KPD 22 9 2015 gatot

8/19/2019 KPD 22 9 2015 gatot

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MORNING REPORT

21th of September 2015Supervisor:dr. I.Made Putra Juliawan, SpOG

Medical Students:

Sari, Ana, Tia, Dilla, Rian, Yande

CASE RESUME

NORMAL LABOR -

PATHOLOGIC LABOR

1 G2P1A0L1 !"-!# $ee%& S'L'IU he() pre&e*t(t+o*$+th PROM , 12 hor&

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CASE REPORT

  Name : Mrs. E

  Age : 28 yo  Address : Gomong-mataram

  Admitted : 21th of september 2015

  at 07.5 Am

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Time Subject Object Assessment Planning

21/09/15

07.45 amPatient come to NTB GH withG2P1A0L1 37-38 weeks !L!"#hea$ %&esentation with in%a&t' (atent

 %hase ) P*+, 12 ho'&s. heconesse$ wate& 'ncont&o((/ (eake$o't &om he& wom since 20!0!15at 1.00 %m c(ea& o$o&(ess an$ waswettin he& ski&t. A$omina( %ain- (oo$/ s(im - 6, ). Histo&/o , - HT - asthma - on

 %atient an$ he& ami(/

L,P 05!01!20159 12!10!2015

Histo&/ AN: ;< at PH:

Last AN: 10!0!15 BP 100!70mmH 35-3;weeks 6HB )Histo&/ #G 1< at $octo& 8!8!15*es'(t 9 11-10-15 96= 1;00& 31-32 estationa( ae.

Histo&/ o ami(/ %(annin - Ne

 %&esentation ) P*+, 12 ho'&s

+s. ,othe& an$ eta(we(( ein.

:"9 mothe& an$ he&ami(/ ao't thee

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TIME SU!E"TI#E O!E"TI#E ASSESTME$T P%A$$I$G

"&r'n'l'g( )21/09/2015*S+Patient conesse$ wate& 'ncont&o((/ (eake$ o't&om he& wom since 20!0!15 at 1.00 %mc(ea& o$o&(ess an$ was wettin he& ski&t.A$omina( %ain - (oo$/ s(im - 6, ).

Histo&/ o , - HT - asthma -L,P 05!01!20159 12!10!2015

O+G: we((BP 100!70 mmH H* 80 %m** 20 %m T 3;8 F:L1 &eech 'h 30cmL2 ack on the &iht si$e ew 270

L3 hea$L4 5!5#: -6HB 12-13-12#T+ , 1 cm- e.. 25- amni'n )*- &eaalable- en'minat'r unclear- 34I- n'talable small art umbilical c'r

PE+16 Pr'm'nt'rium n't

alable26 Sina isc&iaica n't

r'minent76 "'nca8e '. sacrum

6 Os "':(geus M'bile56 Arcus Pubis ; 900

Lao&ato&i'm 21!0!15HB 12.; !$(*B: 4.11 10;!(=B: 13.8 103!(PLT 281BT 320II:T ;00II

HBAG non &eacti@e

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TIME SU!E"TI#E O!E"TI#E ASSESTME$T P%A$$I$G

A+ G2P1A0H1 37-38 weeks !L!"# hea$ %&esentation w! P*+, 12 ho'&s

P )s8 a8ice*+- +

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  !o""o# $p

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Time Subject Object Assessment Planning

10.00 A$omina( %ain #: -6HB 12-12-12

ta&t $&i% o>T -

+

17.00

17.15

A$omina( %ain

A$omina( %ain

#: 4 < 10I J 40K6HB 12-12-12 144 T 5-; cm

+

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Time Subject Object Assessment Planning

17.20 ,othe& wont to ea&in$own

#: 4 < 10I J 40K6HB 12-11-12 140 T 10 cm.

"ns%ection o%enin o@'(@a '(in o %e&ine'm

 %&ess'&e o an's

2n$ stae o (ao& +

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Time Subject Object Assessment Planning

18.45 #: we((#6H 2 ine& e((ow 'mi(ic's

  4th stae o (ao&    B(ee$in 10 cc

1.15 #: we((#6H 2 ine& e((ow 'mi(ic's

4th stae o (ao&    B(ee$in 10 cc

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THANK YOU