10-11-15 kjdr
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Morning ReportNovember 10th , 2015Supervisor : dr. Gede Made
Punarbawa, Sp.OG(K)Medical Students :
Dede, Dila, Nita, Dhani, Farid, Sobri
CASES RESUME NORMAL LABOR
(-)
PATHOLOGY LABOR
1.G2P1A0L1 40-41 weeks S/L/IU head presentation with oligohydramnion
2.G3P0A2H0 43 weeks S/L/IU head presentation with BOH
3. G3P0A2H0 25-26 weeks /S/IUFD/IU + BOH
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• Name : Mrs. M• RM : 56 95 30• Age : 22 years old• Address : Lingsar• Admitted : 8th November 2015 at 08.53
WITA
Case Report
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
08/11/2015
08.53
Patient referred from Akasia Klinik to VK IGD NTB GH with G3P0A2L0 18-20 weeks S/IUFD/IU. Patient 4 months pregnancy confessed dindn’t fell the fetal movement since 1 weeks ago, abdominal pain that spread to flank (-), water leaked from her womb (-), bloody slim (-). history of DM (-), HT (-), asthma (+), alergi (-)
LMP : 15 – 05 - 2015EDD : 22– 02 – 2016GW : 25-26 weeks
History of ANC : 6x at PHC and posyanduLast ANC : 06/11/2015Result : BP 110/70, BW 63 kg, GW 17-18 weeks, UFH 1 finger below umbilicus, ballotement (+), FHB (+) History of USG : 1x at Sp.OGLast : 05/11/2015Result : Fetal S/IUFD/IU 16-17 weeks FM (-), FHB (-)
History of family planning : -Next family planning : -
Obstetrical History :1.Abortus 3 months curretage2.Abortus 2 months curretage3.This
General Status :GC : wellBP : 120/80 mmHgPR : 82 bpmRR : 20 bpm Temp : 36,5oCEye : palor (-/-), icteric (-/-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).
Obstetrical Status :Leopold : can’t performUFH : as the umbilicusUC : -FHB : - Ballotement (+)
VT : Ø 1 cm, eff 10 %, amnion (+), impapable small part of fetus and umbilical cord
Lab :Hb 12,2WBC 10,45PLT 297BT 1’45’’CT 5’12’’HbsAg (-)
G3P0A2L0 25-26 weeks S/IUFD/IU
with BOH
DM Planning :Diagnostiik• Lab (Dl, BT, CT,
HbsAg)
Therapy• Observation
mother well being.
• Obs. Inpartu sign• Suggest mother
to at and drink• Pro termination
with misoprostol induction
09.00DM co to GP, GP
to SPV advice : Insertion misoprostol by the vagina ½ tablet per 6 hours
At 06.00 before patient had take gastrul
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Pelvic score (total) : 3Dilatation 1cm (1), cervix length 2cm(1), station H0(0), consistency rigid (0), position middle (1)
12.00 Insertion of misoprostol ½ tab
14.00 GC : wellBP : 110/70 mmHgPR : 80 bpmRR : 22 bpm Temp : 36,8oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
- Obs mother well being suggest mother to eat and drink
- Obs for vaginal delivery
18.00 GC : wellBP : 120/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,5oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
• Obs mother well being
• Insertion of misoprostol ½ tab
00.00 • Insertion of misoprostol ½ tab
9/11/201506.00
GC : wellBP : 110/70 mmHgPR : 88 bpmRR : 19 bpm Temp : 36,4oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
• Obs mother well being
• Dm co to GP, GP co to SPV, advice increase misoprostol dose be 1 tab/6hours
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
12.00 GC : wellBP : 110/80 mmHgPR : 92 bpmRR : 21 bpm Temp : 36,3oCUC : -VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
- Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours
18.00 Patient confessed abdominal pain still seldom
GC : wellBP : 110/70 mmHgPR : 96 bpmRR : 22 bpm Temp : 36,5oCUC : 2x10’-15”VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
-Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours
19.00 Patient confessed water leaked from her womb
GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,7oCUC : 4x10’-45”VT : dilatation 4cm, eff 50%, amnion (-), hodge II, palpable part of fetal
G3P0A2L0 25-26 weeks S/IUFD/IU with inpartu active phase of labor + BOH
-Obs mother well being suggest mother to eat and drink-Obs progress of labor
19.12 Mother wants to bear down Inspection : bulging perineum, opening vulva, anus pressure
Second stage of labor
Conduct labor
Baby was born at 19.15 death, male, BW 300gr, BL 21cm, Maseration grade III
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
19.20 GC : wellBP : 100/60 mmHgPR : 76 bpmRR : 22 bpm Temp : 36,7oCUC wellUFH 2 fingers above symphisisBleeding about 50ccPerineum intact
3rd phase of labor with IUFD + suspect rest placenta
- Injection oxytocin 1amp IM- placenta was born spontan not complete, doing exploration- UC well- UFH 2 fingers above symphisis- Bleeding about 50cc- Perineum intact- suggest mother to eat and drink
-DM co to GP, GP co to SPV advice : pro USG tomorrow morning
21.00 GC : wellBP : 120/80 mmHgPR : 80 bpmRR : 19 bpm Temp : 36,8oCUC wellUFH 2 fingers above symphisisActive bleeding (-)
2 hours post partum with IUFD + suspect rest placenta
- Obs UC, bleeding, mother well being- Suggest mother to rest well, eat and drink
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10/11/201506.00
GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 18 bpm Temp : 36,6oCUC wellUFH 2 fingers above symphisisActive bleeding (-)
1 day post partum with IUFD + suspect rest placenta
- Obs mother well being, UC, bleeding- Suggest mother to eat and drink- Pro USG this morning
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