Scribd Logo
Upload

Welcome to Scribd!

  • 29 views

    Morning Report March, 24: Supervisor: Dr.H. Doddy A.K., Spog DM: Akbar, Ariq, Asri

    Uploaded by

    Ida Andalos Totha
    1. A 45-year-old woman, G14P11A2L11, was admitted to the hospital with head presentation, history of left foot amputation, severe anemia, IUGR, and observation inpartu. 2. On examination, she was well but anemic with a blood pressure of 100/70 mmHg, fetal heart rate of 136 bpm, and uterine contractions every 10-15 minutes. 3. Her care plan included observation of maternal and fetal well-being, oxygen supplementation, transfusions, antibiotics, and referral to a higher level hospital for delivery due to her high-risk condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Morning Report March, 24: Supervisor: Dr.H. Doddy A.K., Spog DM: Akbar, Ariq, Asri

    Uploaded by

    Ida Andalos Totha
    29 views9 pages
    1. A 45-year-old woman, G14P11A2L11, was admitted to the hospital with head presentation, history of left foot amputation, severe anemia, IUGR, and observation inpartu. 2. On examination, she was well but anemic with a blood pressure of 100/70 mmHg, fetal heart rate of 136 bpm, and uterine contractions every 10-15 minutes. 3. Her care plan included observation of maternal and fetal well-being, oxygen supplementation, transfusions, antibiotics, and referral to a higher level hospital for delivery due to her high-risk condition.

    Original Description:

    jdjdjdjd

    Original Title

    MR 24-03-2014 PJT hsdhdhdhd

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. A 45-year-old woman, G14P11A2L11, was admitted to the hospital with head presentation, history of left foot amputation, severe anemia, IUGR, and observation inpartu. 2. On examination, she was well but anemic with a blood pressure of 100/70 mmHg, fetal heart rate of 136 bpm, and uterine contractions every 10-15 minutes. 3. Her care plan included observation of maternal and fetal well-being, oxygen supplementation, transfusions, antibiotics, and referral to a higher level hospital for delivery due to her high-risk condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    29 views9 pages

    Morning Report March, 24: Supervisor: Dr.H. Doddy A.K., Spog DM: Akbar, Ariq, Asri

    Uploaded by

    Ida Andalos Totha
    1. A 45-year-old woman, G14P11A2L11, was admitted to the hospital with head presentation, history of left foot amputation, severe anemia, IUGR, and observation inpartu. 2. On examination, she was well but anemic with a blood pressure of 100/70 mmHg, fetal heart rate of 136 bpm, and uterine contractions every 10-15 minutes. 3. Her care plan included observation of maternal and fetal well-being, oxygen supplementation, transfusions, antibiotics, and referral to a higher level hospital for delivery due to her high-risk condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 9

    Morning report

    March, 24th 2014


    SUPERVISOR:
    Dr.H. Doddy A.K., SpOG

    DM:
    AKBAR, ARIQ, ASRI
    Cases resume :
    Normal Labor

    Pathologic Labor(s)

    1. G14P11A2L11 A/S/L/IU head presentation with


    observation inpartu + Anemia +IUGR + history of left
    foot amputation e.c suspect Bone carcinoma

    PATIENT IDENTITY
    Name
    Age
    Address
    Admitted

    : Mrs. A
    : 45 yo
    : Pararopa, Dompu
    : March, 24th 2014 at 08.19 WITA

    TIME

    SUBJECTIVE

    24/03/
    2014

    Patient referred from RSUD


    Dompu with G14P11A2L11
    A/S/L/IU with history of left
    foot amputation e.c suspect
    Bone carcinoma + mild
    anemia. Patient confessed
    abdominal pain since 19.00
    WITA (22/03/2014). Water
    come out from her vagiina (), bloody slim (-), fetal
    movement (+).

    08.19
    WITA

    No history of DM, HT,


    asthma. No history of
    allergic reaction to medicine
    or food.
    LMP : 08/07/2013
    EDD: 15/04/2014
    History of ANC : 3x
    Last
    ANC:
    21/02/2014,
    result: BP: 90/60 mmHg, 32
    wk, FHB (+), UFH: 27 cm

    OBJECTIVE
    General status:
    GC: well
    GCS: E4V5M6
    BP: 100/70 mmHg
    PR: 86 bpm
    RR: 25 rpm
    T: 36,4 0 C

    Eye : anemis (-), icteric (-)


    Thorax :
    Cor : S1S2 single reguler,
    murmur (-), gallop (-)
    Pulmo : vesikuler (+/+),
    wheezing (-/-), Ronkhi (-/-).
    Abdomen : scar (-), striae (+),
    linea nigra (+)
    Extremity : edema (-/-), warm
    acral (-/-)
    Obstetrical status:
    L1: breech
    L2: back on the right side
    L3: head
    L4: 4/5
    UFH: 25 cm
    EFW: 2170 gr
    UC: 1x10~20
    FHB: 12-11-11 (136 x/min)

    ASSESTMENT

    PLANNING

    G14P11A2L11
    A/S/L/IU head
    presentation
    with obs.
    Inpartu`+
    history of left
    foot amputation
    e.c suspect
    Bone
    carcinoma +
    severe anemia
    + IUGR

    Obs mother & fetal


    well being
    O2 3 lpm
    DM co to GP pro
    SC, GP advice :
    SC electiv
    Pro transfusi 600
    cc
    Inj. Ceftriaxone 2
    gr/ IV / 24 hours
    DC
    Co. anastesi,
    advice: ECG
    Co. interna, advice:
    Transfution Hb ~
    10 gr%, 1 kolf/day
    20 tpm
    Premed
    dexamethason 1
    amp
    Photo thorax
    Co. Orthopedy

    TIME

    SUBJECTIVE

    OBJECTIVE

    History of USG : History of Family Planning: Next Family Planning: sterile

    VT : 2 cm, eff 25 %, amnion


    (+),
    head
    palpable
    H1,
    denominator
    unclear,
    impalpable small part and
    umbilical cord.

    History of obstetry:
    1. Aterm, spt B, BTA,
    22 yo, live
    2. Aterm, spt B, BTA,
    20 yo, live
    3. Aterm, spt B, BTA,
    19 yo, live
    4. Aterm, spt B, BTA,
    17 yo, live
    5. Abortus
    6. Abortus
    7. Aterm, spt B, BTA,
    15 yo, live
    8. Aterm, spt B, BTA,
    13 yo, live
    9. Aterm, spt B, BTA,
    11 yo, live
    10.Aterm, spt B, BTA,
    10 yo, live
    11.Aterm, spt B, BTA,
    6 yo, live
    12.Aterm, spt B, BTA,
    4 yo, live
    13.Aterm, spt B, BTA,
    2 yo, live
    14.ini

    home,
    home,
    home,
    home,

    home,
    home,
    home,
    home,

    home,
    home,
    home,

    Lab Result
    Hb : 7,8 x 106/ L
    WBC : 21,7 x 103/ L
    PLT : 548 x 103/ L
    HCT : 24,7 %
    BT: 230
    CT: 410
    Cr: 1,3 mg/dl
    Ureum: 84 mg/dl
    OT: 30 mg/dl
    PT: 20 mg/dl
    Alb: 2,6 g/dl
    HBsAg : (-) non reactive

    ASSESTMENT

    PLANNING

    TIME

    SUBJECTIVE
    Chronologist
    S/
    Patient referred from Kito PHC with
    G14P11A2L11 32 weeks S/L/IU
    with prolonged of active phase.
    Patient confessed abdominal pain
    since 19.00 WITA (22/03/2014).
    Water come out from her vagiina (), bloody slim (-), fetal movement
    (+).
    O/
    General status:
    GC: well
    GCS: E4V5M6
    BP: 100/70 mmHg
    PR: 90 bpm
    RR: 24 rpm
    T: 36,50 C
    Status Obstetric
    L1 : head
    L2 : back on the right side
    L3 : breech
    L4 : 4/5
    UFH : 25 cm
    EFW : 2170 gram
    FHR : 12-11-12 (140bpm)
    UC : -

    OBJECTIVE

    ASSESTMENT

    PLANNING

    TIME

    SUBJECTIVE
    VT : 2 cm, eff 25 %, amnion (+),
    head palpable H1, denominator
    unclear, impalpable small part and
    umbilical cord.
    Lab examination:
    Hb: 8,5 gr %
    A/
    G14P11A2L11 32 weeks S/L/IU
    with mild anemia
    P/
    IVFD Dex 5 % 20 tpm
    Amoxicilin tab 500 mg 3x1
    Paracetamol tab 500 mg 3x1
    Referred to NTB GH

    OBJECTIVE

    ASSESTMENT

    PLANNING

    TIME
    18.00
    WITA

    SUBJECTIVE
    Mother confessed pain in body

    OBJECTIVE

    ASSESTMENT

    PLANNING
    Obs mother &
    fetal well being
    DM co to GP, GP
    advice bolus Dex
    40 %, pro check
    GDS 1 hour post
    bolus.

    GC: well
    GCS: E4V5M6
    BP: 110/70 mmHg
    PR: 88 bpm
    RR: 25 rpm
    T: 36,4 0 C
    UC: 1x10~15
    FHB: 12-11-11 (136 x/min)
    UO : 300 cc
    Lab:
    GDS: 68 mg/dl

    22.30
    WITA

    22.30
    WITA

    1 hour post
    bolus Dex 40 %
    Lab:
    GDS: 78 mg/dl
    Ro. Thorax:
    KP Duplex

    G14P11A2L11
    A/S/L/IU head
    presentation
    with obs.
    Inpartu`+
    history of left
    foot amputation
    e.c suspect
    Bone
    carcinoma +
    severe anemia
    + IUGR + KP
    Duplex

    IVFD Dex 5 % 20
    tpm
    Vulva hygine

    TIME
    06.00
    WITA

    SUBJECTIVE
    -

    OBJECTIVE
    GC: well
    GCS: E4V5M6
    BP: 100/70 mmHg
    PR: 84 bpm
    RR: 24 rpm
    T: 36,5 0 C
    UC: 1x10~10
    FHB: 12-11-11 (136 x/min)
    Lab:
    GDS: 68 mg/dl

    ASSESTMENT

    PLANNING
    Obs mother &
    fetal well being

    Thank you

    You might also like