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MORNING REPORT

8th August 2015

Supervisor : dr. I Made Putra Juliawan, SpOG

Medical Student:

Yande,Cinta

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• Name : Mrs. M

•  !e : "" #ears old

•  ddress : $atu %a#ar, %o&ar •  dmitted : 't( u!ust )*+, ++.-

• No. M : +)+/0

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0808201511!15

Patient re11ered 1rom Menintin!P2C wit( G)P+*%+ "34"0wee5s6S6%6I7 (ead presentation,mot(er and 1etal well &ein! 8con1irmation dia!nose. Patientcon1essed a&out &lood lea5ed

out 1rom (er wom& since )+.**9*06*'6)*+. &dominal pain 94.$lood# slim 94, ;M 98. M, andast(ma 1rom patient and (er1amil#.

%MP : ))4++4)*+-

?>> : )/4*'4)*+

2istor# o1 NC : +*@ at P2C%ast NC : '6'6+esult   mot(er con1essed

&leedin! 1rom va!ina, $P +"*6/*,"34"0 wee5s, 7;2 "* cm, (eadpresentation, ;2$ 987SG : )@ at SpOG

%ast 7SG: '6'6+;etal S6%6I7 , 2ead presentation,plasenta at corpus posterior,aterm, ?;< ""+ !ram

2istor# o1 1amil# plannin! : 4Ne@t 1amil# plannin! : 4

O&stetrical (istor# :

+.term6 1emale6 spontan6midwi1e 6P2C 6 - #.o6 alive

GC : wellGCS : ?-AM3$P : ++*60* 2: '- &pm= : "0B C : )+ &pmGeneral Status :?#e : an 9464 , ict 9464

=(ora@ :C : S+S) sin!le re!uler, murmur 94,!allop 94.P : ves 868 , w( 9464. ( 9464

 &domen : scar 94 , striae 98?@tremit# : edema 9464

O&stetrical status :%+ : &reec( 7;2 :

"+cm%) : &ac5 on t(e ri!(t side

%" : (ead%- : 6?;< : )/- !r 7C : 94;2 : +).+".+" 9+) &pmA= : not evaluated

%a& :2G$ : +),3$C : -,'2C= : "0,/

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Time Subject Object Assesment Planning

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#h$%n%l%gist in PMenintingS :Patient con1essed a&out &loodlea5ed out 1rom (er wom&since )+.** 9*06*'6)*+.

 &dominal pain 94. $lood# slim94, ;M 98.

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Time Subject Object Assesment Planning

12!(0"ITA

$lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 94 

Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : ') &pm : )* tpm

= : "3,/O

C7C : 94;2 : +).+).+" 9+-' &pmA= : not evaluated

G)P+*%+ "34"0wee5s6S6%6I7 (eadpresentation, wit(

 P$ e.c plasentaprevia parsial.

• Pro 7SG, result :placenta previaparsial, aterm, e1w :""* !r.

• Pro C=G• Pro termination

pera&dominal wit(CS• Pro deliver# patient

to AD teratai

1)!00"ITA

$lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 98

minimal

Gene$al Status 'GC : wellGCS: ?-AM3

$P : ++*60* mm2!P : '3 &pm : )+tpm= : "3,' OC7C : 94;2 : +".+).+) 9+-' &pmA= : not evaluated

G)P+*%+ "34"0wee5s6S6%6I7 (eadpresentation, wit(

 P$ e.c plasentaprevia parsial.

• C(ec5 C$C, $=6C=,2&S!

• Preparation 1or CS

• O&s mot(er 1etalwell &ein!.• O&servation &leedin!• CI? 1or 1amil#

plannin!

15!(0"ITA $lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 98minimal

Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : '" &pm : )* tpm= : "3,/ OC7C : 94;2 : +).+).+) 9+--&pmA= : not evaluated

>eliver# patient to ODCito

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Time Subject Object Assesment Planning

1*!00"ITA  

• CS was &e!un

1*!15"ITA

  4$a was &orn, male,")** !ram, 2C: ")cm,$% + cm, 4S 0 and /,

anus 98, anomalicon!enital 94.

Plasenta was &ornmanual, complete.

1*!(5"ITA

CS ;inis(ed

18!(5"ITA

iEEiness 94

Gene$al Status 'GC : wellGCS: ?-AM3$P : +)*60* mm2!P : '3 &pm : )+ tpm= : "3,3 OC7;2 : ) 1in!er &elow um&ilical%oc(ea 98$leedin! 9* cc

) (ours post CS • O&serve mot(er well&ein!

• Su!!est mot(er to eatand drin5 i1 mot(er not1eel nausea or didintvomit

• Su!!est mot(er to doearl# mo&iliEation

• DI? mot(er 1or&reast1eedin!

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Time Subject Object Assesment Planning

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Operation wound pain 94 Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : '- &pm : )+ tpm

= : "3,/O

C7;2 : ) 1in!er &elow um&ilical%oc(ea 98$leedin! 94

-ab.'GC : wellP : +-/ &pm : -' tpm= : "3,3OC

+ da# post CS • O&serve mot(er well&ein!

• Su!!est mot(er toeat and drin5

• DI? mot(er 1or&reast1eedin!

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