Morning reportMarch, 24th 2014SUPERVISOR:Dr.H. Doddy A.K., SpOG

DM:AKBAR, ARIQ, ASRI

Name: Mrs. AAge: 45 yoAddress: Pararopa, DompuAdmitted: March, 24th 2014 at 08.19 WITAPATIENT IDENTITY

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING24/03/2014

08.19 WITAPatient 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 (+).

No history of DM, HT, asthma. No history of allergic reaction to medicine or food.

LMP : 08/07/2013EDD: 15/04/2014

History of ANC : 3xLast ANC: 21/03/2014, result: BP: 90/60 mmHg, 32 wk, FHB (+), UFH: 27 cmGeneral status:GC: wellGCS: E4V5M6BP: 100/70 mmHgPR: 86 bpmRR: 25 rpm T: 36,4 0 C

Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single reguler, murmur (-), gallop (-)Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-), warm acral (-/-)

Obstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 25 cm EFW: 2170 grUC: 1x10~20FHB: 12-11-11 (136 x/min)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 anemiaObs mother & fetal well beingO2 3 lpmDM co to GP pro SC, GP co to SPV, SPV advice : SC electivPro transfusi 600 ccInj. Ceftriaxone 2 gr/ IV / 24 hoursDCCo. anastesi, advice: ECGCo. internist, advice:Transfution Hb ~ 10 gr%, 1 kolf/day 20 tpmPremed dexamethason 1 ampX-ray thoraxCo. Orthopedy

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGHistory of USG : -History of Family Planning: IUD Next Family Planning: sterileHistory of obstetry:Aterm, spt B, BTA, home, 22 yo, liveAterm, spt B, BTA, home, 20 yo, liveAterm, spt B, BTA, home, 19 yo, liveAterm, spt B, BTA, home, 17 yo, liveAbortusAbortusAterm, spt B, BTA, home, 15 yo, liveAterm, spt B, BTA, home, 13 yo, liveAterm, spt B, BTA, home, 11 yo, liveAterm, spt B, BTA, home, 10 yo, liveAterm, spt B, BTA, home, 6 yo, liveAterm, spt B, BTA, home, 4 yo, liveAterm, spt B, BTA, home, 2 yo, livethisVT : 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

Lab ResultHb : 7,8 x 106/ LWBC : 21,7 x 103/ LPLT : 548 x 103/ LHCT : 24,7 %BT: 230CT: 410Cr: 1,3 mg/dlUreum: 84 mg/dlOT: 30 mg/dlPT: 20 mg/dlAlb: 2,6 g/dlHBsAg : (-) non reactive

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGChronologist 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: wellGCS: E4V5M6BP: 100/70 mmHgPR: 90 bpmRR: 24 rpm T: 36,50 CStatus Obstetric L1 : headL2 : back on the right sideL3 : breechL4 : 4/5UFH : 25 cmEFW : 2170 gramFHR : 12-11-12 (140bpm)UC : -

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGVT : 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 tpmAmoxicilin tab 500 mg 3x1Paracetamol tab 500 mg 3x1Referred to NTB GH

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING18.00 WITAMother confessed pain in bodyGC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 25 rpm T: 36,4 0 CUC: 1x10~15FHB: 12-11-11 (136 x/min)UO : 300 cc

Lab: GDS: 68 mg/dlObs mother & fetal well beingDM co to GP, GP advice bolus Dex 40 %, pro check GDS 1 hour post bolus.22.30 WITA -1 hour post bolus Dex 40 %22.30 WITA-Lab:GDS: 78 mg/dl

Ro. Thorax:KP DuplexG14P11A2L11 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 tpmVulva hygine

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING25/02/2014

06.00 WITA-GC: wellGCS: E4V5M6BP: 100/70 mmHgPR: 84 bpmRR: 24 rpm T: 36,5 0 CUC: 1x10~10FHB: 12-11-11 (136 x/min)

Lab: GDS: 68 mg/dlObs mother & fetal well being

Thank you