Escolar Documentos
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Cultura Documentos
10 January 2009
1 2 1.
CTH
Time
Assesment
Patient came to emergency care unit with 9 month of pregnacy and confess abdominal discomfort chronologis : Patient confess abdominal discomfort since 08.00, intermient & more often. vaginal discharge (-) Obstetric history: 1. Male, aterm, spontan, 3700 g, 6,5 years 2. This LMP : 14 april 2008 EDD : 21 january 2009
G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase
Time 22.50
Assesment G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase
23.00
Conducted to labor
mother
23.10
23.15
Placenta was born spontaneusly, complete, Uterus contraction well, fundus : 2 digit under umbilicus. BP : 110/70 mmHg
Time 24.15
Subject
Object General status : well BP: 120/70 mmHg, PR: 88 /mnt UC: well, Fundus : 2 digit under umbilical
01.15
General status : well BP: 120/70 mmHg, PR: 88 /mnt UC: well, Fundus : 2 digit under umbilical
07.00
General status : weak GCS : E4V5M6 BP : 80/50 mmHg PR : 100 x/mnt Bleeding pervaginam (+), UC : weak
HPP + hipotensi
07.10
HPP + hipotensi
Lab examination : DL
Time 07.20
Object General status: weak BP : 90/50 mmHg PR : 100 x/mnt Active bleeding (-) UC : weak General status : weak BP : 100/60 mmHg PR : 92 x/mnt Active bleeding (-) UC : weak General status : weak BP : 100/60 mmHg PR : 92 x/mnt
07.30
HPP
08.00
HPP
08.50
HPP
Report to supervisor, Advice : Drip oxytocin 2 ampul in 1 fls RL Metergin 1 ampul/iv Citotec 3 tablet/rectal Tranfusion 1 kolf PRC
Time 09.00
Object General status : weak BP : 100/60 mmHg PR : 92 x/mnt Active bleeding (-) HPP
Assesment
10.00
General status : weak BP : 100/60 mmHg PR : 88 x/mnt UC : well Active bleeding (-)
HPP
Time
Subject
Object
Assesment
Planning
CTH
: 10-01-09 : 12.00 am
Object
Assesment
Planning
12.00 am
Patient reffered by PKM cakranegara with G2P1A0H1 single/life + KPD + Post date Cronology: Patient came to polindes Bertais at 11.00 am (10-01-09) with watery vaginal discharge + abdominal discomfort since 11.00 pm (09-0109) , then she reffered to PKM cakranegara and she got an examination: General condition : well BP : 110/70 Pulse: 84 x/ RR: 20x/ VT : VT : 1 cm Last menstrual period : forgot-032008 History of family planning: injection for 3 month Family planning: IUD ANC : routine in PKM and polindes Obstetrical History : 1. , spontan, midwife,2500 g, 6 years 2. This
General status General condition : well Conciousness : CM BP: 110/70 Pulse: 84x/ RR: 20x/ Temp: 37 C Eyes :an -/-, ict-/Cor/pulmo : normal Lower Extremitas : edema Obstetric status :
Observation maternal and fetal well being. Check Lab: DL, and HBSAg Report to supervisor (01.30 am) : Proposed: induction with oxytocin drip 5 IU Advice :agreed
L1 : breech L2 : left back L3 : head L4: entered pelvic inlet, descend 4/5. UFH: 30 cm EFW : 2945 g Uterine contraction: (+) 2x/1025 FHB : 150 x/mnt VT : 1 cm, eff 20 %, amniotic membran (-), head palpable, descend HI, Denom havent clear, small organ and umbilical cord unpalpable
Time
Subject
Object
Planning
Pelvic score = 6 Servic dilatation 1 = 1 Servic length 2 = 1 Consistency soft = 2 Position mid = 1 Station H1 (-1) = 1 Lab. result: HBsAg (-) Hb : 13 WB = 8700 PLT = 244.000 HCT = 33,9
Time
Subject
Object
Assesment
Planning
02.30 pm
UC FHR
G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours
03.00 pm
UC FHR
UI,
12
03.30 pm
UC FHR
UI,
16
04.00 pm
UC FHR
UI,
20
04.30 pm
UC FHR
UI,
20
Time
Subject
Object
Assesment
Planning
05.00 pm
UC FHR
G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + History of vaginal discharge + II stage of labor
UI,
20
05.30 pm
UC FHR
UI,
20
05.45 pm
UC : 5x/10~45 FHR : 140 x/mnt VT : completed, eff 100 %, amniotic membran (-), head palpable, descend HIII, Denom UUK
06.00
Baby was born: , spontaneusly, Birth weight: 3000 g, length:50 cm, AS:7-9 III stage of labor Injection I oxy 10 IU im
Injection II oxy 10 IU im
Placenta was born with manual placenta, kesan not completed, UC well
Time
Subject
Object
Assesment
Planning
07.00 pm
BP = 110/70 RR: 20 x/mnt Pulse 80 x/mnt Temp: 37 UFH = 3 fingers below the umbilical UC = good lochia (+)
1V stage of laor