MORNING REPORT

January, 14th 2016

Resident In Charge:
Waw/Qos/Mun/Bor/Did/Cil
Chief: dr. Hot
Supervisor:
Dr.dr. Siti Candra, SpOG-K

 Emergency Room : 3
Delivery Room
Physiological case : Pathological case :
Pervaginam : Perabdominam : 1
Ward
:1

Emergency Room
1. Mrs. Sunipah/33 yo
G2P1001Ab000 gr 34-36 weeks S/L
+ Abcess submandibula dekstra
+ Secondary old prime

Patient will be reported

2. Mrs. Maghfirah/ 22 yo
G1P0000Ab000 gr 38-39 weeks S/L
+ Severe preeclampsia
+ Acute Lung Oedem
+ Impending Eclampsia
+ Hipoalbuminemia
+ Susp. pleural effusion D
+ Fetal compromised
Patient will be reported

3. Mrs. Ayu/ 24 yo
Observation of ectopic pregnancy
+fungtional cyst
+ history of rupture of ectopic pregnancy
operation
+ primary infertil
Patient will be reported

Delivery room
1. Mrs. Qoriah / 35 yo
G2P1001Ab000 gr 37-38 weeks S/L
+ First stage active phase
+ Chronic hypertension superimposed
preeclampsia
+ Age 35 y.o
+ Secondary old prime
+ UTI asymptomatic
Patient will be reported

WARD
1. Mrs. Wilujeng/ 66 yo
AUB E dd AUB M
+ Post eksternal drainage ec hyperbilirubinemia dt
cholangio Ca day - 0
+ Anemia
+ Hypoalbuminemia
+ Pleural efusion D/S
+ Fungtional cyst

Patient will be reported

Subjectives
RM : 11272091/ 1601480
Mrs. S/ 33 y.o/ 6 y. o. e/ Farmer
Mr. P / 35 y. o/ 9 y. o. e/ Farmer
Married 1x, 17 years
Address : Ds Watu Gilang RT 4/5, Pasuruan
Admission on January 14th ,2016 at 2.10
pm

Subjective

Patient was consulted from surgery dept

with Right Submandibula absces +
Gravida G2P0101 32-34 weeks

SUBJECTIVE
30/12/2015
Patient felt toothache went to midwife examined, and said that was normal, didnt get any medicine went home
7/ 1/ 2015
Patient felt there was mass at her right lower jaw patient still at home
13/1/2015
at 05.00 pm
The mass got bigger and spread to neck edem (+), pain (+) went to dentist examined, need to spesific treatment
suggest to RSUD Bangil
at 08.00 pm
Patient arrived at RSUD Bangil examined pregnancy was normal, got amoxxicilin 3x1 and roborantia 1x1, patient
suggest to operation , because lack of facilities suggested to RSSA family still discussed
14/1/2016
12.00 pm
Patient arrived at RSSA, examined by Surgery Dept and planne to incicon drainege submandibula dekstra
Hystory of fever (-)

SUBJECTIVE
History of previous delivery:
1.
2.

A/300ogr/SptB /Midwife/M/13 y.o/L

This pregnancy

ANC : Midwife 5x (last controled 30/12/2015)

LMP 20/5/14 3-36 weeks
Contraception: Injection 3 months stop 2 years
ago

OBJECTIVES
GA : Good GCS : 456
BH : 155 cm BW: 51 kg
BP : 110/70 mmHg PR : 88x/m
RR : 20 x/m
Tax : 37,1 oC , T rect : 37,3 oC
H/N : conj. an -/- ict -/At regio submandibula dekstra
Mass size 8x10 cm, smooth surface, hyperemis,
fluctuation (+), punctum (+)
Th : C: S1 S2 single murmur (-)
P: rh - - wh - - - - - Abd
: FH : 26 cm, longitudinal lie U , FHR: 150 bpm (Doppler),
EFW :2015 gr, uterine contraction (-)
VT : not permorfed

LABORATORY
CBC
FH
OT/PT
Ur/Cr
SE

:10,1/11.230/31,0%/346.000
: 9,6/29,50
: 77
: 9,3/0,64
: 129/4,21/99

NST
Baseline rate
Variability
Acc : (+)
Decc : (-)
Conclusion

: 130 bpm
: 5-15 bpm

: Normal CTG

USG FM
Fetal intrauterine single life, longitudinal lie,
head below
BPD : 86,2 mm (34w5d)
AC
: 286 mm (32w5d)
FL : 60,6 mm (31w4d)
AFI
: 11,3
EFW : 2059 gr
Placental implantation at fundus
Maturation grade II

Assessment
G2P1001Ab000 gr 34-36 weeks S/L
+ Abcess submandibula dekstra
+ Secondary old prime

PLANNING
Pdx : Ptx :
- Conservative treatment
- Lung maturation induction : dexametashon 2x16 mg
in 24 hours
- Cygest 400mcg per-rectal 6 hours pre op and 6 hours
post op
- Oral theraphy : Fe 2x1
- Patient will be join care
- Pmo : Obs VS, subj, FHR
- CIE
- -----------------------------------------Acc Dr. dr. Siti Candra,
SpOG-K

Last Condition
Mother performed incision and drainase at
operating room at 11.00 pm

IDENTITY

Register: 11272165
Mrs. A/24 y.o/married 1x , 2,5
years/P0000Ab001/LC :
(-)/Contraception : (-)/LMP : 28-11-2015~
6-8 weeks
Address : Asrama Yonif Linud 502
Kemantren Jabung Malang
Administered 14-01-2016 at 00. pm

SUBJECTIVE

Patient came by herself with

chief complain spotting

SUBJECTIVE

13-01-2016
Patient felt spotting, half of female napkins
patient still stayed at home
14-01-2016 at 05.00 pm
Patient felt spotting more excesive 1 female
napkins went to RSSA

 Patient knew that she was pregnant since early January,

test pack by herself, the result was positive, patient
planned to go to Obstetrician but not yet controlled
History of rupture of ectopic pregnancy operation on
June 2014 at RSSA performed operation at left side
History traditional massage (pijat oyok) (-), trauma (-)
History of leuchore 1 months ago and didnt have
treatment
History of menstruation period was 30 days, 5-7 days,
change female napkins 3-4x/day, pain (-)
History of mictie and defecation wnl

OBJECTIVE
GA
BP

: look moderate illness, CM

: 120/80 mmHg,HR : 80 x/mnt ,RR : 20
x/mnt
H/N : an -/-, Ict -/Th : C/ S1-S2 single, murmur (-)
P/ Rh | Wh |
Abd : fundal height not palpable, soefl,
meteorismus (-),, bowel sound (+) wnl, scar
midline (+)

 GE : flex (+) min

Insp : v/v flex (+) min
PONP closed, smooth, lividae (+)

VT:
v/v flex (-)
POMP closed, smooth, slinger pain (+)
CUAF ~ 6-8 weeks
AP D /S : Mass (-), Pain (-)
CD ~ not prominen

LABORATORIUM
CBC : 11,4/11.480 /33,2/ 244.000
FH
: 10,3/26
Plano test : (+)
B-HCG : 10786
UL : bacteri 82,5 x103

USG
Uterine enlargement 8,91x5,42 cm, cavum uterine
open with fluid collection inside
Seem gestational sac with ring of fire at rigth adneksa
projection diameter 2,53 cm ~ gestational age 6w5d,
seem amorf lesion in cavum douglas. Seem cyst, septa
(-) at rigth adneksa projection diameter 3,67 cm
Conclusion :
Sugested rupture of ectopic pregnancy at rigth adneksa
projection
Rigth simple ovarial cyst

ASSESSMENT
Observation of ectopic pregnancy
+Fungtional cyst
+ History of rupture of ectopic
pregnancy operation
+ Primary infertil

PLANNING THERAPY
PDx : CBC serial/ 6 hours, USG gyn at
work hour
PTx :

Hospitalized at Room 4
IVFD RL ~ 20tpm
Bed rest
Performed abdominal circumterance
Inserted DC
If sign of acute abdomen (+) pro exploration
laparotomy cito
PMo : Obs VS, subj complaint
C/ Supervisor _____________approved by Dr. dr. Siti
Chandra, SpOG-K

Last Condition

DL 10,2/10500/30/229000
Mother at room 4
BP 110/70 mmHg
HR 88x/m
RR 20x/m
No addition of abdominal circumference

Identity
No.RM 11272194
Mrs. MR /22 y.o/ 12 y. o. e/ Housewife
Mr. ID / 27 y. o/ 12 y. o. e/ Soldier
Maried 1x 1 year
Address : Asrama Kikautai 2 Kostrad RT 6/7
Kemantren, Jabung
Admission : January 15th ,2016 at 01.30 am

 Patient was referred by Obstetrician Puri

Bunda Hospital with G1P0000Ab000 gr 3839 weeks S/L + severe preeclampsia +
Impending eclampsia + Lung Oedem

SUBJECTIVES
10/1/2016
Patient felt dizzines stayed at home

14/1/2016
07.00 pm

Patient felt dizziness getting worse went to midwife

examined, BP 170/100 suggest to reffred to Puri

Bunda Hospital
8. 00 pm
Patient arrived at Puri Bunda Hospital, BP 172/122,
protein +3 given with SM40% IM and planned to CS
10.30 pm
Arrived at operating room patient felt shortness of
breath, got examined by anaesthesiology sugested
to be reffred to RSSA familly still discussed

SUBJECTIVE
History of high blood pressure before and
during pregnancy was denied
History of headache (+); Nausea (-);
Vomiting (-); epigastric pain (+)

SUBJECTIVES
History of last pregnancy :
1. This Pregnancy
ANC : Midwife 6x (last control 7/1/2016)
LMP 25-4-2015 ~ 38-39 weeks
Contraception : (-)

OBJECTIVES
GA
: looked severe ill,GCS : 456
BP
: 170/100 mmHg PR : 100x/m
RR
: 24-26x/m Sat O2 : 92-94%
BH
: 155 cm BW : 74 kg
H/N : conj. an -/- ict -/Th
: C: S1 S2 single murmur (-)
P: rh - wh - - - + +
- Abd
: FH 33 cm, longitudinal lie U, FHR 130 x/m
(Doppler), EFW : 3255 gr, uterine contraction
(-)

 VT ( after SM):
0-1 cm, eff 25%, HI, amniotic membran(+),
head presentation, denom difficult to evaluated,
pelvic measurement ~ wnl

LABORATORY

CBC
: 10,4/11660/34,9/264000
FH
: 8,1/28,1
Ur/Cr : 14,2/0,66
OT/PT : 23/10
RBS
: 88
Alb
: 2,58
LDH : 528
SE
: 135/4,21/112
Urinalysis : (+) 3

LABORATORY

pH
: 7,4
pCO2 : 24,7
pO2 :122,7
HCO3 : 15,4
BE
: -9,6
Sat O2 : 97%

Thorax PA

Cardiomegali with
congestive
pulmonum
Pleural effusion D

USG FM
Fetal intrauterine single life, longitudinal lie,
head below
BPD : 94,1mm (38w2d)
AC
: 330 mm (36w6d)
FL : 73,6 mm (37w5d)
AFI
: 9,8
EFW : 3267 gr
Placental implantation at fundus
Maturation grade III

NST
Baseline rate : 130 bpm
Varriabiliy rate : 2-5 bpm
Acc (-)
Decc (-)
Patologic CTG

C/ Cardiology
G1P0Ab0 gr 38-39 weeks
Severe preeclampsia
Hipoalbuminemi
Cardiologi status GCRI class II
ESC Intermediate
Advice
Patient will be join care for general improvement

C/ Pulmonologist
Susp. Right Pleura Efusion
Advice
Pdx : USG thorax promarker
Ptx : Pleura punction test if there is marker from
thorax USG
Patient will be followed

Assessment
G1P0000Ab000 gr 38-39 weeks S/L
+ Severe preeclampsia
+ Acute Lung Oedem
+ Impending Eclampsia
+ Hipoalbuminemia
+ Susp. pleural effusion D
+ Fetal compromised

PLANNING
PDx : c/ cardiology, c/ anaestesiology, c/ pulmonologist
PTx :
Intrauterine resusitation
-

O2 NRBM 10 lpm
Mother at left recumbent position

- Inj SM full dose

-

Inj. SM 20% 4 gr iv
Inj SM 40 % 10 gr IM (+) at Puri Bunda Hospital
Continued with infus SM 40% 6 gr/6 hours until 12 hours post op
Tranfuision Alb 20% until Alb level > 3 gr/dl

- Proposed termination with CS cito + IUD pasca placenta

- Prepare for operation :
-

Inj. Cefazoline 1 gr (skin test)

Inj.Ranitidine 1 Amp iv
Inj. Metochlopramide 1 Amp iv
In furosemide 2 amp iv
Insert DC/ Informed concent/ blood preparation

Pmo : Obs. VS,subjective, FHR, sign of eclampsia, urine production, fluid balance
CIE
c/spv ----------------------------------Acc

Dr.dr. Siti Candra, SpOG-K

OUTCOME
On Friday, January 15th 2016
at 04.17 am
Female baby was born
2800 gr/ 48 cm /AS 6-8

Last Condition
Mother
At RR Emergency Room
GCS on sedation
BP : 117/69 mmHg
PR : 94 x/m
RR : 14 x/m (on ventilator
control )
Urine production 100 cc/hours

Baby
At perinatology
Infus (-)
O2 (-)
Active movement

Identity
No.RM 11272169
Mrs. Q / 35 y.o/ 6 y. o. e/ employee of Food
factory
Mr. R / 37 y. o/ 6 y. o. e/ Carpenter
Maried 1x,16 years
Address : Ds Bunut Wetan RT 6/7 Pakis
Malang
Admission: January 14th ,2016 at pm 08.05

 Patient was reffered by Midwife with

G2P1001Ab000 gr 35-36 weeks with
severe preeclampsia

SUBJECTIVES
14/1/2016 at 10.00 am
Patient felt uterine contraction patient still at home
14/1/2016 at 01.00 pm
Patient felt uterine contraction more frequent patient
went to midwife BP 160/100 suggest to RSSA
family discussed
14/1/2016 at 06.00 pm
Patient went to RSSA
History of blood presure since 2 years ago but didnt
seek any medication
History of dizzines (-), vomiting (-) , nausea (-),
epigastric pain(-), blurred vision(-)

SUBJECTIVES
History of last pregnancy :
1. At/ 2600 gr/SptB/RSSA/F/13 y.o/L
2. This Pregnancy
ANC : Midwife 3x (last control 15/11/2015)
LMP 28-04-2015 ~ 37-38 weeks
Contraception injecton 3 month, stop 1 year

OBJECTIVES
: good,GCS : 456
: 160/100 mmHg PR : 90x/m
: 20x/m
: 36,5 C Trect : 36,8 C
: 147 cm BW : 65 kg
: conj. an -/- ict -/: C: S1 S2 single murmur (-)
P: rh - - wh - - - - - Abd
: FH 32 cm, longitudinal lie U, FHR 148 x/m
(Doppler), EFW : 3100 gr, uterine contraction
(+) 10.3.35/ MS
Dipstick (+) 2

GA
BP
RR
T ax
BH
H/N
Th

 VT ( after SM):
6 cm, eff 100%, HII, amniotic membran(+),
head presentation, denom minor fontanela at 2
oclock, pelvic measurement ~ wnl

LABORATORY
CBC
FH
Ur/Cr
OT/PT
RBS
Alb
LDH
SE
UL

: 12,4/21.300/37,4/359.000
: 8,9/28,3
: 30,6/0,91
: 22/11
: 115
: 3,64
: 556
: 137/3,9/108
: protein (+)2
bacteri 324,4x103

NST
Baseline rate : 140 bpm
Varriabiliy rate : 5-20 bpm
Acc (+)
Decc (-)
Normal CTG

USG FM
Fetal intrauterine single life, longitudinal lie,
head below
BPD : 89,8 mm (36w1d)
AC
: 323 mm (36w1d)
FL : 74,3 mm (38w0d)
AFI
: 10,3
EFW : 3086 gr
Placental implantation at fundus
Maturation grade III

Assessment
G2P1001Ab000 gr 37-38 weeks S/L
+ First stage active phase
+ Chronic hypertension superimposed
preeclampsia
+ Age 35 y.o
+ Secondary old prime
+ UTI asymptomatic

PLANNING
PDx : co/cardiology dept, co/ opthalmology
PTx :
- Inj SM full dose
-

Inj. SM 20% 4 gr iv slowly

Inj SM 40 % 6 gr in RD5 500cc for 6 hours
Inj SM maintenance, SM 40% 10 gr in RD5 500 cc 12 until 24 hours post partum
Nifedipine 3x10mg
Metildopa 3x500mg
Evaluated 2 hours later
Pro expectative pervaginam

Pmo : Obs. VS,subjective, FHR, progress of dilatation sign of impending eclampsia,

uterine contraction, urine production, fluid balance
CIE
c/spv ---------------------------------- Acc

Dr.dr. Siti Candra, SpOG-K

C/ Cardiology
G2P1Ab0 inpartu gr 37-38 weeks + First stage
active phase
Hypertension stage II chronic Superimposed
preeclampsia
Advice
Patient will be join care
PO Metyldopa 3x500
Adalat oros 30-0

Date and
time

Subject

14/1/201
6
10.00
pm

S : Uterine
contraction
regurally

Objective

GA : Good GCS : 456

BP : 154/82 mmHg PR :
102x/m RR : 18 x/m Tax :
36,5 oC , T rect : 36,7 oC

H/N : conj. an -/- ict -/

Th: C: S1 S2 single murmur
(-)
P : wh
Abd : FH : 31 cm,
longitudinal lie U ,
FHR: 148 bpm
(Doppler), EFW : 3100
gr, uterine contraction
(+) 10.3.35/S

VT : 8 cm, eff 100%,

amniotic (-) clearly,
presentation, denom ~
fontanela at 1 oclock,
measurement ~ wnl

HII,
head
minor
pelvic

Assesment

Planning

G2P1001Ab000
gr 37-38 weeks
S/L
+ First stage
active stage
+ Chronic
hypertension
superimposed
preeclampsia
+ Age 35 y.o
+ Secondary old
prime
+ UTI
asymptomatic

Pdx : Ptx :
Evaluation 2 hours
(00.00)
Pro expectative
pervaginam
Pmo : Obs VS, subj,
FHR, uterine
contraction, progress
of dilatation
CIE
Co/Spv
____________
ACC Dr. dr. Siti
Candra Sp.OG-K

Date and
time

Subject

15/1/201
6
00.00
am

S : Uterine
contraction
regurally

Objective

GA : Good GCS : 456

BP : 157/88 mmHg PR :
88x/m RR : 20 x/m Tax :
36,5 oC , T rect : 36,7 oC

H/N : conj. an -/- ict -/

Th: C: S1 S2 single murmur
(-)
P : wh
Abd : FH : 31 cm,
longitudinal lie U ,
FHR: 148 bpm
(Doppler), EFW : 3100
gr, uterine contraction
(+) 10.3.35/S

VT : 8 cm, eff 100%, HII,

amniotic (-) clearly, head
presentation, denom ~ difficult
to evaluate, caput (+)

Assesment

Planning

G2P1001Ab000
gr 37-38 weeks
S/L
+ First stage
active stage
+ Chronic
hypertension
superimposed
preeclampsia
+ Arrest of
dilatation ec CPD
+ Age 35 y.o
+ Secondary old
prime
+ UTI
asymptomatic

Pdx : c/anestesia
Ptx :
Proposed termination
with SC cito + IUD
pasca placenta
Inj. Cefazoline 1 gr
(IV)
Inj Ranitidine 1 amp
Inj Metoclopramd 1
amp
Tokolitik : kaltrofen
supp I
Insert DC/ Informed
concent/ blood
preparation
CIE
Co/Spv
____________
ACC Dr. dr. Siti
Candra Sp.OG-K

OUTCOME
On Friday,
January 15th 2016 at 02.15 am
Male baby was born
3020 gr/ 50 cm /AS 7-9

Last Condition
Mother

At RR OBG
BP : 153/92 mmHg
PR : 101 x/m
RR : 12 x/m (on NRBM 10
lpm)
Sa O2 98%
Urine production : 100
cc/hours

Baby

At Perinatology
Infusion (-)
O2 (-)
Active movement

IDENTITY

Register:
Mrs. W/66 y.o/married 1x , 50
years/P2002Ab000/LC :
44y.o/Contraception : (-)/LMP :
menopause since 13 years ago

SUBJECTIVE

Patient was consulted by Anesthesiolgy

with post opexternal drainage
hyperbilirubinemia dt cholangio Ca +
bleeding from birth canal

SUBJECTIVE
14-1-2016 at 07.00 am
Patient was being operated external billiary
drainage cholangio Ca + obstructive jaundice
14-1-2016 at 10.00 am
Patient post operation at Operating Room
paviliun, blood excess from nirth canal +1
underpad, performed tampoon with baloon
cateter because BP was decreased resusitated
move to ICU

SUBJECTIVE
History of spotting since 3 weeks ago patient
still at home
History of tumor under hepar at
RSSA( 3/2/2015) PA : metastase Adeno Ca
moderate differentiated at ekternal intestine wall
got chemotheraphy 6 series, the last
chemotheraphy on July 2015

SUBJECTIVE
Patient felt her eyes and skin yellow controlle
to Surgeon because suspected obstruction of
duct of gall bladder suggested to operated
family discussed
History of body weigth loss (-)
History of tumor gynecology in family was
denied
History of defecation wnl
History of mictie look like tea in collour

OBJECTIVE
GA
BP

: look moderate illness, CM

: 150/81 mmHg,HR : 88 x/mnt ,RR : 20 x/mnt,

Sat. O2 : 97z5 with NC 4 lpm
H/N : an +/+, Ict -/Th
: C/ S1-S2 single, murmur (-)
P/ Rh | Wh |
Abd : flat, soefl, bowel sound , met (-), drain (+),
operated wound cover by cassa
GE :v/v flex (+), fluor (-)
Insp : v/v flex (+), fluor (-)
POMP closed smooth

VT : v/v flex (+), fluor (+)

POMP closed smooth
CUAF ~ sligth enlarged
AP (D) massa (-), pain (-)
(S) mass (-), pain (-)
CD wnl

LABORATORIUM
CBC : 9,3/9.980 /26,7/ 764.000
OT/PT : 56/49
Alb
: 2,99
RBS : 72
Bil Total/ D/I : 17,99/16,14/1,85
Cholesterol T/ TG/HDL/ LDL :
400/333/17/45

USG
Normal uterus, seem cyst at adneksa with
thin septa, size 5,3x4,8cm
Seem pleural effusion D/S
Sludge vesica velea
Obstructive at distal hepatic duct by mass
(cholangio Ca), make obtructive jaundice

MRI
Conclusion:
Dilatated of IHBD bilateral ec mass billiary
common hepatic bile duct sugestive cholangio ca
klatskin tumor tipe II hepatomegali
Pleural effusion (D)

ASSESSMENT
AUB E dd AUB M
+ post eksternal drainage ec
hyperbilirubinemia dt cholangio
Ca day 0
+ anemia
+ hypoalbuminemia
+ pleural efusion D/S
+ fungtional cyst

PLANNING THERAPY

PDx : USG Gyn at work hour if

transportable, co/ FER
PTx :

General improvement with transfusion PRC

2lb/day until Hb > 10 gr/dl continued curetage
PA I-II
Inj. Traneksamat acid 3x500mg iv
Oral theraphy SF 2x1
PMo : Obs VS, subj
C/ Supervisor ______________approved by Dr. dr. Siti
Candra, SpOG-K

THANK YOU