morning report 20 april 2016 (kii memanjang)
TRANSCRIPT
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
1/24
Morning Report
20 April 2016
Supervisor : dr.Agus Thoriq ,
SpOGDM : An, !el, !rin, Di"s,
#it
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
2/24
$se 1
%"e : Mrs. S% Age : 21 &ers old
RM : '()(1)*+ Address : Sedu, o"-o !rt Ad"itted : 20thApril 2016
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
3/24
Time Subject Object Assessment Planning
20th
April2016
23.00
Patient referred from Sedau PHCwith G1P0A0L0 40-41 weeksS/L/IU head resentation withro!on"ed se#ond sta"e of !a$or%Patient #onfessed a$domina!ain &'( sin#e 1)%00&1*/04/+01,( $!ood. s!ime &'(sin#e 0,%00 &+0/04/+01,( water!eaked from her wom$ &'( sin#e0%00 &+0/04/+01,( &'(%
Histor. of 2 &-( H3 &-( asthma&-( a!!er". &-(%
LP 0 / 0) / +015622 15 / 04 / +01,
G7 40-41 week
Histor. A8C ,9 at PHCLast A8C 11-0+-+01,:esu!t G7 ;0 weeks
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
4/24
Time Subject Object Assessment Planning
Lab $20%0&%2016'"H
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
5/24
Time Subject Object Assessment Planning
+0/04/+01,
14%00
(hronolog# at Se)au P*($20%0&%2016'"S"Patient #onfessed a$domina! ain&'(
O"
General statusGC we!!Cons#iousness C
$s% Si"n of !a$or 4 hours a"ain%
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
6/24
Time Subject Object Assessment Planning
+0/04/+01,
1%00
(hronolog# at Se)au P*($20%0&%2016'"S"Patient #onfessed a$domina! ain &''(
O"
General statusGC we!!Cons#iousness C
$s% Si"n of !a$or + hours a"ain%
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
7/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
8/24
Time Subject Object Assessment Planning
+0/04/+01,
+1%00
(hronolog# at Se)au P*($20%0&%2016'"S"-
O"General status
GC we!!Cons#iousness CH< 11-1+-11 &1;,(
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
9/24
Time Subject Object Assessment Planning
+0/04/+01,
++%00
(hronolog# at Se)au P*($20%0&%2016'"S"Confessed a$domina! ain &'(
O"General status
GC we!!Cons#iousness C
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
10/24
Time Subject Object Assessment Planning
01%;0 A$domina! ain &'( General statusGC we!!Cons#iousness C
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
11/24
Time Subject Object Assessment Planning
0,%00 8o #om!aint General statusGC we!!Cons#iousness C
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
12/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
13/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
14/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
15/24
Re"ining $se
%"e : Mrs. M Age : /1 &ers old Address : A"penn
Ad"itted : April 1th, 2016 %o. RM : 12 (6 1
Time Subject Object Assessment Planning
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
16/24
Time Subject Object Assessment Planning
1*/04/+01,1;%00 wita
Patient from o$stetri# o!.#!ini# withG1P0A0L0 41 weeks S/L/IU headresentation mother dan feta! in"ood #ondition% Patient #onfesseda$domina! ain &-( $!ood. s!ime&-( &'(
8o histor. of 2 H3 asthma&-(%LP 10-0)-+015622 1)-04-+01,G7 40-41 weeks
Histor. of A8C 11 9 at PHC and83< GHLast resu!t &1*/04/+01,(
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
17/24
Time Subject Object Assessment Planning
Pe!@i# S#ore Pe!@i# di!atation 1 #m 1Cer@i# !en"th + #m +Cer@i9 #onsisten#e soft +Cer@i9 osisition ost 0Station -+ 1
Total " 6
Lab"H
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
18/24
Time Subjecti+e Objecti+e Assessment Planning
1,%0&%201613.30
Confessed &-( Genera! #ondition 7e!!GCS C
9.to#in dri started at dm
1&.00 Confessed &-( H9.to#in dri 1+ dm
1&.30 Confessed &-( H9.to#in dri 1, dm
1-.00 Confessed &-( H9.to#in dri +0 dm
1-.30 Confessed &-( H9.to#in dri +4 dm
16.00 Confessed &-( H9.to#in dri + dm
16.30 Confessed &-( H9.to#in dri ;+ dm
1.00 Confessed &-( H9.to#in dri ;, dm
1.30 Confessed &-( Genera! #ondition 7e!!GCS C
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
19/24
Time Subjecti+e Objecti+e Assessment Planning
1/.00 Confessed &-( H9.to#in dri 40 dm
1/.30 Confessed &-( H9.to#in dri 40 dm
1,.00 Confessed &-( H9.to#in dri 40 dm
1,.30 Confessed &-( H9.to#in started >9.to#in dri 40 dm
20.00 Confessed &-( H9.to#in dri 40 dm
20.30 Confessed &-( H9.to#in dri 40 dm
21.00 Confessed &-( H9.to#in dri 40 dm
21.30 Confessed &-( GC we!!GCS C &64E5,(
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
20/24
Time Subjecti+e Objecti+e Assessment Planning
23.30 A$domina! ain &'( GC we!!GCS C &64E5,(
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
21/24
Time Subjecti+e Objecti+e Assessment Planning
21%0&%201606.00
A$domina! ain &'( GC we!!GCS C &64E5,(
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
22/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
23/24
-
7/25/2019 Morning Report 20 April 2016 (KII Memanjang)
24/24