MORNING REPORT MARCH 13 st, 2012

Supervisor : dr.Edi Prasetyo W, SpOG

Medical Student: Fahmi, zul, lili, sankuntala

Cases resume Click to edit Master subtitle style : Normal Labor

Pathologic labor 1.

4/16/12

Name : mrs. M

Admitted to GH NTB april 3, 2012 at 10.00 WITA Objective Assestment Planning

-Obs mother and fetal well being - and HBsAg -Report to GP, GP report to supervisor Supervisor advice : prepare for SC

Age : 22 years old time Subjective

13/03/2012 10.00 WITA

4/16/12

Patient referred from vGeneral status : G1P0A0 41-42 sigerongan PHC with GC: weak, GCS: E4V5M6 weeks /S/L/IU G1A0P0L0 T/L/IU/ 1st stage of BP:130/100 mmHg with 2nd stage labor latent phase with RR: 24 x/mnt active phase of suspect CPD. patient Pulse :88 x/mnt labor with confessed abdominal pain T: 37,7 C suspect CPD since at 01.00 pm. history of Eyes : an(-) ikt (-) rupture of membrane since at Cor : S1S2 single regular and polio 05.00 (+) amnion clear, Murmur (-), Gallop (-) odorless , wetting one cloth, Pulmo : Vesiculer (+/+), rh Blood slim (+). FM (+). (-/-), wh (-/-) History of DM (-), HT (-), Abd : scar (-), striae (+) Asthma (-). History of acute Extremity edema (-/-) paralysis at her left limb since Left lower limb : paralysis (+), childhood atrofi (+) LMP : forgot : 15-6-2011 vObstetric status : EDD: 22-3-2012 L1 : breech UFH: History of ANC : >4x, in 32cm midwife, L2 : back on right History of USG : (-) L3 : head History of family planning : - L4 : 2/5 injection EFW : 3255 g Next family planning: IUD UC : 4x10,45 Obstetrical history: FHB : 12-13-13 x/mnt 1. This VT : 8 cm, eff : 80%, amnion (+), head presentation, caput (+) hodge 2+ PE : tepi spina ischiadika menonjol, distantia interspiinosum <10 cm, os sacrum bengkok ke kanan

time

Subjektive

objective

assestment Planning

Chronologis (at midwife) : 12/03/12 -12.15 Lab exam : S: Patient confessed 9 month of pregnancy vital WBC : 21,8 sign BP; 110/90, PR : 80, RBC : 3,65% HGB :10.3 temp 36 VT : 1 cm, at PLT : 448.000 20.15 VT :2cm, and at Hct : 28,5 04.30 vaginal toucher HbsAg (-) gainded 5 cm and effacement 50%, then at Protenuria : +1 07.45 ruptured Keton : +2 membrane and completed, denominator palpable small part of occipital Today at 07.50 patient refered to tanjung general hospital, then patient diagnosis with with G1A0P0L0 T/L/IU/ 2nd stage of labor suspect malpresentation and observe until 09.45 then refer to NTB general hospital

4/16/12

time
15.00

subjektive
Wound operation pain

Objective

assestment Planning
Observe mother and fetal well being Suggest mother to eat and drink

GC : well G1P1A0 A/S/L/IU BP : 140/90 mmHg face PR : 100 bpm RR : 20presentation tpm with 2nd stage T : 37,5C of labor and UC : 3x10, 30 mild preeclamsia 2 hours post SC

18.00

Wound operation pain

GC : well G1P1A0 A/S/L/IU BP : 140/90 mmHg face PR : 80 bpm RR : 18presentation tpm with 2nd stage T : 36 C of labor and UC : 2x10, 30 mild preeclamsia

Observe mother and fetal well being Suggest mother to eat and drink

4/16/12