Morning Report

Obstetri and Gynecology

September 14th, 2015

Identity
Name: Mrs. F
Age: 26 yo
Address: Merpati Street Num. 11

Banjarmendalan, Lamongan
Date examination: September 14th,2015

Anamnesis
Chief complain: Increased blood pressure
Present Illness History:

A woman 26 years old patient with G1P0000 was

came to emergency room of Muhammadiyah
Lamongan hospital and complained in labor at
40-41 weeks gestation present with increased
blood pressure since the age of 7 months of
pregnancy. About 2 months the patient's leg
began swelling. Frequency to urinate more
frequently but in small increments. Smooth
bowel movements, she felt contraction since 1
days ago, fluid, bloody show and mucus denied.

Anamnesis
Previous Illness History:

HT and DM denied, allergy denied, asthma

denied
Familly Illness History:

DM denied, Heart disease denied

Social Illness History:

Smoking and alcohol denied

Obsetrics History:

1. This pregnancy
Menstruation History:
Menarche 12 years old, regular, for 6-7 days, 2830 days cycles, disminorhea (-)
HPHT 17 Desember 2014
Contraception
Patient never used contraception yet
Merried : 2 years
ANC : always docter Sp.OG

Primary Survey
A: clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)

B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh
-/-, SaO2 99% without O2 support
C: akral warm dry red, CRT <2, PR 94
x/mnt, BP 152/ 93 mmHg
D: GCS 456, lateralisasi -, PBI 3mm/3mm
E: temp 36,5 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, edema -/-

Leopold
L1: Fundal height is 28 cm,round in

palpable , soft, likes buttocks

L2: Right backs,fetal heart beat 132x/min
L3: palpable hard rond , the head still
floating
L4: 5/5, konvergen

VT obs:
Dilatation 0 cm,
Eff 25%
Presentation head,
Hodge I,
Membrane (-)
Vaginal discharge (-)

Planing Diagnosis
DL,UL
USG
NST

Assesment
G1P0000Ab000 / T / H / Gr. 40-41weeks
Preeclamsia mild

Therapy
Observation CHPB
O2 nasal 2 lpm
Inf. RingerAsetat 1500cc/24hour
Consul SpOG

Monitoring
General state
Vital sign
Patients complaints
VT Obs (pembukaan, penipisan, penurunan,

presentasi, denominator, ketuban)

DJJ
Cek Hb

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