N
Age
: 21 yo
Adress : Bayan, KLU
Admitted: October, 11st 2012
TIME
SUBJECTIVE
OBJECTIVE
11/10/
2012
15.45
GC : well
Consciusness : CM
BP : 120/80 mmHg
PR : 100 bpm
RR : 24 bpm
T : 37,2oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral (+/
+)
Obstetrical Status
History of USG : History of family planning : Next family planning : Obstetrical History :
I.Abortus at 3 months
pregnancy
II.This
General Status
of
L1 : empty
L2 :
O
L3 : empty
L4 : UFH : 22 cm
EFW : UC : 3x/10 ~ 40
FHB : 13-13-13 (156 bpm)
VT : 6 cm, eff 75%, amnion (-) clear,
head palpable HI, palpable small part
(fingers) and umbilical cord.
ASSESSMENT
PLANNING
G2P0A1L0
A/S/L/IU
transverse lie +
active phase 1st
stage of labor+
history rupture of
membrane+
prolapse
umbilical cord
TIME
SUBJECTIVE
OBJECTIVE
Lab Evaluation
(11/10/2012)
HB : 12,9 g/dl
HCT : 41,1 %
WBC : 13,7 K/dl
PLT : 268 K/dl
HbSAg : (-)
BT: 145
CT: 600
12.40 wita
S : patient confessed rupture of
membrane and abdominal pain.
O : GC : well
BP : 120/70 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,5oC
Obstetrical status:
UFH : 28 cm
EFW: 2635 g
FHB : 160 bpm
His: 3x10~30
VT : 3 cm, amnion (-), palpable small
part and umbilical cord.
A
P:
Infuse RL
Intra uterine resusitation
Inj. Ampicilin 1 gram
Referred to NTB GH
ASSESSMENT
PLANNING
TIME
16.30
SUBJECTIVE
Intermittent
abdominal pain
OBJECTIVE
BP : 120/80 mmHg
PR : 80 bpm
RR : 24 bpm
T : 37,2oC
ASSESSMENT
PLANNING
Transfer patient to operation room
17.20
C-section began :
Baby was born, male, BW 2900
gram, AS 3-5, meconeal amnion
Anus (+), congenital anomaly (-),
Placenta was born manually,
complete, bleeding + 500 cc.
TIME
SUBJECTIVE
19.30
12/10/
2012
07.00
OBJECTIVE
ASSESSMENT
PLANNING
GC : well
BP : 100/60 mmHg
PR : 80 bpm
RR : 24 bpm
T : 36,0oC
UFH : 1 finger below umbilicus
UC : (+) well
UO : 30 cc/hours
2 hours post CS
GC : well
BP : 110/80 mmHg
PR : 96 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
Operation wound good
1 day post CS
Baby in NICU :
PR : 148 bpm
RR : 42 bpm
T : 36,8OC