Morning Report

October 14th, 2012

Supervisor : dr. Edi Prasetyo W, Sp.OG

Medical Students :
Diah, Rani, Dini F, Subi, Indah
CASES RESUME

NORMAL LABOR PATHOLOGY LABOR

1 1. G1P0A0L0 37-38 weeks /S/L/IU head presentation with severe preeclampsia and impending eclampsia + obs. dyspnea 2. G1P0A0L0 35-36 weeks/S/L/IU head presentation with PROM <12 hours 3. G1P0A0L0 A/S/L/IU head presentation with neglected active phase 1st stage of labor

Case Report
Identity Name Age Address RM Hospitalization : : : : : Mrs. V 17 years old Gangga 061060 October, 14th 2012

TIME 14/10/2 012 12.00

SUBJECTIVE Patient referred from Gangga PHC with G1P0A0L0 41-42 weeks/S/L/IU l with severe preeclampsia and dyspnea. Patient confessed abdominal pain since 01.00 (14/10/2012). History rupture of membrane (-), bloody slim (-), FM (+). Nausea (-), vomiting(-), visual disturbance (-), epigastric pain (+), seizure (-). headache (+). Dyspnea since 5 days ago, intermittent. No history of DM, HT, asthma. LMP : 26-01-12 EDD : 02-11-12 History ANC : > 4x at Posyandu Last ANC : 03-10-2012 Result : BP 120/90 USG : never Last USG : History of family planning :Next family planning : IUD Obstetric History : 1. This

OBJECTIVE General Status GC : well GCS: E4V5M6 BP : 160/120 mmHg PR : 110 bpm RR : 34 bpm T : 36,9oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single regular, murmur (-), gallop (-). Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (+/+), warm acral (+/+). Obstetric Status L1 : breech L2 : back on the left side L3 : head L4 : 4/5 UFH : 28 cm EFW : 2635 gram UC : FHB : 11-12-12 (140 bpm) VT : (-)

ASSESSMENT G1P0A0L0 37-38 weeks /S/L/IU head presentation with severe preeclampsia and impending eclampsia + obs. dyspnea

PLANNING Observe mother and fetal well being. 02 2 lpm DM announce to SPV pro management with severe preeklampsia therapy (Bolus MgSO 4 40% 4 gr IV, Continue Drip MgSO 4 40% 6 gram 28 dpm, Nifedipin 3x1) and CS. SPV acc. Prepare CS at 20.00 wita. CIE patient and family.

TIME

SUBJECTIVE Chronologist at Gangga PHC (14/10/2012) : 10.00 S : Patient confessed abdominal pain since 01.00 wita, dyspnea since 5 days ago. FM (+). LMP : 26-01-12 O:

OBJECTIVE Pelvic evaluation: Spina ischiadica not prominent Os coccygeus mobile Arcus pubis >90

ASSESSMENT

PLANNING

GC : well BP : 160/110 mmHg PR : 88 bpm RR : 32 bpm T : 36,7C

UFH : 34 cm EFW: 3565 g UC :FHR : 11-12-12 (140 bpm) VT : (-) Lab : Hb: 11,7 g/dl Proteinuria: +3 A: G1P0A0L0 41-42 mg S/L/IU preeclampsia and dyspnea. with severe

Lab : HB: 12,8 g/dl Hct: 40,8% PLT: 377 x 103/L WBC: 10,8 x 103/L SGOT: 21 SGPT:11 Kreatinin: 0,6 mgl/dl Ureum: 23 mgl/dl HBsAg : (-) Proteinuria: +3

P : (10.30 wita) 02 2 lpm Salbutamol 3x1 GG 3x1 Drip infus RL + MGSO4 20 % (6 gram) 28 dpm Amoxicillin 3x500 mg Set DC Refer to NTB GH

TIME 13.00

SUBJECTIVE Patient confessed dyspnea (+) headache,

OBJECTIVE GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 84 x/mnt RR: 30 x/mnt T: 36,4 C

ASSESSMENT

PLANNING - Observe mother and fetal well being.

UC: FHB: 12-12-11 (140 x/min) UO: 50 cc/hour

14.00 Patient confessed dyspnea (+) headache, GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 96 x/mnt RR: 28 x/mnt T: 36,4 C UC: FHB: 12-12-12 (144 x/min) UO: 50 cc/hour 15.00 Patient confessed dyspnea (+) headache, GC: well GCS: E4V5M6 TD: 160/120 mmHg HR: 94 x/mnt RR: 32 x/mnt T: 36,4 C UC: FHB: 12-12-11 (136 x/min) UO: 50 cc/hour - Observe mother and fetal well being. - Observe mother and fetal well being. - MgSO4 drip flash II

TIME 16.00

SUBJECTIVE Patient confessed headache , dyspnea (+)

OBJECTIVE GC: well GCS: E4V5M6 TD: 170/110 mmHg HR: 84 x/mnt RR: 26 x/mnt T: 36,4 C UC: FHB: 12-12-11 (140 x/min) UO: 30 cc/hour

ASSESSMENT

PLANNING - Observe mother and fetal well being.

17.00

Patient confessed dyspnea (+)

GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 962x/mnt RR: 28 x/mnt T: 36,4 C UC: FHB: 12-12-12 (144 x/min) UO: 30 cc/hour

- Observe mother and fetal well being.

18.00

GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 88 x/mnt RR: 26 x/mnt T: 36,4 C UC: FHB: 12-12-11 (136 x/min) UO: 50 cc/hour

- Observe mother and fetal well being.

TIME 19.00 -

SUBJECTIVE

OBJECTIVE GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 84 x/mnt RR: 30 x/mnt T: 36,4 C UC: FHB: 12-12-11 (140 x/min) UO: 50 cc/hour

ASSESSMENT

PLANNING - Observe mother and fetal well being. - Prepare CS -skin tes ampi (-) Inj ampi 2 g IV

19.50

GC: well GCS: E4V5M6 TD: 160/110 mmHg HR: 96 x/mnt RR: 28 x/mnt T: 36,4 C UC: FHB: 12-12-12 (144 x/min) UO: 30 cc/hour

- Take patient to operation room

TIME 21.00

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING CS began Baby was born, male, BW : 2600 gram, BL: 49 cm, A-S : 7-9, anus (+), congenital anomaly (-), Placenta was born manually, complete, Bleeding : 500 cc CS finished

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING Observed mother and baby well being Suggest mother to mobilisation.

23.00

Dyspnea (-)

GC: well Cons: CM BP: 140/90 HR : 80 bpm RR : 20 tpm T : 36,0 C UFH : 1 finger below umbilicus UC : + GC: well Cons: CM BP: 140/80 HR : 88 bpm RR : 20 tpm T : 36,6 C UFH : 1 finger below umbilicus UC : + Baby in NICU PR:140 RR: 44 T: 36,2

2 hours post CS

15/10/2 012 07.00

Patient confessed delivery wound pain, dyspnea (-)

1 day post CS

Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.