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  • Case 3: - Name: Mrs. M - RM: 572164 - Age: 8 Years Old - Address: Narmada - Admitted: 5 January 2016

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    Rizka 'icha' Dila Pratami
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    Mrs. M, an 8 year old woman, was admitted to the hospital on January 5th, 2016 for labor at 26 weeks gestation with her third pregnancy. Upon examination, her vitals were stable and she was in the latent phase of the first stage of labor with ruptured membranes and bloody show. An ultrasound showed a breech presentation with a fetal heart rate of 136 beats per minute. Laboratory tests were ordered and she was referred to the regional hospital for continued monitoring and management of her preterm labor.

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    5-1-16 Preterm

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    Mrs. M, an 8 year old woman, was admitted to the hospital on January 5th, 2016 for labor at 26 weeks gestation with her third pregnancy. Upon examination, her vitals were stable and she was in the latent phase of the first stage of labor with ruptured membranes and bloody show. An ultrasound showed a breech presentation with a fetal heart rate of 136 beats per minute. Laboratory tests were ordered and she was referred to the regional hospital for continued monitoring and management of her preterm labor.

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    9 views5 pages

    Case 3: - Name: Mrs. M - RM: 572164 - Age: 8 Years Old - Address: Narmada - Admitted: 5 January 2016

    Uploaded by

    Rizka 'icha' Dila Pratami
    Mrs. M, an 8 year old woman, was admitted to the hospital on January 5th, 2016 for labor at 26 weeks gestation with her third pregnancy. Upon examination, her vitals were stable and she was in the latent phase of the first stage of labor with ruptured membranes and bloody show. An ultrasound showed a breech presentation with a fetal heart rate of 136 beats per minute. Laboratory tests were ordered and she was referred to the regional hospital for continued monitoring and management of her preterm labor.

    Copyright:

    © All Rights Reserved
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    Download as ppt, pdf, or txt
    of 5

    Case 3

    Name
    RM
    Age
    Address
    Admitted

    : Mrs. M
    : 572164
    : 8 years old
    : Narmada
    : 5th January 2016

    TIME

    SUBJECTIVE

    05/01/
    2016

    Patient referred from Sedau PHC with


    G3P0A2L0 26 week S/L/IU with latent
    phase 1st stage of labor. Patient
    confessed abdominal pain that
    spread to frank since yesterday
    morning (4/1/16). Blood from vagina
    (+) since 02.00 (5/1/2016). Water
    leaked out from her womb(-). Bloody
    slim (-), FM (+).

    03.35

    No history of DM, HT, and asthma.


    LMP : 10 07 - 2016
    EDD : 17 04 2016
    GW : 43-44 weeks
    History of ANC : 4x at Midwife
    Last ANC : 8/12/2015
    Result : BP 110/70, BW 45 kg, GW
    21 weeks, UFH 2 fimgers below
    umbilicus, FHB (+),
    History of USG : never
    History of family planning : pils
    Next family planning : IUD
    Obstetrical History :
    1.Abortus
    2.Abortus
    3.This

    OBJECTIVE
    General Status :
    GC : well
    BP : 90/60 mmHg
    PR : 92 bpm
    RR : 20 bpm
    Temp : 36,7 oC
    Eye : palor (-/-), icteric (-/-)
    Cor : S1S2 single regular, murmur (-),
    gallop (-).
    Pulmo : vesicular (+/+), wheezing
    (-/-), ronkhi (-/-).
    Abdomen : scar (-), striae (+), linea
    nigra (+).
    Extremity : edema (-/-), warm acral
    (+/+).
    Obstetrical Status :
    L1 : head
    L2 : back on the right side
    L3 : breech
    L4 : (-)
    UFH : 19 cm
    UC : 2x10 ~ 25
    FHB : 13-13-13
    04.30
    VT : 3 cm, eff 25 %, amnion (-),
    breech palpable, HI, denom unclear,
    palpable small parts and not palpable
    umbilical of fetus.

    ASSESSMENT

    PLANNING

    G3P0A2L0 25-26
    weeks with latent
    phase of labor
    and history of
    ROM

    DM Planning :
    Observation
    mother & fetal
    well being.
    Cek DL and
    HbSAg
    Observation
    progress of labor

    DM co to GP, GP
    coto SPV
    SPV advice :
    Observation
    progress of labor

    TIME

    SUBJECTIVE
    Chronologist at Sedau PHC
    03.00
    S : patient confessed abdominal
    pain since 22.00 (4/1/2016).
    Bloody slim (+).
    O:
    GC : well
    BP : 110/70 mmHg
    PR : 80 bpm
    RR : 20
    T : 37oC
    Palpation breech at fundus, 4/5
    FHB : (+) 136x/m
    UFH :19 cm,
    UC : 2x10~25
    VT : 2 cm, effacement 20 %,
    amnion (+), head palpable,
    denominator unclear.
    A : G3P0A2L0 26 week S/L/IU
    mother and fetal in good
    condition with inpartu latent
    phase 1st of labor.
    P:
    - CIE result of examination
    - IVFD RL 20 dpm
    - Referred to RSUDP Mataram

    OBJECTIVE
    Lab Examination :
    HB : 11,8 g/dl
    RBC : 3,84 x 106/L
    WBC : 14,49 x 103/L
    PLT : 256 x 103/L
    HCT : 33,4 %
    HbSAg : (-)
    PPT : 13,8
    APTT : 32,9
    CT : 700

    ASSESSMENT

    PLANNING

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