MORNING REPORT SEPTEMBER 8th 2011

Supervisor : dr. I Made Putra Juliawan, SpOG

Medical Student: Ika, Sinta, Maria, Eka, Husnul

Cases resume :

Normal Labor G1P0A0H0 7-8 week/S/L Rupture Ectopic Pregnancy 1.

1 1

Name Age Address

Time

: Mrs. H : 22 years old : Labuapi

CTH

: 25th September, 2011 At 13.00 wita

Subject
Patien came to GH with vaginal bleeding, since 13.00 (25/09/2011). Confessed 2 month pregnancy History of vaginal bleeding (+). Abdominal pain (-). LMP: 3/8/2011 EDD : 10/5/2012

Object

Assesment
Abortus iminens + Severe Anemia

Planning
Observe mother well beinng DL and HbSAg checked Coass consult to GP : Pro transfusion until Hb 10 gr/dl & pro USG tomorrow Move to melati

25/9/ 2011 13.00 wita

GC : well cons : E4V5M6 BP : 110/60 mmHg PR : 92 bpm RR : 18 tpm T : 36,7C Status generalis : Eye : anemic (+), icteric (-) Cor :S1S2 single reguler murmur (-), gallop (-) Pulmo : vesiculer (+/+), wh (-/-), rh (-/-) Abdomen : striae (-), Abdominal distention (-) Pain in abdominal palpation (-). Mass unpalpable. UFH unpalpable Extremity : edema (-), warm acral (-) Status gynecology : VT : Dilatation (-), fluxus (+), tissue unpalpable (-), slinger pijn (-), bulging of cavum Douglas (-) Laboratory exam : WBC : 6,2 HGB : 5,7 RBC :2,41 HCT : 19,2 PLT : 226 HbSAg : (-)

Time

Subject Chronologies : 24/09/2011 10.00 Patient came to NTB GH confessed diarrhea (watery diarrhea) since 1 day ago, also felt exhausted and abdominal discomfort. She confessed 2 month pregnancy. Examination in PHC : GC : weak BP : 60/palpasi mmHg PR : 80 bpm RR : 20 tpm T : 37,6C Head and neck : normal Thorax : cor : S1S2 single reguler, murmur (-), gallop (-) Pulmo : vesiculer (+/++, ronki (-/-), wh (-/-) Abdomen : bowel sound (+) , Pain in abdominal palpation (-). Mass unpalpable. Extremity : edema (-), warm acral (-) Diagnosis : GE + severe dehydration Therapy : - RL fast drip 2 flash -Cek DL, GDS, widal - ondansetron 1 A -Ranitidin 1 A

Object

Assesment

Planning

Time

Subject 25/09/2011 13.00 -Vaginal bleeding -Pregnancy : 2 month Planing : -pro USG -Move to melati

Object

Assesment

Planning

Time

Subject

Object

Assesment

Planning

25/09/ 2011 14.30

Nausea

GC : well BP : 110/70 mmHg PR : 88 bpm T : 36,7 C Eye : anemic (+), icteric (-) Active bleeding (-)

Abortus iminens + Severe Anemia

Observe mother well beinng transfusion 1 kolf

26/09/ 2011 09.00

USG : Rupture Ectopic Pregnancy

Advice from supervisor: laparotomy

Time

Subject

Object

Assesment

Planning

11.10

Laparotomy began.

12.10

Laparotomy finished.

Time

Subject (-)

Object GC : well Cons : E4V5M6 BP : 110/80 mmHg PR : 74 bpm RR : 18 bpm T : 38,9C UO : 23 cc/hours

Assesment 2 hours post laparotomy

Planning Paracetamol 3 x 500 mg Observe mother well being Suggest to take rest Pro lab check : DL

14.10

27/09/ 2011 06.00

Pain in operation wound

GC : well Cons : E4V5M6 BP : 110/70 mmHg PR : 80 bpm RR : 20 tpm T : 37C Urine : 25 cc/hours Operation wound good

1 Day post laparotomy

Observe mother well being Suggest to take rest Suggest mother to eat and drink if not vomit