil 1.6 % 0-4
Basophil 0.3 % 0.1
Neutrophil 78.1 % 51-67
Lymphosit 13.6 % 25-33
Monosit 6.4 % 2-5
Faal hemostatic
PPT
patient 9.30 seconds 9.4-11.3
control 10.90 seconds
INR 0.89 <1.5
 Examination Result Normal value
APTT
patient 27.60 seconds 24.6-30.6
control 26.1 seconds
Clinical chemistry
Liver faal
AST/SGOT 17 U/L 0-32
ALT/SGPT 9 U/L 0-33
Albumin 3.12 g/dL 3.5-5.5
Carbohydrate
metabolism
GDS 94 mg/dL <200

Faal Kidney
Ureum 11.80 mg/dL 16.6-48.5
Creatine 0.45 mg/dL <1.2
Rapid test HIV
URINALISYS
Examination Result Normal value
Cloudiness Clear
Color Yellow
pH 7.0 4.5-8.0
Density <=1.005 1.005-1.030
Glucose Negative Negative
Protein Negative Negative
Keton Negative Negative
Bilirubin Negative Negative
Urobilinogen Negative Negative
Nitrit Negative Negative
Leucocyte Negative Negative
Blood Trace-intact Negative
 Examination Result Normal value
10x
Epithel 0.7 /LPK ≤3
Silinder Negative
Hialin - ≤2
Berbutir - Negative
Silinder Leucocyte -
Silinder erytrocyte -
Lain – lain -
40x
Eritrocyte 0.7 /LPB ≤3
Eumorphic -
Dismorphic -
Leucocyte 0.2 /LPB ≤5
Crystal -
Bacteria 216.8 x 103/ml ≤93 x 103 ml
Examination Result Normal value
Bacteria <= 93 x 103/ml
Others
Natrium (Na) 137 mmol/L 136-145
Kalium (K) 3.66 mmol/L 3.5-5.0
Cloride (Cl) 117 mmol/L 98-106
NST
Baseline rate : 150 bpm
Variable : 5-15
Acceleracy (+)
Decceleracy (-)
Category I
USG
Tampak janin intrauterine T/H
Letak bujur kepala di bawah
BPD = 86.2 mm 34 WSD
AC = 292 mm 33 WID
FL = 299 mm 33 WOD
EFW = 2267
Placenta di corpus anterior gr II
ASSESSMENT
G4P3002Ab000 gr. 34-36 weeks S/L
APB ec Placenta previa totalis
Chronic hypertension
Age >35 y.o
Anemia
UTI asymtomatic
PLANNING
PDx : USG FetoMaternal, complete laboratory assessment
PTx :
- perbaikan konservatif dengan induksi maturasi paru dengan dexamethasone
2 x 10 mg selama 24 jam
- bed rest
- inj gentamycin 2 x 1 (?)
- tokolitik kultropin sup II (?)
- asam mefenamat 3 X 1 (?)
- isoxsuprin 3 x 1 (?)
- SF 2 x 1 (?)
Bila TD > 160/110 diberikan nifedipin 3 x 10 dan metildopa 3 x 500
Bila konservatif gagal, maka akan dilakukan pro sc cito
Pmo : observasi vital signs dan fluxus
THANK YOU