Morning Report

August 7th 2015

Supervisor : dr. H. Doddy A. K.,
SpOG(K)
Medical Students :
Rian, Febri
CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1
2

G1P0A0L0 14-15 weeks with Disturbed Ectopic

Pregnancy + severe anemia
G1P0A0H0 39-40 weeks head presentation with
prolonged 2nd stage of labor

CASE 1
Name : Mrs. R
Age
: 24 years old
Address : Bayan KLU
Admitted : 06-08-2015
No. RM
: 56-48-15
G1P0A0H0 14-15 weeks with
disturbed ectopic pregnancy +
severe anemia

Time

Subject

06-08-2015
20.52

Patient reffered from

KLU GH came to NTB
GH
with
Disturbed
ectopic
pregnancy
(abdominal pregnancy)
with 16-17 weeks of
GW and anemia 8.4
gr/dL
and
without
blood supply. Patient
confess pregnant about
3
month,
complain
abdominal pain since
07.00 WITA (06-082015). Vaginal bleeding
(-).
Patient said her LMP
was at 20th April 2015.
History ANC : History of family
planning: Next family planning: -

Object
General status
GC : severe
GCS: CM (E4V5M6)
BP : 100/70 mmHg
HR: 120 x/m
RR: 44 x/m
T: 36,6 C
UO : 200 cc/6 hours
Local status
Eye : an (+/+), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : distention (+),palpation
pain (+), striae gravidarum (-),
linea nigra (-), scar (-)
Ext : edema (-/-), warm (-/-)
Obstetric status
UFH : unpalpable
Genital : inspekulo porsio (-),
bleeding (-), livide (+), portio
slippery, fluor albus (+)
VT : (-) slinger pain (+),
bleeding (-), apcd: bulging
cavum douglas, Corpus Uteri
Anteflexion

Assessment

Planning

G1P0A0H0 1415 weeks with

disturbed
ectopic
pregnancy
+
severe anemia

Obs. mother well

being
Explain about the
examination result
IC
O2 3 lpm
Check CBC, BT,CT,
HbsAg
In KLU GH
Double line
infusion right
hand RL no V
and left hand
Hes no II
DC (+)
Ranitidine and
ketorolac inj 1
amp (18.00)
Ampicillin Inj
(19.30)

Time
06-08-2015

Subject

Object
Laboratory(21.04)
HGB = 6.1 g/dl
RBC = 2 K/ul
WBC = 18.48 M/ul
HCT : 18 %
PLT = 181 K/ul
HBsAg = (-)

Assessment

Planning

Time

Subject
C
Chronologist : at KLU GH (06-08-2015)
15.00 WITA
S : Patient came from Senaru PHC with
susp disturbed ectopic pregnancy dd
acute appendicitis confessed abdominal
pain since 06/08/2015 at 07.00.
tenderness (+). Yesterday patient
confess only urinate at small amount
and pain when urinate. Mother can still
feel the FM (+).
O:
GC : severe
Cons : CM
BP : 80/60mmHg
HR : 104x/m
RR : 22x/m
T : 36.3oC
UFH : 3 fingers above umbilicus
UC : FHB : 158x/minute
A : Disturbed Ectopic Pregnancy 16-17
weeks with anemia and no suplly of
blood
P:
RL 4 flash
NaCl 1 flash
Ampicilin 1 gr/IV at 12.30 at PHC

Object

Assessment

Planning

Time

Subject
06/08/2015(15.15)
-DC
-Laboratory Check
Result :
HGB = 8.4 g/dl
RBC = 2.75 K/ul
WBC = 22.2 M/ul
HCT : 26.6 %
PLT = 314 K/ul
Urinalysis :
Color :Yellow
BJ : 1.010
Protein +1
Glucose (-)
Ketonuria (+4)
06/08/2015(15.30)
Consult to SPV Obgyn at KLU GH
USG was done by SPV
Result : single, live, abdominal
Advice : pro laparotomi cito
Ready 2 kolf WB
CIE and IC
Two way infusion
Injection ampicillin 1 gr

Object

Assessment

Planning

Time

Subject
06/08/2015(16.15)
Consult to OK co to Anesthesia doctor
Advice : ranitidine inj 1 amp
ketorolac inj 1 amp
16.30
Get the 2nd line of infusion, using NaCl high
dpm
18.00
Injection ranitidine and ketorolac
18.30
CIE Family family agree
19.30
Injection ampicillin 1 gr / number II
20.00
RL flash number V
20.30
Widahes flash number II

Object

Assessment

Planning

Time
21.00

Subject

Object
GC : severe
GCS: CM (E4V5M6)
BP : 100/60 mmHg
HR: 120 x/m
RR: 42 x/m
T: 36,9 C

21.15
21.30

22.00

Assessment

Planning
RL Flash VI

DM co to GP advice blood
transfusion 2 kolf
GC : severe
GCS: CM (E4V5M6)
BP : 100/60 mmHg
HR: 120 x/m
RR: 42 x/m
T: 36,7C

RL Flash VII

DM co to GP co to SPV advice
pro laparotomy
CIE husband and family

22.30

Laparotomy begin abdominal

pregnancy, bleeding >1500 cc
Blood transfusion (WB)
I : 22.30
II : 23.30
Laparotomy end at 23.20

23.50

01.50

Patient
rooming in

General status
GC : moderate
GCS: CM (E4V5M6)
BP : 100/60 mmHg
HR: 120 x/m
RR: 20 x/m
T: 36 C
UO : 200 cc/1 hours

Post
laparotomy

General status
GC : well
GCS: CM (E4V5M6)
BP : 90/60 mmHg
HR: 88 x/m
RR: 20 x/m
T: 36 C
UO : 900 cc/2 hours

Post op
laparotomy 2
hours

Observation for mother well

being
Observation for active bleeding
Ceftriaxone inj 1 gr/12 hours
Ketorolac 30 mg/8 hours
Pro blood transfusion until Hb
>10 gr/dL

Post op
laparotomy
H+1

Observation for mother well

being
Observation for active bleeding
Ceftriaxone inj 1 gr/12 hours
Ketorolac 30 mg/8 hours
Pro blood transfusion until Hb
>10 gr/dL

Operation wound well cared, active

bleeding (-)
07.00

Abdominal
wound pain

General status
GC : well
GCS: CM (E4V5M6)
BP : 100/60 mmHg
HR: 84 x/m
RR: 20 x/m T: 36,2 C
UO : 300 cc/2 hours
Operation wound well cared, active
bleeding (-)