MORNING
REPORT
Saturday, 25 th
January 2025 Supervisor:
PONEKdr. CASE
I Nyoman Sayang, Sp. OG
PATIENT
IDENTITY
Name : NWT
Medical Record : 35.14.58
Date of birth : November 27th 1996
Age : 28 years old
Sex : Female
Religion : Hindu
Marital Status : Married
Occupation : House wife
Education : Bachelor’s degree
Address : Br. Griya, Bangli
Admitted Date : January 24th 2025,
ANAMNESIS
A 28-year-old female patient, G2P1001, with a gestational age of 9-
10 weeks, was brought to the ER delivery room of RSUD Bangli by her
husband at 11.30 WITA in a conscious state, complaining of vaginal
bleeding since 11.00 WITA. Bleeding occurred suddenly when the patient
was doing her usual activities at home. The patient complained of bright
red blood coming out in quite large volumes and appear-disappear. The
bleeding was felt to be getting worse when the patient was doing
activities and there were no factors that alleviated the complaint. Vaginal
bleeding was accompanied by complaints of abdominal pain from the
lower abdomen spreading to the lower back.
ANAMNESIS
The pain had been felt since 03.00 PM WITA. Complaints of pain felt
like being squeezed and were continuous (NRS 4/10). History of coitus
(+), fever (-), dizziness (-), blurred vision (-), trauma (-), no complaints of
urination and defecation.
Menstruation
Menarch
Cycle
History
: 14 years old
: Reguler
Duration : 4-5 days
Change pads : 4-5x/day
No complaints during menstruation
HPHT : 13 November 2024
TP : 20 August 2025
Obstetric
No Year
History
Gender BBL Term/Preterm/ Life and Pspt/SC/VaE/FE Health
Abortion death facilities/Non
health facilities
1. 2023 M 3400 gr Aterm Life SC Health Facilities
2. Pregnant now
Marital History
Married at 26 year old
Marriage lasted 2 years ago
History of Contraceptive Use
No history of contraceptive use
Past Medical History
History of systemic disease was denied
Antenatal Care
Every month the patient checks her pregnancy with the
obstetrician, the last check-up was on Monday. The patient
said there were no problems during the check-up.
History of Transfusion
There is no history of blood transfusion
History of Surgery
1. Sectio caesarea (2023)
History of allergy
There is no history of Allergy
History of medication
During pregnancy, patients routinely consume
iron supplements and pregnancy vitamins.
Family History
Family history of systemic diseases such as hypertension, diabetes mellitus,
asthma, heart disease, kidney disease, and gynecological diseases was
denied by the patient.
Personal, social and environmental history
The patient is a housewife who does light to moderate activities every day. The
patient denied a history of smoking and drinking alcohol. The patient lives with
her husband, child, and in-laws. None of the patient's family members have a
smoking habit. This pregnancy was unplanned, but the patient and family
accepted it. The patient recently had a history of stress due to a family member
who died.
Physical
examination
Present status
General appearance : Intense pain
Consciousness : Compos Mentis
GCS : E4 V5 M6
Blood Pressure : 116/65 mmHg
Pulse Rate : 80 x/min, regular
Respiration Rate : 20 x/min
Axillary temperature : 36.3°C
SpO2 : 98% on RA
Height : 162 cm
Weight before pregnancy : 52 kg
Weight after pregnancy : 54 kg
Physical
examination
General Status
Head : Normocephalic
Eye : anemic conjunctiva (-/-), icteric sclera (-/-)
ENT : Discharge (-), hyperemic pharyngeal (-)
Mouth : cyanosis (-)
Neck : Thyroid enlargement (-), lymph node enlargement (-)
Thorax : symmetrical, rash (-)
Cor : S1 S2 single, regular, murmur (-)
Pulmo : ves +/+, wh -/-, rh -/-
Mammae : according to obstetric status
Abdomen : according to obstetric status
Genital : gynecology status
Extremities: Warm + | + pitting edema - | - CRT <2 sec
+|+ -|-
0 Physical
examination
Obstetry Status
Mamae :
Inspection: symmetrical shape, hyperpigmentation of mammary areola,
prominent nipples, discharge (-/-), adequate hygiene
Palpation: tenderness (-/-), mass (-/-), discharge (-/-)
Abdomen
Inspection: striae gravidarum (-), surgical scar (+), Distention (-)
Auscultation : bowel sounds (+), DJJ : (Not heard)
Percussion : Timpani
Palpation : Slight pain (+), His (-), Fundus height not yet palpable
0 Gynecology
Status
Anogenital
Insp: Bleeding is visible (+), stitches (-), edema (-), hematoma (-)
Inspekulo: -
vaginal toucher: V/V normal, protruding portion, rocking pain (-),
bleeding spots (+)
A G2P1001 GA 9-10 weeks + Abortus Imminens + LMR 1x
P Therapy Education and Counseling
1. IVFD RL 20 tpm
Explain the results of the history, physical
2. Bed rest
examination, supporting examination and
3. Progesteron 1x 200 mg
diagnosis to the patient and family.
4. Tranexamic acid 3 x 500 mg
Monitoring:
1. Observation of complaints
Laboratory Examination
(24/01/25)
THANK YOU
