MORNING REPORT

Departement of Obstetric and

Gynecology

April 10th 2017

Identity
Name: Ms. A
Age: 26 years old
Address: Lamongan
Date examination: April 10th 2017
 Anamnesis
Chief complain: abdominal contraction
Present Illness History: patient came with lower
abdominal contraction since yesterday, the time
between every contractions is 5 minutes. Patient also
complained clear fluid came out from her vagina
since 6.5 hours before admission. nausea and
vomiting (-). watering and defecation within normal
limit. Appetite within normal limit.

HPHT:
Patient forgot her first day of last period (but she just
remember the months (july 2016)/
Menarche 15th years old/Cycle 28
days/7days/dismenorhea (+)
Previous Illness History: allergy (-), asthma (-),
DM (-), HT (-)
Familly Illness History: allergy (-), asthma (-),
DM (-), HT (-)
Social Illness History: smoking (-), alcohol (-),
consumption drug or herbal medicine (-)

Gynecology history: menarche : 15 years old,

usually 7 days), Dismenorhea (+)
Primary Survey
A: clear, gargling (-), snoring (-), speak
fluently (+), potential obstruction (-)
B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh
-/-, SaO2 98 % without O2 support
C: akral warm dry red, CRT <2, PR 104
x/mnt, BP 131/82 mmHg
D: GCS 456, lateralisasi -, PBI 3mm/3mm
E: temp 36,7 C
Secondary Survey
GCS 456
H/N: aicd
Tho: sim, ret -/-
P: ves/ves; rh -/-, wh -/-
C: S1S2 single, murmur -, gallop
Abd:flat, soepel, H/L not palpable,
meteorismus (-), BU (+) N, mc burney sign
(-), rovsing sign (-), psoas sign (-), blumberg
sign (-)
Ext: aie -, acral warm dry red
Pmx obs
Leopold:
L1: TFU 39cm, rounded, puffy, appearance
like gluteus
L2: DJJ: 127x/m, right back
L3: Rounded and hard,app like head, not
yet insert in to PAP
L4: 5/5 convergen
VT obs : 1cm
Planning Dx
DL
UL
NST
 Laboratory Findings
GDA MCV 83.3
79
Metode 1 non reactive MCH 26
HbsAg (-) MCHC 32
PT 10,30 Trombosit
APTT 29,40 279
Leukosit 12.1 LED 1 77
Neutrofil 57 LED 2 94
Limfosit 19
Monosit 8.9
Eritrosit 4.42
Hb 11.9
UL
Glukosa (-) Eritrosit urine
Bilirubin (-) (+2)
Keton urin (++) Leukosit urine
Darah (+) (+2)
PH 6.5 Parasit urne
Protein (-) (-)
Bakteri (+)
Cylinder eritrosit
(-)
Epitel (+ 5)
Assesment
G1P1A0 36weaks with primary rupture
membranes
UTI
Therapy
Inf RL 1500cc/24 hour
Misoprostol 1/8 tab (250 mikrogram) per
vaginam
Monitoring
General state
Vital sign
Patients complaints
Development of labour
Laboratory findings: leukosit
Education
Explain to patients and her family about :
pregnancy, therapy to make delivery
faster, complication and prognosis
Explain to patients and her family about
side effects of therapy