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7/24/2019 5. FM Ward Report 4 October
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Residents : 1. dr. Donny Mega Surya
2. dr. R.A.Dewi Utari
3. dr. Paul Alwin Khoman
Department o !"stetri#s and $yne#ologyMedi#al %a#ulty & Uni'ersitas Sumatera Utara
Adam Mali( $eneral )ospital2*1+
FETOMATERNAL WARDREPORT
Monday, October 4th
2015
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,ard Patients : 2
patients
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Mrs. R- 2 yo- $1P*A*
Diagnosis : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0)ead Presentation 0
4i'e %etus Super'isior: dr. )otma P Pasari"u- M(ed!$- Sp.!$ Resident in #harge: dr. Donny Planning :
/ 56pe#tant Management
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signs oimpending e#lampsia
Mrs. )- 3* yo- $1P*A*
Diagnosis : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga0 4i'e %etusSuper'isior: dr. Mel'in 8$ 9arus- M(ed!$- Sp.!$
Resident in #harge: dr. Aeng
Planning :/ Amniousion
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Mrs. R- 22 yo- P2A*
Diagnosis : Post A#ti'e Phase management 0 PostSpontaneous ;aginal Deli'ery 0 PD 1 0 Anemia
Super'isior: dr.- Risman % Ka"an- M(ed!$- Sp.!$ Resident in #harge: dr. Paul Planning :
/ + 9ags PR< =ransussion 2 "ags per day
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%ollow up Saturday- 3rdo !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0 )eadPresentation 0
4i'e %etus
=h>
/;%D R4 0 MgS! *B 3* ##C 1 gtt>i
/n. De6amethasone gr>12 h
/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine1* mg>3* minutes ma6 12* mg>2 hours
Plan:
/56pe#tant Management
/5'aluate 'ital signs- etal heart rate- #ontra#tion and signs oimpending e#lampsia
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%ollow up Sunday- th o !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0 )eadPresentation 0
4i'e %etus
=h>
/;%D R4 0 MgS! *B 3* ##C 1 gtt>i
/n. De6amethasone gr>12 h
/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine1* mg>3* minutes ma6 12* mg>2 hours
Plan:
/56pe#tant Management
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signso impending e#lampsia
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%ollow up Monday- +th o !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere Pre/e#lampsia 0 P$ 0 UP 32/3 wga 0 )eadPresentation 0
4i'e %etus
=h>
/;%D R4 C 2* gtt>
/8iedipine ta" 61* mg- i 9P E 17*>11* mm)g gi'e 8iedipine
1* mg>3* minutes ma6 12* mg>2 hours
Plan:
/56pe#tant Management
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion and signso impending e#lampsia
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0#$10$15 04$10$15
)" : 12-? gr>d4)t : 3-+
4eu : 13-F1 >mm3P4= : 233*** >mm3
P= : 12-7 < 1 sAP==: 2-1F < 33-+ s== : 2*-+ < 1?-+ s
8R : *-F
%i"rinogen: 3?+D/Dimer: 1?**Random "lood glu#ose: F+ mg>d4Ureum : +?-3+ mg>d4
d4
8a : 131 m5G>4K : -7 m5G>44Proteinuria Urinalysis : 0
Proteinuria Urinalysis : 03
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%ollow up %riday- 2ndo !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga 0 4i'e%etus
=h>
/ ;%D R4 C 2* gtt>i
/ n. 12 h
/ n. De6amethasone mg > 12 hr
/ 8iedipine ta" 3 6 1* mg
/ Po#ari sweat 2 4 > day
Plan:
/ Amniousion
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion
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02$10$15
)" : 1*gr>d4)t : 31-4eu : 122* >mm3P4= : 1?*** >mm3
P= : 1+-2 < 1 sAP==: 31-F < 33-+ s== : 12-+ < 1?-+ s8R : 1-*7
Random "lood glu#ose: 7F mg>d4Ureum : 1+ mg>d4d4
8a : 1* m5G>4K : 3-3 m5G>44
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%ollow up Saturday- 3rdo !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga 0 4i'e%etus
=h>
/ ;%D R4 C 2* gtt>i
/ n. 12 h
/ n. De6amethasone mh>12 hr
/ 8iedipine ta" 3 6 1* mg
/ Po#ari sweat 2 4 > day
Plan:
/ Amniousion
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion
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%ollow up Sunday- tho !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga 0 4i'e%etus
=h>
/ ;%D R4 C 2* gtt>i
/ n. 12 h
/ n. De6amethasone mh>12 hr
/ 8iedipine ta" 3 6 1* mg
/ Po#ari sweat 2 4 > day
Plan:
/ Amniousion
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion
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%ollow up Monday- +tho !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Se'ere oligohidramnios 0 P$ 0 UP 27/3* wga 0 4i'e%etus
=h>
/ ;%D R4 C 2* gtt>i
/ n. 12 h
/ n. De6amethasone mh>12 hr
/ 8iedipine ta" 3 6 1* mg
/ Po#ari sweat 2 4 > day
Plan:
/ Amniousion
/ 5'aluate 'ital signs- etal heart rate- #ontra#tion/ US$
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%ollow up Monday- +tho !#to"er 2*1+ *7.** am
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=hora6 :
9reathing sound : ;esi#ular- rales /
)eart :
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D6 : Post A#ti'e Phase management 0 Post Spontaneous;aginal Deli'ery 0 PD 1 0 Anemia
=h>
/ ;%D R4 C 2* gtt>i
/ n. 12 h
Plan:
/ =ransuse + "ags PR< 2 "ags PR< ha'e "een transused
04$10$15
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04$10$15
)" : -7gr>d4)t : 1+-74eu : 17*>mm3
P4= : 1F3*** >mm3
P= : 1- < 1-1 sAP==: 31-3 < 33-7 s== : 1-+ < 1?-2 s8R : 1-1F
Random "lood glu#ose: 3? mg>d4Ureum : 13-1 mg>d4d4
8a : 1* m5G>4K : 3-3 m5G>44
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THANK YOUTHANK YOU