Morning Report

CASES RESUME
NORMAL LABOR
PATHOLOGY LABOR

1. Mola Hidatidosa

TIME

SUBJECTIVE

16/12/
2012
20.10

Patient referred from KLU GH

with G1P0A0L0 12 weeks.
Patient
confessed
blood
came out from her womb
since 15 days ago, but
minimal, since 2 days ago,
lot of blood came out from
her womb. Dizzy (+). Patient
confessed last menstrual
periode was at the middle of
September. Fetal Movement
(+) 2 days ago. No history of
DM, HT, asthma.
LMP : Forget
EDD :History of ANC : Never
Result : History of USG : Never
History of family planning : Next family planning : Obstetrical History :
I. This

OBJECTIVE
General Status
GC : weak
Consciousness : CM
BP : 130/70 mmHg
PR : 80 tpm
RR : 20 bpm
T : 37,6 oC
Eye : anemis (+/+), icteric (-/-)
Cor : S1S2 single reguler, M (-),
G (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (-), linea nigra (-).
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical Status
UFH : 2 finger above the
umbilicus
UC : FHB : Inspeculo : Tissue (+),Active
Bleeding (+)
VT : (+), tissue palpable,
Slinger pain (-), APCD in the
normal range.
Lab Evaluation
HB : 5,6 g/dl
RBC : 1,94 x106 /l
HCT : 16,6 %
WBC : 13,4 x 103 /l

ASSESSMENT

PLANNING

Ab Incomplete,
susp Mola
Hidatidosa

IVFD RL 28 tpm
O2 3 lpm
Observation patient
well being
Check CBC and
HBsAG
Observation
bleeding
Digital result :
tissue (+)
minimum, Active
Bleeding (-)
GP co to SPV
Observation
PRC 2 Kolf

TIME

SUBJECTIVE
Chronologist at Tanjung PHC:
12.00 (16/12/2012)
S : Patient came confessed lot of
blood came out from her womb
since 2 days ago and dizzy (+)
O : General Status : Well
Consciousness : Composmentis
BP : 100/70 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,5 C
UFH : On the umbilicus
Inspeculo : Tissue (+)
VT : 2 cm, Tissue palpable
Hb: 5,1 g/dL
A : G1P0A0 20 weeks S/IU with Ab
Incomplete
P : CIE patient and family
Infusion RL 20 dpm
Co GP referred to KLU GH
(15.00)

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at KLU GH:
15.10 (16/12/2012)
S : Patient referred from tanjung PHC
with Ab Incomplte. LMP August
2012.
O : Genera Status : Well
Consciousness : Composmentis
BP : 100/60 mmHg
PR : 88 bpm
RR : 20 bpm
T : 38,0 C
UFH : On The Umbilicus
Inspekulo : Tissue (+)
VT : 2 cm, Tissue palpable
Hb: 4,7 g/dL
A : G1P0A0 20 weeks S/IU with Ab
Incomplete
P : CIE patient and family (16.00)
Prepare to go to RSUP NTB GH
(18.00)

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

17/12/
2012
07.00

Patient confessed abdominal

pain

OBJECTIVE
GS : Well
Consciousness : CM

ASSESSMENT

PLANNING

Ab Incomplete,
susp Mola
Hidatidosa

Obsevation General
status and vital
sign
First PRC transfusion
was finished
Observation
bleeding

Mola hidatidosa

Observation patient
well being
Observartion
bledding
Continue transfusion
Pro USG

BP : 100/70
PR : 80 tpm
RR : 20 tpm
T : 36,9 C
12.00

Patient confessed abdominal

pain +++

GS : Well
Consciousness : CM
BP : 110/70
PR : 92 tpm
RR : 20 tpm
T : 36,7 C
Mola Tissue came out 500 gr,
digital : tissue ramining (+)

18/12/
2012
07.00

GS : Well
Consciousness : CM
BP : 110/70
PR : 68 tpm
RR : 16 tpm
T : 36,6 C
Active Bleeding (-)

Pro USG this Morning