FETOMATERNAL WARD

REPORT
Thursday, September 3rd
2015

Residents :

1. dr. Donny Mega Surya

2. dr. R Ajeng
3. dr. Paul Alwin Khoman

Department of Obstetrics and Gynecology

Medical Faculty Universitas Sumatera Utara
Adam Malik General Hospital
2015

1. Mrs. R, 29 yo, P1A0

Diagnosis

: Post STAH d/t uterine atony + PD 1

Plan
: Transfussion 5 bags PRC
Supervisor In Charge
: Dr. dr. Sarma N Lumbanraja,
Mked(OG), SpOG(K)
Resident In Charge
: dr. Donny
Days in care
: 5 days

New patient
person

: 1

1 PATIENT
st

 Follow up 1 September 2015

S : Heartburn
O : Sens : Fully alert Anemic : (+)
BP
: 120/80mmHg
Icteric : (-)
HR
: 84/min
Cyanotic : (-)
RR
: 20x/min Dyspnoe : (-)
Temp : Afebrile Oedem
: (-)
Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic +/+,

icteric (-)/(-)
Nose : Nasogastric tube (+), greenish colored fluid, vol 60cc
Ear

: Within normal limit

Mouth
Neck

: Within normal limit

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax

: Breathing sound
: Vesicular
Abnormal breathing sound
: (-)
Heart
: Cor S1S2 (N)
Abdomen
: Laxed, peristaltic (+)
Operation wound
: Covered with gauze
Drain: greenish colored fluid, vol vol 500cc
Micturition
: (+) via catheter UOP 400cc/hour
Defecation
: (-), flatus (+)

A : Post STAH d/t Uterine atony + PD 4

P : - IVFD RL 20 drops/minute
- Inj Ketorolac 30 mg/8 hours
- Inj Ceftriaxone 1 gr/12 hours
- Drips Metronidazole 500 mg/8 hours
- Inj Ranitidine 1 amp / 8 hours
- Magatida Syr 3C1
- Additional therapy as per Surgery & Anesthesia department
Planning: Transfuse 2 bags of fresh WB

 Follow up 2 September 2015

S : Heartburn
O : Sens : Fully alert Anemic : (+)
BP
: 120/80 mmHg Icteric : (-)
HR
: 81/min
Cyanotic : (-)
RR
: 18x/min Dyspnoe : (-)
Temp : 37oC
Oedem
: (-)
Generalized state
Head : Eye

: Conjuctive Palpebra Inferior anemic +/+, icteric

(-)/(-)
Nose : Within normal limit
Ear

: Within normal limit

Mouth
Neck

: Within normal limit

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax

: Breathing sound
: Vesicular
Abnormal breathing sound
: (-)
Heart
: Cor S1S2 (N)
Abdomen
: Laxed, peristaltic (+)
Operation wound
: Covered with gauze
Drain: greenish colored fluid, vol vol 500cc
Micturition
: (+) via catheter UOP 400cc/hour
Defecation
: (-), flatus (+)

A : Post STAH d/t Uterine atony + PD 5

P : - IVFD RL 20 drops/minute
- Inj Ketorolac 30 mg/8 hours
- Inj Ceftriaxone 1 gr/12 hours
- Drips Metronidazole 500 mg/8 hours
- Inj Ranitidine 1 amp / 8 hours
- Magatida Syr 3C1
- Additional therapy as per Surgery & Anesthesia department
Planning: Transfuse 2 bags of fresh WB

 Follow up 3 September 2015

S : Heartburn
O : Sens : Fully alert Anemic : (+)
BP
: 120/70 mmHg Icteric : (-)
HR
: 85 x/min Cyanotic : (-)
RR
: 18 x/min Dyspnoe : (-)
Temp : 37,3 oC
Oedem
: (-)
Generalized state
Head : Eye

: Conjuctive Palpebra Inferior anemic +/+, icteric

(-)/(-)
Nose : Within normal limit
Ear

: Within normal limit

Mouth
Neck

: Within normal limit

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax

: Breathing sound
: Vesicular
Abnormal breathing sound
: (-)
Heart
: Cor S1S2 (N)
Abdomen
: Laxed, peristaltic (+)
Operation wound
: Covered with gauze
Drain: greenish colored fluid, vol vol 110 cc
Micturition
: (+) via catheter UOP 50 cc/hour
Defecation
: (-), flatus (+)

A : Post STAH d/t Uterine atony + PD 6

P : - IVFD RL 20 drops/minute
- Inj Ketorolac 30 mg/8 hours
- Inj Ceftriaxone 1 gr/12 hours
- Drips Metronidazole 500 mg/8 hours
- Inj Ranitidine 1 amp / 8 hours
- Magatida Syr 3C1
- Additional therapy as per Surgery department
Planning: Transfuse 2 bags of fresh WB

THANK YOU