mr 15082015.pptx
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Morning Report
August, 18th 2015
Supervisor:dr. Gede made punarbawa, Sp.G
!M "aga:#ebri, rian
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Morning Reportaugust 10th 2015
Case Resume$RMA%%A&R
0
'A()%G*+S
%A&R
1. G3P2A0L2 38-39 weeks S/L/IU, transversepresentation with P!"#12 ho$rs
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ase 1
$ame : Mrs. MAge : -- ears o/dAddress : &aan
Admitted : 15082015$o. RM : 552-8
G3P2A0L2 38-39 weeks S/L/IU,transverse presentation % P!" #12
ho$rs
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&I"' SU()'*&I+' !()'*&I+' ASS'SS"'& PLAIG
11/08/20123.12 wita
Patient reere ro LU G to&( G with G3P2A0L2 38-39weeks S/L/IU transversepresentation. Patient onessea4oina5 pain sprea to the5ank 6%7 sine as a:o,water 5eake o$t ro herwo4 6%7 sine as a:o,45oo s5i 6-7, ;" 6%7.
istor o /12/201'0 :, G= 3>-38weeks, U; 32 , transversepresentation, ;( 6%7, (= 9k:
Genera5 stat$sG* = we55onsio$sness= *"(P = 110/>0 :P= 8 4p= 20 4p&= 3@,8B*
Loa5 stat$s'e = an 6-/-7, it 6-/-7P$5o = ves 6%/%7, rh 6-/-7, wh6-/-7*or = S1S2 sin:5e re:$5ar, 6-7, : 6-7
A4 = striae :raviar$ 6%7,5inea ni:ra 6%7, sar 6-7
'?t = eea 6-/-7, war ara56%/%7.
!4stetri stat$sL1 = 4akL2 = hea on the ri:ht sieL3 = -L = /U;= 31
'; = - :r U* = 1?10C D0E;( = 11-12-12+& = F 0 , e 0, anion6-7, transverse presentation.
G3P2A0L2 38-39weeks S/L/IU,transversepresentation %P!" #12 ho$rs
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&I"' SU()'*&I+' !()'*&I+' ASS'SS"'& PLAIG
istor o USG = 2?, at Sp!GLast = 1/08/201es$5t = S/L/IU, transverse G=38-39 weeks, ';= 320 :r,anion not 5ear, inia5,p5aenta at $n$s :r II-III, ;(6%7 100-120?/in$teS$::estion = pro S*&Pistor o ai5 p5annin:= -e?t ai5 p5annin: = InH 3onth
!4stetri istor=I. Ater/a5e/Spt/2>00 :r/
ears/5iveII. Ater/ea5e/Spt/2900 :r/3
ears/5iveIII. &his
Laboratory (11/08/2015 23.56):(= 10.8 :/5(*= 3.9*&= 31.1 (*= 8.3PL&= 294sA:= non reative(& = 3C10E*& = @C1E
Chronologist : at KLU GH(15-08-2015)
12.50 !"#$ : 'atient reered #orm
obstetri3 po/ with #eta/distress and 'RM 5 das
transverse presentation.'atient 3on#essed historo# water /ea4ed out #romher womb sin3e 5 dasago, #eta/ movement 67.
'atient 3on#essed this isthe -rd pregnan3. $ohistor o# abortus. A// thebab are /ive. )istor o#
severe disease 7 %M' : 9129201
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&I"' SU()'*&I+' !()'*&I+' ASS'SS"'& PLAIG
!4stetri stat$sL1 = 4reehL2 = 4ak on the 5et sieL3 = heaL = 1/U;= 30
A4* = 9>'; = 2910 :r U* = -;( = 13>?/in$tes+& = not o
# : G3P2A0L2 38 weeks S/L/IU,transverse presentation withP!" as % eta5 istress
' : 3o to S'=
2 /pm*n#us !5 20 tpm!Reered to $(& G)1-.15!oing 02 /pm*n#usion !5 20 tpm!o !S4in (est ampi3i//in
in>e3ted at 1-.-0 wita
1.00 ?)& 67 12
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&I"' SU()'*&I+' !()'*&I+' ASS'SS"'& PLAIG
20.00 Genera5 stat$sG* = we55onsio$sness= *"(P = 110/>0 :P= 80 4p= 18 4p&= 3@,>B*
U* = 1?10C D0E;( = 11-12-12
*-Setion 4e:in at21.00
At 21.1> (a4 was4orn, a5e, A-S @-8,3000 :, (L 0 , *3 , an$s 6%7on:enita5 anoa5 6-7
P5aenta was 4ornop5ete5
Intraoperative inin: =4iorn $teri
22.30 G* = we55onsio$sness= *"(P = 110/80 :P= 88 4p= 20 4p&= 3@.B*
U* = we55U; = 2 in:ers 4e5ow $4i5ia5U! = 200 /ho$rs
Ative 45eein: 6-7
2 ho$rs post *S !4servation :enera5onition an vita5si:n
!4servation U*,U;, an ative45eein:
1@/08/2010>.00
G* = we55onsio$sness= *"(P = 110/>0 :P= >@ 4p= 20 4p&= 3@.3B*
U* = we55
U; = 2 in:ers 4e5ow $4i5ia5U! = 100 /ho$rsLohea r$4ra 6%7
!4servation :enera5onition an vita5si:n
!4servation U*,U;, an 5ohea
*I' other to eat anrink
*I' other to 4reast
eein: *I' other to
o4i5iJation
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.. "han& 'ou ..
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