morning report dr.dian

7/28/2019 Morning Report Dr.dian

1/13

MORNING REPORTMarch 19th , 2013


2/13

IDENTITY OF PATIENT

Med.record number : 651298

Name : Mrs. Siti Arofah

Age : 30 y.o

Address : Rungkut Menanggal Harapan Education level : Vocational High School

Occupation : Housewife

Religion : Moslem

Ethnic group : Javanese

Date of entry : 19-3-2013

Time : 17.00 WIB


3/13

IDENTITY OF HUSBAND

Name : Yoyok Agus S

Age : 41 y.o

Occupation : Employee

Education level : Vocational High School


4/13

HISTORY TAKING

Patient was recommendation from private midwife,

came to VK Hospital of Haji Surabaya at 17.00 with

an abdominal contraction since 11.00. Then, ruptur

of fetal membran was happen at 15.30 today.

Yesterday, there was a mucous show at 6.00 in themorning and the bloody spot appeared 5 days ago.

Fetal movement (+)

First day in the last menstruation is September 10th,

2012 and the estimation of born date is June 17th,2013 (Menarche at 14 y.o, cycle of menstruation is

7 days)


5/13

Marriage history : Patient was married since 12

years ago and once.

Obstretic history :

1. Abortion/2 months/Curetage (-)

2. Aterm/Spontaneous/Head presentation/Girl/3900

gr/Midwife/9 y.o

3. Aterm/Spontaneous/Head presentation/Boy/2500

gr/Midwife/2,5 y.o

4. Now Pregnancy


6/13

Antenatal care history :

1st trimester : Once at midwife

2nd trimester : Twice at midwife

3rd trimester : -

Contraceptional history : Injection in every month = 3

years

History of the disease before :

Hypertension (-)

Diabetes Mellitus (-)

Allergic (-)


7/13

Status Generalis

Mata : Konj.anemis (-/-), sklera ikterik (-/-)

Thorax

Pulmo : v/v, simetris, Rh (-/-), Wh (-/-)

Cor : S1-S2 reguler, murmur (-/-), gallop (-/-)

Genitalia eksterna : Lendir dan darah (-), vulva

edema (-)

Ekstermitas : Edema sup (-/-), inf (-/-)


8/13

PHYSICAL EXAMINATION

General appearance : Good

Consciousness : Composmentis, 456

Vital Sign :

BP: 110/70 mmHg

HR : 88x/mnt

RR : 21 x/mnt

T rectal: 38C

Body height/Body weight : Havent asked yet


9/13

General Status

Eyes : Anemic of conj. (-/-), icteric of sclera (-/-)

Thorax

Pulmo : v/v, symmetrical, Rh (-/-), Wh (-/-) Cor : S1-S2 regular, murmur (-/-), gallop (-/-)

External outface of vagina : Mucous and blood (+),

vulva edema (-)

Extremity : Edema sup (-/-), inf (-/-)


10/13

OBSTETRIC EXAMINATION

Leopold 1: TFU 22 cm, head like

palpable

Leopold 2: long captivity palpable in a

right side , Fetal heart rate 165 x/mnt

Leopold 3: soft palpable, bracht

presentation

Leopold 4: the lowest presentation of fetal

is bracht, and already enter the high side

of pelvic

VT obs: 2cm/ eff 50%/ Bracht


11/13

Diagnose : G1 P00000+39-40

minggu+T/H+KPP+Taksiran Berat Janin 2945

gr

Planning : Bed Rest

NST

Obs.T rektal/3 jam

Rippening misoprostol 4x50mg/vag/6 jam sampai PS>5 Bila PS>5 pro OD 12 jam setelah misoprostol terakhir

Bila inpartu pro SptB

Inj.Ceftriaxon 2x1mg

Monitoring VS/Keluhan/DJJ/His


12/13

PEMERIKSAAN OBSTETRI

Leopold 1: TFU 30 cm, teraba kesan

bokong

Leopold 2: tahanan memanjang di kiri,

DJJ 142x/m

Leopold 3: teraba bulat keras, kesan

kepala

Leopold 4: presentasi jain terbawah belum

masuk PAP

VT obs: 2cm/ eff 25%/ letkep/ Ketuban

+ merembes Lakmus merah biru /


13/13

Diagnosa : G1 P00000+39-40

minggu+T/H+KPP+Taksiran Berat Janin 2945

gr

Planning : Bed Rest

NST

Obs.T rektal/3 jam

Rippening misoprostol 4x50mg/vag/6 jam sampai PS>5 Bila PS>5 pro OD 12 jam setelah misoprostol terakhir

Bila inpartu pro SptB

Inj.Ceftriaxon 2x1mg

Monitoring VS/Keluhan/DJJ/His

morning report dr.dian

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