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Coassistent: 1. Dino Luthfi Jauhar 2. Fernanda Pangestu 3. M.Rizki Idriansyah

1. The morning report summarizes a 38-year-old pregnant patient, Mrs. J, admitted to the obstetrics and gynecology department with complaints of bleeding from her genitals for two weeks accompanied by abdominal pain. 2. Laboratory tests indicate anemia with a hemoglobin level of 11.1 g/dL. Ultrasound shows signs of abortion. 3. The diagnosis is suspected abortion. The treatment plan is intravenous fluid replacement and folate supplementation, with consultation to the perinatology department and monitoring of vital signs and uterine bleeding.

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Fernanda Pangestu
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67 views12 pages

Coassistent: 1. Dino Luthfi Jauhar 2. Fernanda Pangestu 3. M.Rizki Idriansyah

1. The morning report summarizes a 38-year-old pregnant patient, Mrs. J, admitted to the obstetrics and gynecology department with complaints of bleeding from her genitals for two weeks accompanied by abdominal pain. 2. Laboratory tests indicate anemia with a hemoglobin level of 11.1 g/dL. Ultrasound shows signs of abortion. 3. The diagnosis is suspected abortion. The treatment plan is intravenous fluid replacement and folate supplementation, with consultation to the perinatology department and monitoring of vital signs and uterine bleeding.

Uploaded by

Fernanda Pangestu
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We take content rights seriously. If you suspect this is your content, claim it here.
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OBSTETRICS & GYNECOLOGY DEPARTMENT

MORNING REPORT (Ward)


Thursday, Desember 23th 2021

Coassistent :

1. Dino Luthfi Jauhar


2. Fernanda Pangestu
3. M.Rizki Idriansyah

Department of Obstetrics and Gynecology


RSU Haji Medan
2021
New Patient

1. Mrs. J 38 y.o, G5P3A2


Diagnosis : Sus Abortus
Supervisor : dr. Putri Aini Daulay, M.Ked(OG), SpOG
Planning : Curretage
PATIENT 1
Mrs. J, 38 y.o, G5P3A2, Javanese, Moeslem, Junior High School,
housewife, married to Mr. I, 40 y.o, Javanese, Moeslem, senior high
school, Laborer. The patient was admitted to RSU Haji Medan on
Desember 21th 2021, at 22.00 with:

Cc : blood coming out of the genitals.


Review : Bleeding from the genitals since 2 weeks is accompanied
by abdominal pain, nausea, profuse bleeding, the
patient is pregnant with her fifth child
History of Previous illness :-
History of Medication :-
History of Surgery :-
History of contraception :-
LMP : 27 – 09 - 2021
EDD :-
ANC : Nurse
History of pregnancy :
1. Baby boy, premature, clinic, 17 years a go, passed away
2. Baby Girl, 2700gr, aterm, SVD, Midwife, clinic, 14 years old,
Healthy.
3. Baby girl, 3000gr, arerm, SVD, Clinic, 9 years old, healthy
4. Abortus
5. this pregnancy
Present state
Cons: CM Anemic : (-)
BP : 117/80 mmHg Icteric : (-)
Pulse : 80x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 36,5°C Edema : (-)

General state : Good


Nutritional state : normoweight (BW: 50 kg, BL: 155 cm)
Illness State : Moderate
Generelize State
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
• Abdomen: Hepar and Lien not palpable
• Extremities sup/inf : Edema (-), Cyanosis : (-)
Obstetrical State
• Abdomen : Asymmetrically enlarged, linea nigra (+), striae gravidarum (-)
• Vaginal Bleeding : (+)
• Micturition : (+) normaly
• Defecation : (+) Normal

Gynecological State
Inspeculo : blood (-), Mucus (-), Lividae (-)
TVS
Desemmber, 21th 2021 at 16:06
Laboratory Findings
Desember, 21th 2021
PEMERIKSAAN HASIL NILAI RUJUKAN
HEMATOLOGI
Darah Lengkap
- Hemoglobin 11,1 11.7 – 15.5 g/dL
- Hematokrit 34,9 37 – 45 %
- Leukosit 10,10 4 – 11 ribu/mm3
- Trombosit 262 150 – 440 ribu/mm3
- Eritrosit 3,72 4.00 – 5.00 juta/uL
- PDW 16.0 9.0 – 13.0 fL
- RDW-CV 13,8 11.5 – 14.5 %
- MPV 10,9 7.2 – 11.1 fL
- PCT 0.265 0.150 – 0.400 %
Indeks Eritrosit
- MCV 92 80 – 100 fL
- MCH 30 26 – 34 pg
- MCHC 33 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 1 1–3%
- Neutrofil Segmen 76 50 – 70 %
- Limfosit 20 20 – 45 %
- Monosit 4 4–8%
Laboratory Findings
November, 19th 2021

PEMERIKSAAN HASIL NILAI RUJUKAN


Jumlah Total Sel
- Total Lymphosit 2.00 0.58 – 4.47 ribu/uL
- Total Basofil 0.01 0 - 0.1 ribu/uL
- Total Monosit 0.35 0.17 – 1.22 ribu/uL
- Total Eosinofil 0.07 0 - 0.61 ribu/uL
- Total Neutrofil 7,7 1.88 – 7.82 ribu/uL

HEMOSTASIS
- Masa Pendarahan (BT) 2 1 – 3 menit
- Masa Pembekuan (CT) 4 2 – 6 menit

KIMIA KLINIK
Karbohidrat
- Glukosa Darah Adrandom <200 mg/dL

IMUNOSEROLOGI
- Swab Antigen Rapid covid19 Negatif Negatif
Hepatitis Marker
- HBsAg Negatif Negatif
- HIV Non reaktif Non Reaktif
Diagnosis:
 Pua (abnormal uterine bleeding).

Therapy:
• IVFD RL 20 dpm
• As Folat 1x1

Planning:
Consult to Perinatology Dept.

Monitoring
Monitoring vital sign, uterine Bleeding.
THANK YOU

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