Morning Report Friday, 30th August 2013

MRS
: Obstetric and Gynecology Obstetri Physiologic Patologic Gynekologiy Surgery Obstetric Gynecology Rest of Delivery Room Cempaka ward ICU

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Leader of stage
Coass:
Leader : Ahmad Fachrurrazi Delivery Room: Yasmin Cempaka ward/ elective surgery: Faizal Mahfudh Policlinic: Joyce

1. Mrs. Siti/31 y.o/ Alive Child :1 (10 y.o) Hospitalized 29/8/2013 about 10.05 WITA Reffered by : Policlinic Ulin Hospital First diagnosis : G2P1A0 + 37 - 38 weeks pregnancy not inparturia + Severe Pre eclampsia + susp. Macrosomia baby + SLFIU + head presentation + EFW 4200 gr Last diagnose : P2A0 + Post SC indicated by severe preeklampsia + macrosomia baby The baby was born at 14.00//4400gr/52cm/7-8-9 The mother last condition: TD = 160/80 HB = 14,3 The baby last condition : In stable condition, rooming with her mother at cempaka ward Additional Information : Hb pre op. 14,2 g/dl, dipstick +2

2. Mrs. Rusmawati /37 y.o/ Alive Child :3 (10 y.o) Hospitalized 29/8/2013 about 11.30 WITA Reffered by : Public health Tabunganen First diagnosis : G4P3A0 + 34 weeks pregnancy not inparturia + PROM 18 hours + SLFIU + Gemelly Last diagnose : P5A0 + Post SC indicated by Gemelly and Post Tubektomi bilateral The 1st baby was born at 15.36 / / 2300gr / 46cm / 7-8-9 The 2nd baby was born at 15.38/ / 2100gr / 46cm / 7-89 The mother last condition: TD = 120/80 HB post OP : 10,4 The baby last condition : In NICU II B Additional Information : Hb pre op. 10,6 g/dl

3. Mrs. Idoh Mulyani/28 yo Hospitalized 27/8/2013, 02.00 pm Referred From Policlinic RSUD Ulin with diagnose Ca vulva stage 1B First diagnosed: Ca Vulva Stage 1B

29/8/2013 10.15 am : Hemivulvektomi dextra and limfadenektomi.

Present Diagnose: Post hemivulvektomi dextra a.i Ca vulva stage 1B

Patient Last Condition: BP 120/80, others in the normal range Keterangan tambahan : Hb Post Op 12,9

4. Mrs. Mursida/33 y.o/ Entering the hospital since 30/8/2013, pkl 04.00 referred: midwife: G1P0A0 breech presentation 1st diagnose : G1P0A0 + 39-40 weeks of pregnancy inpartu kala 2 + Breech Presentation + SFLIU 30th August 2013 at 04.40 born baby girl/1850/43/7-8-9 Last diagnose : P1A0 + Post Partum Manual Aid+perineorafi (H0) Mother Last Condition: BP: 120/80 mmHg Baby Last condition : In stable condition, in Teratai ward level 2A

REST DELIVERY ROOM

1. Mrs. Hairiati/ 30 y.o Hosp. at 29-08-2013 10.00 pm Patient reffered from Obstetrician with G2P1A0 33 W + Not in Labour + HAP e.c PPT First Diagnose : G2P1A0 33 W + Not in Labour + HAP e.c PPT + SLFIU + Head presentation Treatment : -IVFD -Dexametahason 2x6 mg -Hb Count -Total Bed Rest -CITO OP (this morning) Patient Last Condition : BP : 110/80 mmHg, others in the normal range Annotate : Hb 10,7, Active Bleeding (+)

2. Mrs. Lusiana Kartika Sari/30 y.o alive child : 2 children, 6 y.o Hospitalized 22nd August 2013 , 09.45 a.m Refferal :1st Diagnose: Ca Cervix Management : waiting visit of supervisor Annotate : Hb

3. Mrs. Giyarti/ 20 y.o Hosp. at 29-08-2013 09.35 pm Patient referred by midwife to delivery room with diagnose G1P0A0 41 weeks + Susp. Macrosomia + Latent Phase + Head Presentation + SLFIU. First Diagnose : G1P0A0 41 weeks + Latent Phase + SLFIU + Head Presentation Treatment : -CTG -Observation The Progress of Delivery Patient Last Condition : BP : 130/90 mmHg, others in the normal range Annotate : Hb 11,8. WBC 12,7. Opening 7 cm/ Hodge 2/DJJ 144 HIS 2x / 10 menit / 20-40 detik

4. Mrs. Elma Dhini/ 23 y.o Hosp. at 29-08-2013 12.00 am Patient came by herself (not in reffered) to delivery room First Diagnose : G2P1A0 + 32-33 weeks + Not in Labour + Severe Preeclampsia + HAP + SLFIU + Head Presentation + Post SC 3 years Ago
Treatment : -Bedrest -MgSO4 Regiment -Nifedipin 3x10 mg -Laboratory Examination -Bleeding monitoring -Total Bedrest Patient Last Condition : BP : 180/110 mmHg, others in the normal range Annotate : Hb 15,3. Sahli : 12,1 Urinary Protein : +3

The Scheduled Treatment from Cempaka

1. a. b. 2. Operation: Sectio caesaria elektif: - person Ginekologi: 1 person Other: Kuretage: - persons

Ginecologist
1. Mrs. Lia/32 Years Old 3 child alive MRS 28/8/2013, 17.45 Referred : Midwife with diagnose Post Partum Hemorrhage First Diagnosed : P3A0 Post Spontan Labour + HPP + Ruptur Uteri Last Diagnosed : P3A0 Post Histerectomi Supravaginal + Complete Rupture Uteri The Scheduled Operation : Rehecting Drain Operator: dr. Iwan Darma Putra Sp.OG (K) Last Examination : BP 100/70 Add Information: HB: 9,5

Supervisor List
State Supervisor (period : 26 August 1 July 2013)
Kamar Bersalin : dr. Ferry Armanza, Sp.OG (K) Cempaka : dr.Iwan Darma Putra, Sp.OG (K) Policlinic : dr. Bambang Abimanyu, Sp.OG (K) Operator Obstetri : Dr.dr.Adjar Wibowo, Sp.OG (K) Operator Ginekologi : dr.Hariadi, Sp.OG (K)

Present Supervisor (30 August 2013):

Dr. Ihya Ridlo Nizomy, Sp.OG

THANK YOU