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Morning Report Khodijah
Morning Report Khodijah
Morning Report Khodijah
1.
PATIENT 1
: Unclear
ANC
: Midwife 5 x
Hystory of pregnancy :
1.
2.
3.
4.
This pregnancy
Vital Sign
Cons
BP
Pulse
RR
Temp
: apatis
Anemic
: (-)
: 180/100 mmHg
Icteric
: (-)
: 94x/i
Cyanosis
: (-)
: 28 x/i
Dypsnoe
: (+)
: 36,2C
Edema
: ( -)
Proteinuria : +3
Localized State :
Head : Conj Palpebra inferior anemic ( -)/(-), icteric (-)/(-)
Neck
: in normal limit
: Vesiculer
: Wheezing(-)/(-), Rhonki (-)/(-)
Obstetrical state
Abdomen
Fundal Height
Teregang
Terbawah
Movement
His
FHR
VT
:
:
:
:
:
:
assymetricaly enlarged
3 fingers above umbilical
right
head
::: Servix closed
Planning:
- Inj. MgSO4 20% 4 gram loading
dose
- Inj. MgSO4 40% 12 gram
maintenance dose
- Inj. Dexamethasone 10 10 5 5
gram (48 hours)
Report to supervisor Dr. dr. Sarma
N. Lumbanraja, M.Ked(OG), SpOG.K
Acc
APT
: 129,8
C= 33,5 S
PT
: 65,2
C= 14 S
TT
: 29,5
C = 17,8 S
Ureum
: 14,87
N : 10-50 mg/dl
Creatinin
: 1,3
N : 0,6-1,2 mg/dl
Natrium
: 128 mg/dl N : 135-155 mg/dl
Kalium
: 6,9 mg/dl N : 3,6- 5,5 mg/dl
Klorida
: 85 mg/dl N : 96-106 mg/dl
USG TAS
Single fetus, head presentation
FM (-), FHR (-)
BPD 7,69 cm
FL 5,31 cm
AC 25, 69 cm
HC 28,22 cm
Placenta corpus anterior
Amnion fluid : MVP = 4
Kesan : IUFD + IUP (29-30) gw + Head
presentation
THANK YOU