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Morning Report

25 April 2014
Supervisor : dr. I Made Putra
Juliawan, Sp.OG
Medical Students :
Kiki, Ardi, Dandi
CASES RESUME
NORMAL LABOR
PATHOLOGY LABOR 1. G2P1A0L1 41-42 weeks S/L/IU with severe pre-eclampsia
Case Report
Name : Mrs. S
RM : 537284
Age : 32 years old
Address : Aik Genit, Batu Layar
Admitted : 24 April 2014, 10.36

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
24/04/
2014

10.36

WITA
Patient referred from Meninting
PHC with G2P1A0L0 41-42
weeks S/L/IU head presentation,
with severe preeclampsia.
water came out from her womb (-
), bloody slim (-), FM (+).
No history of blurred vision,
epigastric pain, nausea and
vomit.
No history of DM, HT, asthma.

LMP : 13/7/2013
EDD : 20/4/2012

History of ANC : > 9x at PHC
Last ANC : 23/04/2014
History of USG : never

History of family planning : (-)
Next family planning : IUD

Obstetrical History :
I. Aterm, Spontan, 3300 gr, male
2 yo
II. This

General Status :
GC : well
BP : 160/100 mmHg
PR : 84 bpm
RR : 20 bpm
T : 37,0
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesicular (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (+/+), warm acral
(+/+).

PS : 5
Prod urine : 50 cc

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 30 cm
EFW : 2945 gram
UC : 3x/10~15
FHB : 12-12-11 (140 bpm)
VT : -
G2P1A0L1 41-42
weeks S/L/IU with
severe
preeclampsia
Observation mother
& fetal well being.
Observation
progress of labor.
Bolus MgSO
4
40% 4
gram
DM co to GP, GP co
to SPV, advice :
continue therapy of
severe
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist (24/04/2014)
08.30
S : Patient came to PHC wants to check
the pregnancy..
O : GC : well
BP : 150/100 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,8
O
C
Head presentation
UFH : 28 cm
UC : -
FHB : (+) 11-11-11 (132 x/min)
VT : -
Lab : protein urine (+) 4
A :
G2P1A0L1 41-42 weeks S/L/IU head
presentation with severe preeclampsia
P :
Drip MgS04 6 g/IV (23.15)
Down Catheter
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubis > 90
o

Pelvic Score : 5
Cervix dilatation 1 cm : 1
Cervix length 2 cm : 1
Station H1 : 1
Cervix consistency moderate : 1
Cervix position mid : 1

Lab Examination :
HGB : 12,8g/dl
HCT : 36,,3 %
RBC :4,38 M/uL
WBC : 10,77 K/uL
PLT : 235 K/uL
HbSAg : (-)
Protein urine : +3
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
12.25


- General Status :
GC : well
BP : 160/100 mmHg
PR : 88 bpm
RR : 22 bpm
T : 36,8
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesicular (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (+/+), warm acral
(+/+).

PS : 5
Prod urine : 400 cc

Obstetrical Status :
UC : -
FHB : 12-12-11 (140 bpm)
VT : -
DM co to GP pro
CTG, GP ad CTG
Obs. Mother and
fetal being
14.00 - - _ DM co to GP resul
CTG, GP co to SPV,
SPV ad :
Termination with oxy
drip
Re- CTG while
inpartu
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14.10


- General Status :
GC : well
BP : 170/100 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,8
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesicular (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (+/+), warm acral
(+/+).

PS : 5
Prod urine : 600 cc

Obstetrical Status :
UC : -
FHB : 12-12-12 (144 bpm)
VT : -
RL + MgSO
4
40% 4
gram 28 tpm

15.00 - - _ Give D5% + oxy drip
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
15.00 - UC : -
FHB : 11-12-12 (140 bpm)
Flash I
Drip oxytocin began 8
tpm
15.30 - UC : -
FHB : 12-12-12 (144 bpm)
Drip oxytocin 12 tpm
16.00 - UC : -
FHB : 12-12-12 (144 bpm)
Drip oxytocin 16 tpm
16.30 - UC : -
FHB : 12-12-11 (140 bpm)
Drip oxytocin 20 tpm
17.00 - UC : -
FHB : 12-12-13 (148 bpm)
Drip oxytocin 24 tpm
17.30 - UC : -
FHB : 11-11-11 (132 bpm)
Drip oxytocin 28 tpm
18.00 Abdominal Pain and relieved UC : 2 x 10 ~ 10
FHB : 12-12-12 (132 bpm)
Drip oxytocin 32 tpm

18.30 Abdominal pain came and
relieved
UC : 2 x 10 ~ 10
FHB : 11-11-11 (132 bpm)
Drip oxytocin 36 tpm
19.00 Abdominal pain came and
relieved
UC : 2 x 10 ~ 20
FHB : 11-11-11 (132 bpm)
Drip oxytocin 40 tpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
19.00


Abdominal Pain General Status :
GC : well
BP : 160/100 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,8
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesicular (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (+/+), warm acral
(+/+).

Obstetrical Status :
UC : -
FHB : 12-12-12 (144 bpm)
VT : -
RL + MgSO
4
40% 4
gram flash II
Obs. Fetal and
mother being

21.00 Abdominal Pain
Obstetrical Status :
UC : 2x10~20
FHB : 12-12-12 (144 bpm)
VT : 1 cm eff 10 % amnion +,
denom unclear
-
Laten phase of
Labor

Give D5% + oxy drip
flas II
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
21.00 Abdominal Pain and relieved

UC : 2X10~10
FHB : 11-12-12 (140 bpm)
Drip oxytocin 40 tpm
21.30 Abdominal Pain and relieved

UC : 2x10~10
FHB : 12-12-12 (144 bpm)
Drip oxytocin 40 tpm
22.00 Abdominal Pain and relieved

UC : 2X10~10
FHB : 12-12-12 (144 bpm)
Drip oxytocin 40 tpm
22.30 Abdominal Pain and relieved
-
UC : 2x 10~10
FHB : 12-12-11 (140 bpm)
Drip oxytocin 40 tpm
23.00 Abdominal Pain and relieved
-
UC : 2x 10~10
FHB : 12-12-13 (148 bpm)
Drip oxytocin 40 tpm
23.30 Abdominal Pain and relieved
-
UC : 2 X 10~10
FHB : 11-11-11 (132 bpm)
Drip oxytocin 40 tpm
25/4/2014
00.00
Abdominal Pain and relieved UC : 2 x 10 ~ 10
FHB : 12-12-12 (132 bpm)
Drip oxytocin 40 tpm
00.30 Abdominal pain came and
relieved
UC : 2 x 10 ~ 10
FHB : 11-11-11 (132 bpm)
Drip oxytocin 40 tpm
1.00 Abdominal pain came and
relieved
UC : 2 x 10 ~ 20
FHB : 11-11-11 (132 bpm)
Drip oxytocin 40 tpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
25/04/
2014

01.00


Water leaked fom her womb (+) General Status :
GC : well
BP : 160/100 mmHg
PR : 90 bpm
RR : 20 bpm
T : 36,9
O
C
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesicular (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (+/+), warm acral
(+/+).

Obstetrical Status :
UC : 2x10~10
FHB : 12-12-12 (144 bpm)
VT : 2 cm eff 25 %, amnion (-)
RL + MgSO
4
40% 4
gram flash II
Obs. Fetal and
mother being

21.00 Abdominal Pain
Obstetrical Status :
UC : 2x10~20
FHB : 12-12-12 (144 bpm)
VT : 1 cm eff 10 % amnion +,
denom unclear , caput (+), head
palpable H1,
Urine Prod : 1000cc
-
G2P1A0L1 41-42
wk, L/H/IU with
severe
preeklampsia with
failed oxy drips
DM co to GP pro CS,
GP co to SPV, SPV
ad: CS at 07.00 am
Skin Test ampi (-)
Injection ampicillin
CIE family and
patient
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

07.00


- CS began
Baby was born (7.28),
male 3100 gram. AS
6-8. Anus (+).
Congenital anomaly (-
).
-Amnion clear
-Placenta was born
Complete. Bleeding
300cc
-Inserted IUD

-CS finished

07.35 Wound pain
GC : well
BP : 140/90 mmHg
PR : 80 x/minute
RR : 20 x/minute
T : 36,7 C

UC : +
UFH : 2 finger below umbilicus
LActive bleeding : -
UO : 100 cc/hours

Baby moved to NICU

2 hours post CS

-Obs. Mother well
being.
- Suggest mother to
mobilisation.
- Continue drip
MgSO
4
40% 6 gram
28 tpm.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
09.35 Delivery wound pain GC : well
BP : 130/90 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,8
O
C
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra : (+)
UO : 100 cc/hours
One day post
partum
Observed mother well being
Suggest mother to mobilisation,
eat and drink, medication.
Continue drip MgSO
4
40% 6
gram 28 tpm.