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    MR 24-05-2019

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    Fafan upin
    1. The morning report summarizes a case of a 35-year-old pregnant woman, P4A0H3 post spontaneous childbirth day 7 with a history of preeclampsia. 2. The patient was admitted on May 21st complaining of dizziness and blurred vision and was referred from a public health center due to preeclampsia. 3. As of May 24th, the patient's condition was assessed as P4A0L4 post spontaneous childbirth day 7 with anemia and a history indicating risk of impending eclampsia. Her treatment plan included continued medication and monitoring.

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    MR 24-05-2019

    Uploaded by

    Fafan upin
    15 views12 pages
    1. The morning report summarizes a case of a 35-year-old pregnant woman, P4A0H3 post spontaneous childbirth day 7 with a history of preeclampsia. 2. The patient was admitted on May 21st complaining of dizziness and blurred vision and was referred from a public health center due to preeclampsia. 3. As of May 24th, the patient's condition was assessed as P4A0L4 post spontaneous childbirth day 7 with anemia and a history indicating risk of impending eclampsia. Her treatment plan included continued medication and monitoring.

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    1. The morning report summarizes a case of a 35-year-old pregnant woman, P4A0H3 post spontaneous childbirth day 7 with a history of preeclampsia. 2. The patient was admitted on May 21st complaining of dizziness and blurred vision and was referred from a public health center due to preeclampsia. 3. As of May 24th, the patient's condition was assessed as P4A0L4 post spontaneous childbirth day 7 with anemia and a history indicating risk of impending eclampsia. Her treatment plan included continued medication and monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    15 views12 pages

    MR 24-05-2019

    Uploaded by

    Fafan upin
    1. The morning report summarizes a case of a 35-year-old pregnant woman, P4A0H3 post spontaneous childbirth day 7 with a history of preeclampsia. 2. The patient was admitted on May 21st complaining of dizziness and blurred vision and was referred from a public health center due to preeclampsia. 3. As of May 24th, the patient's condition was assessed as P4A0L4 post spontaneous childbirth day 7 with anemia and a history indicating risk of impending eclampsia. Her treatment plan included continued medication and monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 12

    Morning Report

    24th May, 2019

    Supervisor: dr. Ario Danianto, SpOG

    Team in Charge: Wulan, Amelia, Diana


    Case Resume

    Normal Labor -

    Pathologies Labor -

    Remain Patient 1. Female/35 years old/P4A0H3 Post SC D+7 with history of


    PEB
    Case I
    Name : Ms. H
    Age : 35 y.o.
    Address : Batu Layar
    Admitted : 21th May, 2019
    MR Number : 030600
    TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
    21-05-2019 Main complaint: dizziness and General Status: P4A0H3 post SC day-5
    23.20 blurred vision GC: well with PEB impending
    GCS: CM eklampsia + Anemia
    Patient reffered from Meninting’s BP: 150/80 mmHg
    public health centers to PR: 86 bpm
    emergency unit NTB General RR: 28 x/min
    Hospital with P4A0H3 post SC Temp: 37,0oC
    day 4 caused PEB. Patient W: 45 kg
    complaint dizziness since 18.00 H: 147 cm
    (21-05-2019) and blurred vision. IMT: 20,4
    No active bleeding(-), no seizure
    (-). Local Status:
    Eye: anemic +/+, icteric -/-
    Patient was came to hospital on Cor: S1S2 single reguler,
    17-05-2018 because PEB and murmur (-), gallop (-)
    termination SC. She was going Pulmo: vesikuler (+/+),
    home on 20-05-2019. wheezing (-/-), ronkhi (-/-)
    Abdomen: BU (+), luka
    There’re history of HT but not bekas SC (+), TFU
    routine drug consumption. No 3fingers bellow umbilical
    history of DM, and heart disease. Extremity: edema (-/-)
    History of asthma (-). pada ekstrimitas bawah,
    warm acral (+/+)
    TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
    History medication at PKM Lab (22-05-2019 pukul P4A0H3 post SC day-5 Planning
    Meninting 00.43): with PEB impending Diagnostic:
    - Nifedipin 10mg/oral HB 7,2 g/dl eklampsia + Anemia Complete blood count
    - Infus RL 20tpm HCT 23% Urinalisis
    - Drip MgSO4 40% 6 gram 28 WBC 14.630/uL
    tpm RBC 2,73 x 10-6/uL Observation:
    PLT 312000/uL - Obs. Vital sign Mother
    Obstetrical History:
    1. 2004/ Female/ 2300 gram/ Urinalisa Therapy in PHC
    Pervaginam/ no/ home/ dead BJ : 1025 - Nifedipin tab 10 mg
    40 days. Ph : 7,5 (22.41)
    2. 2009/ male / 2500 gram/ Nitrit (-) - Drip MgSO4 6 gr
    pervaginam/ midwife/ PHC/ Protein (-) dalam RL (22.47)
    life Glukosa (-) - DC
    3. 2013/ female/ 2200gram/ Keton (-) DM co to GP, GP co to
    pervaginam/ midwife/ PHC/ Urobilinogen 0,1mg/Dl SPV, advice:
    life Bilirubin (-) • Pro transfusion PRC
    4. 2019/ female/ 2200gram/ Darah/HB : +1 1 kolf
    SC/ doctor/ life Wbc : (-) • Stop drip MgSO4,
    replace Ringer
    Laktat
    • Nifedipin tab 3x1
    • Move to VK teratai
    TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
    23-05-2019 Headache (+), blurry vision General Status: P4A0L4 post SC hari • Nifedipin 3x1 tab
    14.00 decreased GC: well ke-6 dengan Anemia +
    GCS: CM history of PEB
    BP: 140/90 mmHg impending eclampsia
    PR: 84 bpm
    RR: 20 x/min
    Temp: 37,1oC

    UFH 3fingers bellow the


    umbilical, lochea minimal

    23-05-2019 Headache (+) General Status: P4A0L4 post SC hari • Nifedipin 3x1tab
    18.00 GC: well ke-6 dengan Anemia +
    GCS: CM history of PEB
    BP: 110/80 mmHg impending eclampsia
    PR: 84 bpm
    RR: 20 x/min
    Temp: 37,1oC

    UFH 3fingers bellow the


    umbilical, lochea minimal
    TIME SUBJECTIVE OBJECTIVE ASESSMENT PLANNING
    23-05-2019 Headache (+) General Status: P4A0L4 post SC hari • Nifedipin 3x1 tab
    21.00 GC: well ke-6 dengan Anemia +
    GCS: CM history of PEB
    BP: 130/90 mmHg impending eclampsia
    PR: 84 bpm
    RR: 20 x/min
    Temp: 37,1oC

    UFH 2fingers bellow the


    umbilical, lochea (-)

    24-05-2019 Headache (+) General Status: P4A0L4 post SC hari • Nifedipin 3x1tab
    06.00 GC: well ke-7 dengan Anemia +
    GCS: CM history of PEB
    BP: 130/80 mmHg impending eclampsia
    PR: 88 bpm
    RR: 20 x/min
    Temp: 36,5oC

    UFH 2fingers bellow the


    umbilical, lochea (-)
    Childs and
    Mother
    Health Book
    USG Test
    Result:
    - single , female
    - Head presentation
    - GA 33-34 weeks
    - Placenta at fundus
    - Amnion enough
    - EFW 2212 gram
    - EDD 15-06-2019
    Chronology
    Thank you 

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