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S
Patient referred from Narmada PHC with
hypovolemic shock et causa suspect Abortus
infectious.
Chronologist :
Patient came to Narmada PHC at 8 p.m
(24/07/2010) confess vaginal bleeding since
three days ago with volume 10 15 cc with
descend conciousness.
Examination at Narmada PHC:
General condition : well
Conciousness
: somnolen
Vital sign
: BP 60 mmHg palpation
PR 120 x / minutes, weak
pulse
RR 28 x / minutes
Tax 37,5 0C
Head & neck : eye anemi -/- , icterus -/Thorax : *Cor : S1S2 Single/ reguler/mur-mur
- , gallop *Pulmo: ves +/+, whz -/-, rh-/Abdomen :
Extremity : cold
VT : CD 1 cm, unpalpable tissue, bad smell,
active bleeding, yellowish secret.
PP test : +
Therapy from Narmada PHC
- RL flash 1, fast drops
- Amoxicillin 3 x 500 mg
-Paracetamol 3 x 500 mg
A
Disturbed Ectopic
Pregnancy with
Compensated shock
P
-
time
Subjective
objective
assesment
planning
Amniotomy
Found amnion fluid
clearly
Obstetric history :
1.This
Contraception history : not yet
LMP : 15-11-08
EDD : 22-08-09
ANC : 5 x
22.10
Abdominal pain ++
Referred to VK
22.30
BP : 110/80 mmHg
PR : 80 x/
UFH : 31 cm
RR : 20 x/
EFW : 3100 gr
Tax : 37,0
UC : 3-4x/10~ 45
FHR : 140 x/
VT : CD 8 cm, eff 80%, AM (-),
head palpable, HIII, denominator
fontanella minor left anterior, small
part and umbilical cord wasnt
palpable
23.00
UC : 4x/10~50
FHR : 142 x/
Doran teknus perjol vulka
Motivated mother to
bearing down
Baby was born at 23.05,
male, 3250 gr, A-S : 7-9
time
Subjective
objective
assesment
planning
01.15
BP : 110/70 mmHg
PR : 79 x/
RR : 18 x/
Tax : 36,8
UFH : 2 finger umbilical below
AC : good
Bleeding : 40 cc
07.00
BP : 100/50 mmHg
PR : 100x/
RR : 24 x/
Tax : 37,0
UFH : 2 finger umbilical below
AC : good
Stolcel : 100 cc
02.15
A
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
P
- Obs fetal and mother
Wellbeing
- Check DL,HBsAg
- Report to supervisor.
Advice :
Cefotaxime 1 gr iv
Antipiretic
Resucitation IU
Left lateral position
O2
RL : D5- 2:1
time
Subjective
objective
Obstetric history :
1.This
assesment
planning
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
BP : 90/60 mmHg
PR : 92 x/
RR : 22 x/
Tax : 37,0
UC : 2x/10~ 20
FHR : 164 x/
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
Resusitasi intrauterine
continued
Motivated mother to drink
and eat sweet drinks
04.15
BP : 90/60 mmHg
PR : 96 x/
RR : 22 x/
Tax : 37,2
UC : 2-3x/10~ 25
FHR : 162 x/
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
05.15
BP : 90/60 mmHg
PR : 100 x/
RR : 26x/
Tax : 37,4
UC : 2-3x/10~ 30
FHR : 158 x/
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
time
Subjective
objective
assesment
planning
07.00
BP : 90/60 mmHg
PR : 96 x/
RR : 24x/
Tax : 37,5
UC : 3x/10~ 35
FHR : 154x/
VT : CD 5cm, eff 50 %, AM (-),
green, H1 caput
G1P0A0H0 A/S/L/IU,
head presentation with
neglected labor
Name
: Mrs. Zaenab
age
: 22 years
Address
: Keruak-Lotim
Admitted
: 07-08-2009
: 22.10
Time
Subject
Object
Assesment
Planning
22.10
In VK IRD to VK room at
22.20, from examination
found :
General status :
General condition: well,
Conciousness: CM
BP: 150/110 mmHg
RR: 20 x/mnt
PR: 88 x/mnt
T: 37 C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Observation mother
and fetal well being.
Advice patient to take
left lateral position,
and take drink and eat
Laboratory
examination : DL,UL
HBsAg
Report to supervisor
propossed to drip
oxytocin
Advice : proposed
agreed
Chronologis :
Patient came to keruak polindes
at 09.30 wita (07/08/09)
for routine examination,
there is diagnosis with
severe preeclampsia and
then patient refere to
Selong GH at 10.00
wita.
Subjective
complain (-), abdominal
pain (-), watery vaginal
discharge (-).
From examination found :
(14.00)
General condition: well
BP : 160/100 mmHg
Pulse : 88x/
RR : 20x/
UFH : 33 cm
T : 36,8 C
EFW : 3410 gr
UC : (-)
Obstetric status :
L1 : breech
L2 : left back
L3 : head
L4 : was in pelvic inlet 4/5
UFH 31 cm
EFW : 3100 g
UC : (-)
FHR : 148x/mnt
VT : CD 1 cm, eff 25%,
AM(+), head descencus H1,
unpalpable small part of fetus
or umbilical Cord
Pelvics score: 5
Opening: 1
station : 0
Time
Subject
(14.30)
Drip MgSO4 40% 6 gr 28 dpm
Bolus MgSO4 40% 4 gr IV
Insert DC
Report to supervisor,
Advis Induction
(18.30)
FHR : 160x/mnt
VT : CD 1 cm, AM (+),
head descencus H1,
unpalpable small part of fetus
or umbilical cord
Induction Delayed
LMP : 10/11/08
EDD : 17/08/09
Obstetrical history :
1. Abortus, 8 month
2. Abortus, 3 month
3.This
History of family Planning: (-)
Family planning: (-)
Object
Assesment
Planning
Time
Subject
Object
Assesment
Planning
22.30
BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : (-)
DC : 500 cc since 22.00 pm
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Drip MgSO4 Fl 2
Start to induction, oxy
5 iu in D5% => 8 dpm
Observation mother
and fetal well being.
Advice patient to take
left lateral position
Advice patient to take
drink and eat
23.00
FHR : 148x/mnt
UC : (-)
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
23.30
BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : (-)
DC : 50 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
24.00
FHR : 144x/mnt
UC : (-)
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
Time
Subject
Object
Assesment
Planning
01.30
FHR :
UC :1x/10~10
DC : 170 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
02.00
FHR : 148x/mnt
UC : (-)
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
02.30
FHR : 148x/mnt
UC : (-)
DC : 40 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
03.00
FHR : 148x/mnt
UC : (-)
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Maintenance
dpm
drip
40
Time
Subject
Object
Assesment
Planning
04.30
FHR : 144x/mnt
UC : (-)
DC : 40 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Drip MgSO4 Fl 3
Drip oxytocin flash 2
05.00
FHR : 148x/mnt
UC : (-)
DC : 40 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Maintenance
dpm
drip
40
05.30
BP : 150/110 mmHg
PR : 88x/mnt
FHR : 143x/mnt
UC : 1x/10~35
DC : 100 cc
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Maintenance
dpm
drip
40
06.00
FHR : 155x/mnt
UC : 2x/10~30
G3P0A2H0 39-40
W/S/L/IU
head
presentation laten
phase of labor with
severe preeclampsi
+ mild anemia
Maintenance
dpm
drip
40
age
: 22 years
Address
: Banjar kemuning-Selong
Time
Subject
03.00
: 02.45 wita
Object
General status :
General condition : well
GCS: E4V5M6
Vital sign
BP : 100/70 mmHg
Pulse: 88 x/
RR: 20 x/
Temp: 37,3c
Cor/Pulmo: normal
Eye: an-/-, ict-/Akral: warm, edema -/Obstetric status
L1: Head
L2: left back
L3: Breech
L4: wasnt pelvic inlet
UFH : 19 cm
EFW : 1085 g
FHR: 156x/mnt
HIS: 1x/10~20
VT : not be done
Lab Result:
Hb: 11.2
WBC: 10.400
PLT: 240.000
HCT: 34.0
HbSAg : (+)
Assesment
Planning
G1P0A0H0
27-28
W/S/L/IU
breech
presentation with APB
susp.Placenta previa
Time
Subject
Object
Assesment
Planning
G1P0A0H0
27-28
W/S/L/IU
breech
presentation with APB
susp.Placenta previa
LMP : 15/02/09
EDD : 22/11/09
04.00