Download - 25-1-09
-
8/13/2019 25-1-09
1/7
Morning Report25 January 2009
Supervisor : dr. Agus Thoriq , SpOGMedical Student:
1. Hadian2.Miftah
1.
Cases resume :
1. LMR (history SC) + PROM + hipertension 1
2. Prolong in 2nd
stage of labor 1
3. Retensio placenta 1
4.
Normal labor 3
-
8/13/2019 25-1-09
2/7
s
Name / Age : Mrs. Ruslul / 20 years old CTH : 25 January 2009
Address : Pringgarata Time : 10.30
Time Subject Object Assesment Planning
10.30 Patient refered by PKM Pringgarata
(midwife: Nining Ardiani) with retensio
placenta
Chronologis:
08.00 (25-1-09)
Patient came to PKM Pringgarata
confess abdominal abdominal
discomfort and felt to bearing down.
Examination:
General status: wellBP: 100/70 mmHg PR: 80x/mnt
T: 36C
UFH: 28 cm FHB: (-)
VT: DC 10 cm, eff 100 %, AM (-), head
palpable, descensus HIII.
Patient then conducted to labor
08.30 (25-1-09)
Baby was born, female, 2000 g, AS: 0
(death).Management 3th stage of labor
09.00 (25-1-09)
Placenta was not born.
Patient then refered to Mataram general
hospital.
Tx: IVFD 2 fls RL rapid drop.
General status :
General condition: well
Conciousness: CM
BP: 100/70 mmHg
RR: 20 x/mnt
PR: 96 x/mnt
T: 36,6C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range
UFH : 2 finger above umbilicus
UC: wellInspection : active bleeding (-),
umbilical cord appear in vulva
VT: DC 1 cm palpable umbilical
cord.
Laboratorium:
Hb: 11,4 g%
WBC: 20.000/mm3
PLT : 306.000/mm3HCT : 31,4 %
Retensio placenta Observation vital sign
and bleeding
Lab examination
Report to supervisor:
advice :
Antibiotic
Drip Oxytocin 1
ampul 24 drop/mnt
-
8/13/2019 25-1-09
3/7
Time Subject Object Assesment Planning
11.30 Vaginal bleeding (-) General status: well
BP: 100/70 mmHg
UFH: 2 finger above umbilical
UC: well
Retensio placenta Ampicilin test (-)
Injection 1 g ampicilin
Applied oxytocin drip
24 drop/mnt
14.00 Vaginal bleeding (-)
Abdominal discomfort (+)
General status: well
BP: 100/70 mmHg
UFH: 2 finger above umbilical
UC: well
Retensio placenta Applied oxytocin drip
24 drop/mnt
16.00 Vaginal bleeding (-)
Abdominal discomfort (-)
General status: well
BP: 100/70 mmHg
UFH: 2 finger above umbilical
UC: well
Retensio placenta Supervisor call, advice:
Prepare manual placenta
in operation room
17.00 Vaginal bleeding (-) General status: well
BP: 100/70 mmHg
UFH: 2 finger above umbilical
UC: well
Retensio placenta Applied dauer catheter
Injection 2 g ampicilin
Send patient to operation
room
-
8/13/2019 25-1-09
4/7
Time Subject Object Assesment Planning
18.12 Operation begun
Operator done manual placenta,
result: not complete
Then operator done curetase, result:
placenta remain
Suspect rest plaenta Supervisor advice:
Lab examination
Pro USG at thusday
Ampicilin 1 g/days
Mefenanic acid 3 x daily
19.00 feeling weak
Vaginal bleeding (-)
General status:well
BP: 110/80 mmHg PR: 90 x/mnt
Active bleeding (-)
Suspect rest placenta Lab examination
Pro USG at thusday
21.00 Vaginal bleeding (-) General status: well
BP: 110/70 mmHg
Active bleeding (-)
Lab:
Hb: 10,5 g%
WBC: 22.100/mm3
PLT: 253.000/mm3
HCT: 28,3%
Suspect rest placenta Pro USG at thusday
-
8/13/2019 25-1-09
5/7
s
Name / Age : Mrs. Halwiati / 36 years old CTH : 22 January 2009
Address : Lingsar Time : 20.00
Time Subject Object Assesment Planning
15.00 Patient came to emergency care unit
with pregnancy 9 month and confess
vaginal discharge.
Chronologis:
Patient confess vaginal discharge since
12.00 (25-1-09). Abdominal discomfort
(-).
LMP: forgot
History of pregnancy
1. male, SC (transvers presentation),
3000 g, 8 years
2. this
History of family planing:
Injection 3 month since 8 years ago.
Last injection 1 years ago.
Planing for family planing:
IUD
General status :
General condition: well
Conciousness: CM
BP: 120/80 mmHg
RR: 20 x/mnt
PR: 80 x/mnt
T: 37,8C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range
Obstetric status:L1 : breech
L2 : left back
L3 : head
L4 : descensus descencus4/5
UFH 34 cm
EFW : 3565 g
UC : (-)
Fetal Heart Rate : 15-16-15
VT : DC 1 cm, eff 10 % AM (-),green, head palpable, descensus HI,
umbilical cord or small part of fetal
unpalpable,
G2P1A0H1 A/S/L
LMR (SC) + PROM
+ febris
Observation mother
and fetal well being
IVFD RL
Resusitation
intrauterin
Report to supervisor,
advice: SC
-
8/13/2019 25-1-09
6/7
Time Subject Object Assesment Planning
15.30 Febris (+), abdominal discomfort (-
)
General status: well
BP: 120/80 mmHg
FHB: 12-13-13
G2P1A0H1 A/S/L LMR
(SC) + PROM + febris
Ampicilin test (-)
Injection 2 g ampicilin
Applied dauer catheter
16.30 Febris (+), abdominal discomfort (-
)
General status: well
BP: 120/80 mmHg
FHB: 12-13-13
G2P1A0H1 A/S/L LMR
(SC) + PROM + febris
Send patient to operation
room
17.50 Baby was born, male,
3650 g, AS: 7-9, AF:
green
19.00 General status: well
BP: 120/80 mmHg
UC: well
Bleeding (-)
-
8/13/2019 25-1-09
7/7
Time Subject Object Assesment Planning