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Morning Report

April, 1st 2016

Supervisor:
Dr. H. Agus Thoriq, Sp. OG
DM Jaga:
Agus, Agvianty, Amy, Widya, Fauzan
Morning Report
April, 1st 2016
Case Resume
PATHOLOGIES 1. G1P0A0L0 35-36 weeks S/L/IU with placenta previa
totalis + obs febris D-5 ec viral infection
LABOR

REMAIN
PATIENT
Case 1
Name : Ny. S
Age : 32 years old
Address : Bima
Admitted:1st April 2016
RM :576149
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

1/04/ Patient referred from Bima GH General status: G1P0A0L0 35-36 DM planing:
2016 with G1P0A0L0 35-36 weeks GC: moderate weeks S/L/IU with Diagnostik
S/L/IU head presentation with GCS: E4V5M6 placenta previa CBC, BT, CT, PPT,
10.00 obs. Febris ec DHF with placenta BP: 130/80 mmHg totalis + obs febris APTT
previa totalis. The patient HR: 88 bpm D-5 ec viral CTG
confessed cough and dyspnea RR: 36 x/min infection USG
since 2 days ago. Fever since 5 T: 360C Inspeculo
days ago. Theres no active
bleeding from her womb. Eye : anemis (-), icteric (-) Therapy
Abdominal pain (-), water leaked Thorax : Obs mother & fetal
from her womb (-), bloody slim Cor : S1S2 single reguler (murmur well being
(-), FM (+). -), (gallop -) Observation bleeding,
Pulmo : vesikuler (+/+), wheezing FHB, BP every 6
No history of DM, HT, and (-/-), Ronkhi (+/+). hours
asthma Abdomen : scar (-), striae (+), linea IVFD RL
History of family: DM (-), HT (+) nigra (-) epigastric tenderness (+)
mother, asthma (-) Extremity : edema (-/-), warm acral DM co GP, GP co SPV,
(+/+) SPV advice (1/04/16):
LMP: -
EDD: - Obstetrical status: - Lab. Test
GW: - L1: breech - Paracetamol 3x500
L2: back on left side mg PO (K/P)
History of ANC: 2x at PHC L3: head presentation - Concult Interna
Last result (12/12/2015): BP L4: 5/5 - If patient is well
110/70 mmHg, GW 18 weeks, UFH: 28 cm dyspnea (-)
UFH 2 finger below umbilicus, EFW: 2480 gram referred to Segara
FHB (+) UC: - Anak
FHB: 12-12-12 (144 bpm)
VT: - 14.00, SPVY visite :
- Lab. Test every 2-3
days
- If dypsneu still (+)
Concult Cardiologist
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
History of USG: 3x at Sp.OG Lab: (01/04/16) Co Internist, advice :
Last result (1/04/16) HB: 10,0 g/dl - obs. Febris ec viral
BPD: 34-35 w RBC: 3,87 M/dl infection
AC: 33-34 w WBC: 7,77 K/dl - Paracetamol tab 3 x
HC: 33-34 w PLT: 170 K/dl 500 mg if needed
FL: 36 w - CIE family about the
EFW: 2.442 g PPT : 12,2 patience condition
EDD: 4/05/16 APTT : 27.2
Corp ant Placenta covering entire
OUI/III/Amnion enough Lab at Prodia ( 31/03/16)
Dengue IgG (-)
History of family planning: - Dengue IgM (-)
Next family planning: -

Obstetrical history:
I. This
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Chronology at Bima GH

01/4/2016

S: Patient came to Bima GH refered from


PHC after confessed febris since (26/3/16).

O:
GC: well
GCS: E4V5M6
BP: 100/60 mmHg
HR: 89 bpm

A: G1P0A0H0 35-36 weeks S/L/IU with


placenta previa totalis + obs. Febris ec DHF

P:
- Co Cardiologist
- Do USG : 29/03/16
- Concult Interna (28/03/16)
- Amlodipine 2x10 mg
- Refer to NTB GH

27/03/2016
- Inj. Ceftriaxon 2 x 1
- Inj. Ranitidin 2 x 1
- Inj. Dexamethason 2 x 6 mg
- Vit. C 2 x 400 mg
- PCT Infus 4 x 1
- Kaltrofen sup 3 x 1
- RL 12 kolf
- NaCl1 kolf
- Drip MgSO4 4 gr 2 fl : RL 500 cc
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
14.00 Dyspneu (+) BP: 150/80 mmHg G1P0A0L0 35-36 - O2 4 lpm
Active bleeding from her HR: 82 bpm weeks S/L/IU with - Obs mother & fetal well being
womb (-) RR: 40 placenta previa
T: 36,70C totalis + obs febris
DJJ : 12-12-12 (144 bpm) D-5 ec viral
UC: - infection

15.00 Dyspneu (+) BP: 150/80 mmHg - O2 4 lpm


Active bleeding from her HR: 82 bpm - Obs mother & fetal well being
womb (-) RR: 38
T: 36,70C
DJJ : 11-11-12 (132 bpm)
UC: -

16.00 Dyspneu (++) BP: 140/80 mmHg DM planning :


Active bleeding from her HR: 87 bpm - Pro ECG
womb (-) RR: 40 - Pro Thoraks photo
T: 36,90C - Obs mother & fetal well being
DJJ : 12-13-12 (148 bpm) DM co GP, GP advice :
UC: - - Acc to ECG
- Acc to thoraks photo
Tho : rh (+/+), wheez (-/-)
16. 20 WITA :
Patient go to Radiologyst Lab and do the
thoraks photo. Result is :
CTR > 50 % cardiomegali

DM Planning :
- Co Cardiologist
- Co Pulmologist
GP advice :
- Acc to co cardiologist
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
17.00 Dyspneu (+) BP: 140/80 mmHg G1P0A0L0 35-36 - O2 4 lpm
Active bleeding from her HR: 82 bpm weeks S/L/IU with - Obs mother & fetal well being
womb (-) RR: 30 placenta previa
T: 36,70C totalis + obs febris
DJJ : 12-12-12 (144 bpm) D-5 ec viral 17.30, Cardiologist advice :
UC: - infection + - Inj. Lasix 1 x 1 amp
Decomp. Cordis

18.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm


Active bleeding from her HR: 84 bpm - Obs mother & fetal well being
womb (-) RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

19.00 Dyspneu (++) BP: 140/80 mmHg - O2 4 lpm


Active bleeding from her HR: 88 bpm - Obs mother & fetal well being
womb (-) RR: 32
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

20.00 Dyspneu (++) BP: 130/80 mmHg - O2 4 lpm


Active bleeding from her HR: 86 bpm - Obs mother & fetal well being
womb (-) RR: 30 - Paracetamol tab 500 mg po
T: 37,80C
DJJ : 14-15-15 (176 bpm)
UC: -

21.00 Dyspneu (+) BP: 140/80 mmHg - O2 4 lpm


Active bleeding from her HR: 80 bpm - Obs mother & fetal well being
womb (-) RR: 28
T: 37,40C
DJJ : 12-13-12 (148 bpm)
UC: -
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
22.00 Dyspneu (+) BP: 140/80 mmHg G1P0A0L0 35-36 - O2 4 lpm
Active bleeding from her HR: 82 bpm weeks S/L/IU with - Obs mother & fetal well being
womb (-) RR: 30 placenta previa
T: 36,70C totalis + obs febris
DJJ : 12-12-12 (144 bpm) D-5 ec viral
UC: - infection +
Decomp. Cordis

23.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm


Active bleeding from her HR: 84 bpm - Obs mother & fetal well being
womb (-) RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

24.00 Dyspneu (+) BP: 140/80 mmHg - O2 4 lpm


Active bleeding from her HR: 88 bpm - Obs mother & fetal well being
womb (-) RR: 26
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

06.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm


Active bleeding from her HR: 88 bpm - Obs mother & fetal well being
womb (-) RR: 24
T: 35,80C
DJJ : 12-12-12 (144 bpm)
UC: -
Case 2
Name : Mrs. V
Age : 20 years old
Address : Lingsar
Admitted : April 1st, 2016 at 20.00 PM
No. RM : 576165
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
01/04/2016 Patient reffered from Lingsar General status G1P0A0L0 42-43 DM planning:
21.30 PHC with G1P0A0H0 42 weeks GC : well weeks S/D/IU head Diagnostic :
S/D/IU inpartu laten phase of GCS : CM (E4V5M6) presentation with - CBC
labor. Patient 9 months BP : 120/90 mmHg inpartu active phase
pregnant confessed that the PR: 80 bpm of labor + IUFD Therapy :
fetal movement decreased RR: 20 bpm - Ampicillin 1 gr IV / 6
since 2 days ago (29/03/2016) T: 36.6C hours
and confessed that the fetal - Obs. progress of labor
movement cannot be felt at all Local status - CIE : CIE mother and
since morning (1/04/16). Eye : an (-/-), ict (-/-) family about
Abdominal pain (+) since 05.00 Pulmo : ves (+/+), rh (-/-), wh diagnostic planning
(1/04/16), water leak from her (-/-) and therapeutic
womb (-), bloody slime (+) since Cor : S1S2 single regular, m planning
15.00 (-), g (-)
Abd : scar (-), striae DM co GP, GP co SPV,
History of DM (-), HT in gravidarum (+), linea nigra (-), SPV advice :
pregnancy (-), asthma (-) and ballottement (+) - Acc to obs. progress
allergy (-). Ext : edema (-/-), warm acral of labour.
History of Family: DM (-),HT (-), (+/+).
asthma (-)
Obstetric status
LMP : 13-06-2015 L1 : breech
EDD : 20-03-2016 L2 : back on the right side
GW : 42-43 weeks L3 : head
L4 : 4/5
History of ANC : 8x at UFH: 29 cm
Posyandu EFW : 2635 g
Last result: (12/03/2016) UC : 3x10 -30
BP 110/70 mmHg, GW 40-41 FHB : (-)
weeks, UFH 32 cm, head VT : 4 cm, eff 50%, amnion
presentation (+), head palpable, H1, ROA,
not palpable small part and
umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
History of USG :1x at SpOG Lab
Last result: (01/04/2016) Hb 10,6 g/dL
S/IUFD/FHB(-) 36 weeks, RBC 4,8 x 10^6/uL
anhydramnion, spalding sign (+) HCT 34,6 %
WBC 21,43 x 10^3/uL
History of family planning: - PLT 325 x10^3/uL
Next family planning : - Protein (-)
PTT: 9
Obstetrical history APTT: 16
I. This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology at Lingsar PHC
(1/04/2016)

19.00
S:
Patient confessed abdominal
pain (+) since (05.00
01/04/2016), water leak out
from her womb (-), bloody slime
(+) since 15.00, FM (+).

O:
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.5C

Obstetric status
UFH 30 cm, breech palpable in
the fundus, head presentation,
back on the right side, FHB(-),
4/5, UC : 2x10-15

VT : 2 cm, eff 25%, amnion


(+), head palpable, H1,
denominator unclear, not
palpable small part and
umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
A: G1P0A0L0 42 weeks S/D/IU
mother in good condititon with
inpartu laten phase

P:
- (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
01.30 Abdominal pain (+) General status G1P0A0L0 42-43 - Obs mother well being
(02/04/16) GC : well weeks S/D/ IU head - Obs. progress of labor
GCS : CM (E4V5M6) presentation with - pro amniotomi
BP : 120/90 mmHg inpartu protraction
PR: 80 bpm active phase of labor
RR: 20 bpm + IUFD DM consult to GP, GP consult to
T: 36.6C SPV, advice:
UC : 3x10 -30 - Amniotomi
FHB : (-)
VT : 4 cm, eff 01.45
50%, amnion (+), Do the amniotomi amnion
head palpable, H1, meconeal (+) 10-20 cc
ROA, not palpable
small part and
umbilical cord

02.30 Abdominal pain (+) General status G1P0A0L0 42-43 - Obs mother well being
GC : well weeks S/D/IU head - Obs. progress of labor
GCS : CM (E4V5M6) presentation with - pro acceleration dryp oxy
BP : 120/90 mmHg inpartu protraction
PR: 80 bpm active phase of labor
RR: 20 bpm + IUFD DM consult to GP, GP consult to
T: 36.6C SPV, advice:
UC : 3x10 -30 - acc to acceleration with oxy dryp
FHB : (-) start 8 dpm
VT : 4 cm, eff
50%, amnion (+),
head palpable, H1,
ROA, not palpable
small part and
umbilical cord

11.00 pm Abdominal pain (+) GC ; well -Ins. Misoprostol 50 ug/ vaginam


Consciousness : CM -Obs mother well being
BP: 140/90 mmHg -Obs. progress of labor
PR : 96 bpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

15.15 am Abdominal pain increase General status -Obs mother well being
GC : well -Obs. progress of labor
consciousness:
CM -DM consult to GP, GP consult
BP : 140/90 mmHg to SPV, advice:
PR: 90nbpm - Amniotomi do amniotomi
RR: 20 bpm amnion clear, volume 2000 cc
T: 36.8C
UFH: 38 cm
UC : (+) 1x10~15
VT: 2 cm, eff
25%, amnion (-)
clear, head
palpable, H1, not
palpable small
part & umbilical
cord.