MORNING REPORT

10 December 2017
Supervisor:
dr. Ratih Barirah, Sp.OG
Medical Students:
Nita, Shiva, Agnes
CASE RESUME
NORMAL LABOR -

PATHOLOGIES CASE 1. Vaginal Bleeding e.c. Susp. Cervix Cancer with

Anemia

REMAIN CASE -
 Tidak ada
pertanyaan
yang salah
 Case I
• Name : Mrs. R
• Age : 38 years old
• Address : Bima
• Admitted : December 10th 2017
• RM : 599323
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10/12/ Patient referred from Bima General General Status : Vaginal bleeding e.c. DM Planning:
2017 Hospital with suspect Cervix cancer GC : well suspect Cervix Ca Diagnostic:
with anemia. Patient confessed blood GCS : CM with anemia • Laboratory test
05.10 leaked out from her vagina since July BP : 120/70 mmHg • PAP smear
am 2017. Sometimes lots of blood leaked, PR : 96 bpm
no clots, abdominal pain (-), vaginal RR : 18 x/min Therapy:
discharge (+), smelly. She often had Temp : 37,9oC • Blood transfusion
slight fever since then. 2 kolfs
Eye : anemic +/+, icteric -/- • CIE patient to drink
No history of DM, HT, asthma and heart Cor : S1S2 single regular, more water
disease. murmur (-), gallop (-).
Pulmo : vesicular (+/+),
History of marriage, she had married wheezing (-/-), DM co to GP, GP co
since 15yo, married for 3 years. rales (-/-). to SPV, advice:
Abdomen : bs (+) • Blood transfusion
Obstetrical History : Extremity : edema (-/-), 2 kolfs
1. Female/ 20yo/ home/ 9 months/ warm acral (+/+). • RL :D5 = 1:2,
pervaginam/ shaman 20dpm
2. Male/ 19yo/ home/ 9 months/ Obstetrical Status : • Inj. Cefotaxime 1
pervaginam/ shaman VT : not done gr/ 12 hours
3. Female/ 17yo/ home/ 9 months/ Inspekulo : not done • Observ. Vaginal
pervaginam/ shaman bleeding and VS

History of family planning: injection

contraception
Next family planning : she’s not planning
to have another pregnancy
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Lab: (10/12/2017)
HB : 8,7 g/dl
RBC : 3,37 x 10^6/uL
MCV : 78,9 fL
MCH : 25,8 fL
HCT : 26,6%
WBC : 25,65 x
10^3/uL
PLT : 390 x 10^3/uL
HbSAg : non reactive
RBG : 61 mg/ dl
Ureum : 21 mg/ dl
Creatinin : 0,7 mg/ dl
Albumin : 3,3 mg/ dl
AST : 16 mg/ dl
ALT : 14 mg/ dl

09.30 Vaginal Bleeding (+) Vaginal bleeding e.c. Patient moved to

am suspect Cervix Ca Segara Anak
with anemia
Reference Note
TERIMA KASIH