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Morning Report July, 21 2014: Supervisor: Dr. I Made Putra Juliawan, SP - OG DM Jaga: Zia, Yid, Santi, Ayu
Morning Report July, 21 2014: Supervisor: Dr. I Made Putra Juliawan, SP - OG DM Jaga: Zia, Yid, Santi, Ayu
Morning Report
st
July 21 2014
Case Resume
NORMAL
LABOR
Case 1
Name : Mrs. N
Age : 16 years old
Address : Gn.sari, Lobar
Admitted : 21-07-2014
No. RM : 54-48-09
G2P0A1L0 29-30 weeks/S/L/IU head
presentation + PROM > 24 hours
Time
Subject
21-072014
12.00
Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 84 x/m
RR: 20 x/m
T: 36,6 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
M(-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar
(-)
Ext : edema (-/-), warm
(+/+)
Obstetric status
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5
UFH: 35 cm
EFW : 3720 gram
UC : (-)
FHB : 12-12-12
Assessment
Planning
G2P1A0L1
A/S/L/IU with
latent phase
Time
Subject
History of USG : 1x
Last USG (18-082014): S/L/IU head
presentation, female,
placenta at fundus
grade II, 28-30
weeks , EFW 1377 gr,
EDD : 01/11/2014
History of family
planning : Next family planning :
injection
History of obstetric :
I. AB 3 months
II.This
Object
VT: 2 cm, eff. 25%, amnion
(+), head palpable, denom
unclear, H1, unpalpable
small part/umbilical cord
Lab:
HGB = 10.7 g/dl
RBC = 3.86 K/ul
WBC = 8.81 M/ul
HCT : 32.7 %
PLT = 196 M/ul
HBsAg = (-)
Assessment
Planning
Time
Subject
14.00
16.00
Abdominal
wound pain
Object
Assessmen
t
Planning
Do CTG
Co to GP, acc drip
GC: well
BP: 120/80 mmHg
HR: 82 bpm
T 36,70C
RR 20 x/m
UC: 2x/10 ~ 20
FHB: 11-12-12
Start acceleration
(oxytocin drip) 8 dpm
16.30
UC: 2x/10 ~ 20
FHB: 12-12-12
17.00
UC: 2x/10 ~ 20
FHB: 12-11-12
17.30
UC: 2x/10 ~ 20
FHB: 12-12-12
Time
17.30
Subject
Patient
confessed
abdominal pain
Object
UC: 4x/10 ~ 40
FHB: 13-13-12 (152x/mnt)
VT: 8 cm, eff. 80%,
amnion (-) clear, head
palpable, denom unclear,
H1, unpalpable small
part/umbilical cord
Assessmen
t
Planning
Active phase
of labor
20.00
GC: well
BP: 120/80 mmHg
HR: 82 bpm
T 36,70C
RR 20 x/m
UC: 4x/10 ~ 40
FHB: 12-12-12
20.30
UC: 4x/10 ~ 40
FHB: 12-12-12
21.00
UC: 4x/10 ~ 40
FHB: 12-12-12
Time
Subject
Object
Assessmen
t
Planning
21.30
UC: 4x/10 ~ 40
FHB: 12-12-12
VT: 6 cm, eff. 25%,
amnion (+), head palpable,
denom unclear, H1,
unpalpable small
part/umbilical cord
22.00
Patient
confessed water
came out from
her womb
UC: 4x/10 ~ 40
FHB: 12-11-11
VT: complete, eff. 100%,
amnion (-) clear, head
palpable, denom unclear,
H2, unpalpable small
part/umbilical cord
Inspection: perineum
bulging, opening vulva,
Mother wants to
bearing down
22.30
Time
Subject
Object
Assessment
Planning
01.30
Abdominal pain
GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 79x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 150cc/ 2 hours
Lokea rubra (+) 10cc
2 hours post
partum
Observation mother
and baby well being
Suggest mother to
eat and drink
Suggest mother to
mobilization
Suggest mother to
early breast feeding
22-072014
7.00
am
Abdominal wound
pain
GC: well
cons:E4V5M6
BP: 100/60 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 60cc/hour
Lokea rubra (+) 5 cc
Baby:
Pulse : 144 bpm
RR : 52x/m
T : 36,7 C
.. Thank
You ..