Morning Report 27-5-2015

Morning report 27/05/2015 Supervisor: dr H. Agus Thoriq SpOG

Morning report 27/05/2015Supervisor: dr H. Agus Thoriq SpOGKoas: Dede, Nadiah, Diah, OriqCases G4P3A0L3 41-42 weeks S/L/IU head presentation with PROM < 12 hours + Gestasional Hypertension (observation)G1P0A0L0 A/S/L/IU head presentation with severe pre eclampsia ( observation )

Name: Mrs. MRM: 102175Age: 33 years oldAddress: Gn. Sari, West LombokAdmitted: May 26th 2015, at 23.05

Case 1TimeSubjectObjectAssessmentPlanning26/05/201523.05

Patient referred from Gn. Sari PHC with G4P3A0L3 42-43 weeks S/L/IU head presentation with PROM < 12 hour + gestasional Hypertension. Patient confessed water leaked out from her womb since 19.00 (26/05/2015). Abdominal pain (-).Blood slim (-). FM (+). Headache (-), Blurry vision (-), nausea (-), vomiting (-)History of DM (-), HT (-), asthma (-).LMP : ForgetEDD : -GW : 38-39 weeks (based on USG result)History ANC : 8x at PHC, last 18-04-2015Result : BP 140/100, 33-34 w ,head presentation, UFH : 28 cm, FHB +, proteinuri (-), History of USG : 1x at SpOGLast 26-11-2014Result: Fetal S/L/IU , 12-14 week AF enough, EDD: 06-06-2015

History of family planning: injection 3 monthsNext family planning: tubectomyObstetric History:Female/ aterm/ traditional practitioner/ 19 y.oMale/ Aterm/ traditional practitioner/ 14 y.oMale/ aterm/ midwife/ 2900 gr/ 11 y.o this

General statusGC : wellGCS: CM (E4V5M6)BP : 140/100mmHgPR: 848x/mRR: 20 x/mT: 36,74C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext uper: warm (+/+) edema (-/-)Ext lower: warm (+/+) edema (-/-)

Obstetric statusL1 : breech UFH: 34 cm EFW : 3565 gramL2 : back on the right sideL3 : headL4 : 4/5UC : - FHB : 11.12.12 (140x/min)VT : (-), consistency of cervix average, palpation in fornix feel like head palpable

PS : 3Dilatation of servix : 0Consistency of cervixPosition of cervix : 1Length of cervixIn Hodge I : 1

G4P3A0L3 38-39 weeks S/L/IU head presentation with PROM < 12 hours + Gestasional hypertensionObs. Mother and fetal well being.CIE mother to eat, drink and lie down to the left sideObs. Sign of inpartuInj. ampicillin 1 gr IV/6 hours (at PHC 19.30 Wita)DM co to GP pro CTG, GP agree .

TimeSubjectObjectAssessmentPlanningChronologist at Gunung sari PHC 26-05-2015 (15.00 wita) S :Patient confessed water leaked out from her womb since 19.00 (26/05/2015). Abdominal pain (-).Blood slim (-). FM (+). Headache (-), Blurry vision (-), nausea (-), vomiting (-)O :GC : wellGCS : CM (E4V5M6)BP : 140/100 mmHgPR : 84x/mRR : 20 x/m Temp : 36,7oCObstetric statusL1 : breech UFH: 30 cm EFW : 2945 gramL2 : back on the right sideL3 : headL4 : 4/5UC : - FHB : 12.12.12 (144x/min)VT : (-), consistency of cervix average, palpation in fornix feel like head palpable

A : G4P3A0L3 42-43 weeks head presentation mother and fetal in well condition with PROM < 12 hours + gestasional hypertension.

P: Inj. Ampicilin 1 gr/IM (19.30) IVFD RL 20 dpm referred to NTB GH

Lab : 22.00 Hb: 10,8Wbc 13,65Plt 431HbsAg (-) Proteinuria (-), Glucose: (-)

G4P3A0L3 A/S/L/IU head presentation with PROM < 12 hours + Gestasional hypertension

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING27/05/201500.50Mother transfer to VK TerataiGC : wellGCS : CMBP : 140/90 mmHgPR : 84 x/mRR : 22 x/mT : 36,4CUFH : 34 cmUC : -FHB : I. 12-12-11 (140 x/m)

G4P3A0L3 A/S/L/IU head presentation with PROM + gestational hypertension

.Observe mother and fetal well being.CIE mother to eat and drinkInjection ampicilin 1gr/IV04.00Abdominal pain (+)GC : wellGCS : CMBP : 140/80 mmHgPR : 80 x/mRR : 24 x/mT : 36,6CUC : 3x10~35FHB : I. 12-11-12 (136 x/m)VT : 4 cm, eff 50%, amnion (-), head palpable, denominator sutura sagitalis melintang, H I, impalpable small part / umbilical cord. Active phase 1st stage of labor with ROM + gestational hypertensionObserve mother and fetal well being.CIE mother to eat and drinkCIE mother to lie down on the left sideObservation progress of labor06.00Abdominal pain more frequentGC : wellGCS : CMBP : 140/90 mmHgPR : 88 x/mRR : 22 x/mT : 36,8CUC : 3x10~35FHB : I. 12-12-13 (148 x/m)Observation mother and fetal well beingDM co to GP, advice: observation progress of labor

Name: Mrs. DFRM: 561062Age: 37 years oldAddress: Seteluk, West sumbawaAdmitted: May 27th 2015, at 03.55

Case 2TimeSubjectObjectAssessmentPlanning27/05/201503.55

Patient referred from KSB GH with G1P0A0L0 41 weeks S/L/IU head presentation with severe pre eklampsia. Patient confessed water leaked out from her womb (-). Abdominal pain (-).Blood slim (-). FM (+). Headache (-), Blurry vision (-), nausea (-), vomiting (-)History of DM (-), HT (-), asthma (-).LMP : ?/8/2014EDD : ?/5/2015

History ANC : 11x at PHC, last 24-05-2015Result : BP 140/100, 38-39 w ,head presentation, UFH : 36 cm, FHB +, proteinuri (+), History of USG : 1x at SpOGLast 26-05-2015Result: Fetal S/L/IU , AF enough, EFW: 3120 gr EDD: 13-06-2015

History of family planning: -Next family planning: -Obstetric History:this

General statusGC : wellGCS: CM (E4V5M6)BP : 160/100mmHgPR: 96 x/mRR: 20 x/mT: 36,74C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext uper: warm (+/+) edema (-/-)Ext lower: warm (+/+) edema (-/-)

Obstetric statusL1 : breech L2 : back on the right sideL3 : headL4 : 4/5UFH: 32 cmEFW : 3255 gramUC : - FHB : 11.12.12 (140x/min)VT : (-), consistency of cervix average, palpation in fornix feel like head palpable

PS : 4Dilatation of servix : 0Consistency of cervix : 1Position of cervix : 1Length of cervix : 1 In Hodge I : 1

G1P0A0L0 A/S/L/IU head presentation with severe pre eclampsia Obs. Mother and fetal well being.CIE mother to eat, drink and lie down to the left sideCervical rippening with misoprostol 50 mcg / 8 hourPro termination oxytocin drip when PS > 5CtgBolus MgSO4 4 gram IV Drip MgSO4 in RL 500 cc 28 dpm DM co to GP , GP co to spv, advice: pro termination with induction. Give MgSO4 for severe pre-eclampsia. First (bolus 4gr cont drip 6 gr in RL 500cc), after 2 hours, start induction with oxytocin drip No need misoprostol.

TimeSubjectObjectAssessmentPlanningChronologist at KSB GH 26-05-2015 (23.30 wita) S :Patient confessed water leaked out from her womb (-), Abdominal pain (-).Blood slim (-). FM (+). Headache (+), Blurry vision (-), nausea (+), vomiting (-)O :GC : wellGCS : CM (E4V5M6)BP : 160/100 mmHgPR : 96 x/mRR : 20 x/m Temp : 36,7oCObstetric statusL1 : breech UFH: 32 cm EFW : 3255 gramL2 : back on the right sideL3 : headL4 : 4/5UC : - FHB : 12.12.12 (144x/min)VT : -

A : G1P0A0L0 A/ S/L/IU head presentation mother and fetal in well condition with severe pre eclampsia

P: IVFD RL 20 dpm referred to NTB GH

Lab : (04.00)Hb: 11,8Wbc 15,97Plt 281HbsAg (-) Proteinuria (+1), Glucose: (-)

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING27/05/201506.00GC : wellGCS : CMBP : 160/90 mmHgPR : 84 x/mRR : 22 x/mT : 36,4CUC : -FHB :12-12-11 (140 x/m)

G4P3A0L3 A/S/L/IU head presentation with PROM + gestational hypertension

.Observe mother and fetal well being.CIE mother to eat and drinkMgSO4 40% 4gr iv in 10 minutes

06.10Start drip MgSO4 40% 6 gr, 2 hours later start induction of oxytocin drip 5 IU in D5% 500cc 8 dpm double line.