idham mornink
TRANSCRIPT
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Morning Report
October 07th 2009
Supervisor : dr. Edy P.W., SpOG
Medical Student:
Titin, Halida, Idham, Holis
1.
Cases resume :
G1P0A0 with prolonged 2nd stage 1
G1P0A0 with susp.big baby 1Normal labor 4
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s
Name : Mrs. Zohrah CTH : 07102009
Age : 22 years :
Address : johar pelita - sesela
Waktu Subject Object Assesment Planning
13.00 Patient came to emergency care unit
of NTB province hospital (12.20)
with G1P0A0 A/S/L laten phase 1stlabour + watery vaginal discharge +
febris
cronologis :
Patient felt abdominal pain ( since 05-
10-2009) and watery vaginal
discharge at 07.00 am (07-10-2009),
then she went to gunung sari PHC at
11.00 am (07-10-2009). Bloody show
(-) , the fetal movement was active.
History of febris (-). History of
malaria -, history of thipoid -.
The examination gunung sari PHC
General status : well
BP : 120/70 mmHg
Pulse =88 x/mnt
RR: 20 x/mnt
Temp = 38,6C
UFH = not mention it
FHB = 171 x/mnt
11.00 WITA
VT : 3 cm, eff 25 %, amnionic
membrane (-), head palpable, descend
HI, unpalpable small organ and
umbilical cord.
Terapi in PHC:
Injeksi ampi 1 gr in PHCParacetamol 1 tab in PHC
12.00 patient referred to mataram GH
In emergency room :
General status :
General condition: well,Conciousness: E4V5M6
BP: 130/80 mmmHg
RR: 20 x/mnt
Pulse :80 x/mnt
T: 37,6C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech TFU; 31 cm
L2 : left back
L3 : head
L4 : 4/5
EFW : 3100 g
UC : 3x/10 ~35
FHB : 173 x/mnt
VT : 3 cm, eff 25 %, amnionic
membrane (-,) dry, head palpable,
descend HI, unpalpable small organ and
umbilical cord.
Pelvic evaluation;
Promontorium not prominent
Spina isciadica not prominent
Arcus pubis > 90
Os coxigeus mobile
G1P0A0 Aterm/single/
life + laten phase of 1st
stage labor + wateryvaginal discharge +
febris + fetal
tachicardy
Observation mother
and fetal well being.
Laboratoryexamination : DL,
HBsAg
Resusitation intra
uterine
CTG post resusitation
Base line 156
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Time Subject Object Assesment Planning
17.00
18.00
History of family planning : (-)
Familly planning = injection 3
month
ANC Routine at posyandu > 4 x
Obstetrical history :
1.This
Abdominal pain >>>
Abdominal pain +++
Mother want to bearing down
Lab. result:
HB = 10 gr%
WB = 23.700
PLT = 249.000
HCT = 32,5HBsAg (-)
UC : (+) 3x/1035
FHB : 144x/mnt
L4 : 3/5VT : 9 cm, eff 90 %, amnionicmembrane (-,) dry, head palpable,
descend HII,denominator fontanella
minor left anterior. unpalpable small
organ and umbilical cord
UC : (+) 3-4 x/1040
FHB : 144x/mntL4 : 3/5VT : complete, amnionic membrane
(-,) dry, head palpable, descend
HII,denominator fontanella minor
left anterior. unpalpable small organ
and umbilical cord.
G1P0A0 Aterm/single/
life + active phase of
1st stage labor +
watery vaginaldischarge
G1P0A0 Aterm/single/
life + 2nd stage of
labor
-Observation mother
and fetal well being
-Evaluation 1 hours
again
-Left laterl position
-Educated mother to
drinking and eating.
Squating position
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Time Subject Object Assesment Planning
20.00
20.30
22.30
Abdominal pain +++
Active bleeding
UC : (+) 4 x/1040
FHB : 154x/mnt
L4 : 2/5VT : complete, amnionic membrane
(-,) dry, head palpable, descendHIII,denominator fontanella minor
left anterior. unpalpable small organ
and umbilical cord.
BP = 120/70
RR: 20 x/mnt
Pulse 84 x/mnt
UFH = 1 fingers below the
umbilical
UC = good
G1P0A0 Aterm/single/
life + prolonged 2nd
stage of labor
2 nd stage of labor
3 rd stage of labor
IV stage of labor
Report to supervisor
Propose vacum
extraction
Proposed agreed
Baby was born with
vacum extraction male,
3300 gram, A`S : 6-8
Amniotic fluid green thinNuchal cord baby sent
to NICU
Placenta was born
compleete
Observation VS and
subjective complain
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Time Subject Object Assesment Planning
07.00
am
Subjective complain
Active bleeding -BP = 110/70
RR: 22 x/mnt
Pulse 84 x/mnt
UFH = 2 fingers below the
umbilicalUC = good
Wound episiotomy: dry
baby:
HR : 120
RR: 36x/mnt
T: 36.7 c
1st day of vacum
extraction
Observation VS and
subjective complain