5. fm ward report 4 october

7/24/2019 5. FM Ward Report 4 October

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Residents : 1. dr. Donny Mega Surya

2. dr. R.A.Dewi Utari

3. dr. Paul Alwin Khoman

Department o !"stetri#s and $yne#ologyMedi#al %a#ulty & Uni'ersitas Sumatera Utara

Adam Mali( $eneral )ospital2*1+

FETOMATERNAL WARDREPORT

Monday, October 4th

2015


2/35

,ard Patients : 2

patients


3/35

Mrs. R- 2 yo- $1P*A*

Diagnosis : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0)ead Presentation 0

4i'e %etus Super'isior: dr. )otma P Pasari"u- M(ed!$- Sp.!$ Resident in #harge: dr. Donny Planning :

/ 56pe#tant Management

/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signs oimpending e#lampsia

Mrs. )- 3* yo- $1P*A*

Diagnosis : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga0 4i'e %etusSuper'isior: dr. Mel'in 8$ 9arus- M(ed!$- Sp.!$

Resident in #harge: dr. Aeng

Planning :/ Amniousion


4/35

Mrs. R- 22 yo- P2A*

Diagnosis : Post A#ti'e Phase management 0 PostSpontaneous ;aginal Deli'ery 0 PD 1 0 Anemia

Super'isior: dr.- Risman % Ka"an- M(ed!$- Sp.!$ Resident in #harge: dr. Paul Planning :

/ + 9ags PR< =ransussion 2 "ags per day


5/35


6/35

%ollow up Saturday- 3rdo !#to"er 2*1+ *7.** am


7/35

=hora6 :

9reathing sound : ;esi#ular- rales /

)eart :


8/35

D6 : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0 )eadPresentation 0

4i'e %etus

=h>

/;%D R4 0 MgS! *B 3* ##C 1 gtt>i

/n. De6amethasone gr>12 h

/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine1* mg>3* minutes ma6 12* mg>2 hours

Plan:

/56pe#tant Management

/5'aluate 'ital signs- etal heart rate- #ontra#tion and signs oimpending e#lampsia


9/35

%ollow up Sunday- th o !#to"er 2*1+ *7.** am


10/35

=hora6 :


)eart :


11/35


4i'e %etus

=h>

/;%D R4 0 MgS! *B 3* ##C 1 gtt>i

/n. De6amethasone gr>12 h

/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine1* mg>3* minutes ma6 12* mg>2 hours

Plan:


/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signso impending e#lampsia


12/35

%ollow up Monday- +th o !#to"er 2*1+ *7.** am


13/35

=hora6 :


)eart :


14/35


4i'e %etus

=h>

/;%D R4 C 2* gtt>

/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine

1* mg>3* minutes ma6 12* mg>2 hours

Plan:


/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signso impending e#lampsia


15/35

0#$10$15 04$10$15

)" : 12-? gr>d4)t : 3-+

4eu : 13-F1 >mm3P4= : 233*** >mm3

P= : 12-7 < 1 sAP==: 2-1F < 33-+ s== : 2*-+ < 1?-+ s

8R : *-F

%i"rinogen: 3?+D/Dimer: 1?**Random "lood glu#ose: F+ mg>d4Ureum : +?-3+ mg>d4

d4

8a : 131 m5G>4K : -7 m5G>44Proteinuria Urinalysis : 0

Proteinuria Urinalysis : 03


16/35


17/35

%ollow up %riday- 2ndo !#to"er 2*1+ *7.** am


18/35

=hora6 :


)eart :


19/35

D6 : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga 0 4i'e%etus

=h>

/ ;%D R4 C 2* gtt>i

/ n. 12 h

/ n. De6amethasone mg > 12 hr

/ 8iedipine ta" 3 6 1* mg

/ Po#ari sweat 2 4 > day

Plan:

/ Amniousion

/ 5'aluate 'ital signs- etal heart rate- #ontra#tion


20/35

02$10$15

)" : 1*gr>d4)t : 31-4eu : 122* >mm3P4= : 1?*** >mm3

P= : 1+-2 < 1 sAP==: 31-F < 33-+ s== : 12-+ < 1?-+ s8R : 1-*7

Random "lood glu#ose: 7F mg>d4Ureum : 1+ mg>d4d4

8a : 1* m5G>4K : 3-3 m5G>44


21/35

%ollow up Saturday- 3rdo !#to"er 2*1+ *7.** am


22/35

=hora6 :


)eart :


23/35


=h>

/ ;%D R4 C 2* gtt>i

/ n. 12 h

/ n. De6amethasone mh>12 hr



Plan:

/ Amniousion



24/35

%ollow up Sunday- tho !#to"er 2*1+ *7.** am


25/35

=hora6 :


)eart :


26/35


=h>

/ ;%D R4 C 2* gtt>i

/ n. 12 h




Plan:

/ Amniousion



27/35

%ollow up Monday- +tho !#to"er 2*1+ *7.** am


28/35

=hora6 :


)eart :


29/35


=h>

/ ;%D R4 C 2* gtt>i

/ n. 12 h




Plan:

/ Amniousion

/ 5'aluate 'ital signs- etal heart rate- #ontra#tion/ US$


30/35


31/35

%ollow up Monday- +tho !#to"er 2*1+ *7.** am


32/35

=hora6 :


)eart :


33/35

D6 : Post A#ti'e Phase management 0 Post Spontaneous;aginal Deli'ery 0 PD 1 0 Anemia

=h>

/ ;%D R4 C 2* gtt>i

/ n. 12 h

Plan:

/ =ransuse + "ags PR< 2 "ags PR< ha'e "een transused

04$10$15


34/35

04$10$15

)" : -7gr>d4)t : 1+-74eu : 17*>mm3

P4= : 1F3*** >mm3

P= : 1- < 1-1 sAP==: 31-3 < 33-7 s== : 1-+ < 1?-2 s8R : 1-1F

Random "lood glu#ose: 3? mg>d4Ureum : 13-1 mg>d4d4

8a : 1* m5G>4K : 3-3 m5G>44


35/35

THANK YOUTHANK YOU

5. fm ward report 4 october

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