Morning report

March, 24th 2014

SUPERVISOR:
Dr.H. Doddy A.K., SpOG
DM:
AKBAR, ARIQ, ASRI

PATIENT IDENTITY
Name
Age
Address
Admitted

: Mrs. A
: 45 yo
: Pararopa, Dompu
: March, 24th 2014 at 08.19 WITA

TIME

SUBJECTIVE

24/03/
2014

Patient referred from RSUD

Dompu with G14P11A2L11
A/S/L/IU with history of left
foot amputation e.c suspect
Bone carcinoma + mild
anemia. Patient confessed
abdominal pain since 19.00
WITA (22/03/2014). Water
come out from her vagiina
(-), bloody slim (-), fetal
movement (+).

08.19
WITA

OBJECTIVE
General status:
GC: well
GCS: E4V5M6
BP: 100/70 mmHg
PR: 86 bpm
RR: 25 rpm
T: 36,4 0 C

Eye : anemis (-), icteric (-)

Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
No history of DM, HT, Pulmo : vesikuler (+/+),
asthma. No history of wheezing (-/-), Ronkhi (-/-).
allergic reaction to medicine Abdomen : scar (-), striae (+),
or food.
linea nigra (+)
Extremity : edema (-/-), warm
LMP : 08/07/2013
acral (-/-)
EDD: 15/04/2014
Obstetrical status:
History of ANC : 3x
L1: breech
Last
ANC:
21/03/2014, L2: back on the right side
result: BP: 90/60 mmHg, 32 L3: head
wk, FHB (+), UFH: 27 cm
L4: 4/5
UFH: 25 cm
EFW: 2170 gr
UC: 1x10~20
FHB: 12-11-11 (136 x/min)

ASSESTMENT

PLANNING

G14P11A2L11
36-37 wk
S/L/IU head
presentation
with obs. Sign
of labor`+ IUGR
+ history of left
foot amputation
e.c suspect
Bone
carcinoma +
severe anemia

Obs mother & fetal

well being
O2 3 lpm
DM co to GP pro
SC, GP co to SPV,
SPV advice :
SC electiv
Pro transfusi 600
cc
Inj. Ceftriaxone 2
gr/ IV / 24 hours
DC
Co. anastesi,
advice: ECG
Co. internist,
advice:
Transfution Hb ~
10 gr%, 1 kolf/day
20 tpm
Premed
dexamethason 1
amp
X-ray thorax
Co. Orthopedy

TIME

SUBJECTIVE

OBJECTIVE

History of USG : History of Family Planning:

IUD
Next Family Planning: sterile
History of obstetry:
1.Aterm, spt B, BTA, home,
22 yo, live
2.Aterm, spt B, BTA, home,
20 yo, live
3.Aterm, spt B, BTA, home,
19 yo, live
4.Aterm, spt B, BTA, home,
17 yo, live
5.Abortus
6.Abortus
7.Aterm, spt B, BTA, home,
15 yo, live
8.Aterm, spt B, BTA, home,
13 yo, live
9.Aterm, spt B, BTA, home,
11 yo, live
10.Aterm, spt B, BTA, home,
10 yo, live
11.Aterm, spt B, BTA, home,
6 yo, live
12.Aterm, spt B, BTA, home,
4 yo, live
13.Aterm, spt B, BTA, home,
2 yo, live
14.this

VT : 2 cm, eff 25 %, amnion

(+),
head
palpable
H1,
denominator
unclear,
impalpable small part and
umbilical cord.
Lab Result
Hb : 7,8 x 106/ L
WBC : 21,7 x 103/ L
PLT : 548 x 103/ L
HCT : 24,7 %
BT: 230
CT: 410
Cr: 1,3 mg/dl
Ureum: 84 mg/dl
OT: 30 mg/dl
PT: 20 mg/dl
Alb: 2,6 g/dl
HBsAg : (-) non reactive

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
Chronologist
S/
Patient referred from Kito PHC
with G14P11A2L11 32 weeks
S/L/IU with prolonged of active
phase.
Patient
confessed
abdominal pain since 19.00 WITA
(22/03/2014). Water come out from
her vagiina (-), bloody slim (-), fetal
movement (+).
O/
General status:
GC: well
GCS: E4V5M6
BP: 100/70 mmHg
PR: 90 bpm
RR: 24 rpm
T: 36,50 C
Status Obstetric
L1 : head
L2 : back on the right side
L3 : breech
L4 : 4/5
UFH : 25 cm
EFW : 2170 gram
FHR : 12-11-12 (140bpm)
UC : -

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
VT : 2 cm, eff 25 %, amnion (+),
head palpable H1, denominator
unclear, impalpable small part and
umbilical cord.
Lab examination:
Hb: 8,5 gr %
A/
G14P11A2L11 32 weeks S/L/IU
with mild anemia
P/
IVFD Dex 5 % 20 tpm
Amoxicilin tab 500 mg 3x1
Paracetamol tab 500 mg 3x1
Referred to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME
18.00
WITA

SUBJECTIVE
Mother confessed pain in body

OBJECTIVE

ASSESTMENT

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 25 rpm
T: 36,4 0 C
UC: 1x10~15
FHB: 12-11-11 (136 x/min)
UO : 300 cc

PLANNING
Obs mother &
fetal well being
DM co to GP, GP
advice bolus Dex
40 %, pro check
GDS 1 hour post
bolus.

Lab:
GDS: 68 mg/dl
22.30
WITA

22.30
WITA

1 hour post
bolus Dex 40 %
Lab:
GDS: 78 mg/dl
Ro. Thorax:
KP Duplex

G14P11A2L11
A/S/L/IU head
presentation
with obs. Sign
of labor +
history of left
foot amputation
e.c suspect
Bone
carcinoma +
severe anemia
+ IUGR + KP
Duplex

IVFD Dex 5 % 20
tpm
Vulva hygine

TIME
25/02/
2014
06.00
WITA

SUBJECTIVE
-

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 100/70 mmHg
PR: 84 bpm
RR: 24 rpm
T: 36,5 0 C
UC: 1x10~10
FHB: 12-11-11 (136 x/min)
Lab:
GDS: 68 mg/dl

ASSESTMENT

PLANNING
Obs mother &
fetal well being

Thank you