Morning Report 18 April 2016 (KPD)

7/25/2019 Morning Report 18 April 2016 (KPD)

1/29

Morning Report

20 April 2016

SPV : dr., SpOG

DM : Amy, Ana, Bella, Brian,Vita


2/29

a!e 1

"ame : Mr!. SA

Age : #2 year! old

RM : $%&%1# Addre!! : 'ediri, (om)o* Barat

Admitted : 20t+April 2016


3/29

Time Subject Object Assessment Planning

17th

April2016

23.00

Patient referred from MenintingPHC with G1P0A0L0 33-34weeks S/L/! head "resentationwith P#$M %1& ho'rs ( "reterm)Patient *onfessed water +eakedfrom her wom, (. sin*e 0&)001/04/&01. a,domina+ "ain (.sin*e 0&)00 1/04/&01. ,+ood2s+ime -. M (.)

Histor2 of M -. H5 -. asthma-. a++erg2 -.)

LMP 6 & / 07 / &018 6 01 / 0 / &01G9 6 33-34 week

Histor2 A:C 6 ;< at Pos2and'Last A:C6 &&-03-&01#es'+t G9 &7-&= weeks >P 6110/70 mmHg >96 4=; kghead "resentation !H6 &*mH> (. edema -.)

Histor2 of !SG 6 -

Histor2 of fami+2 "+anning6 -:eC L8 !rina+2sis Lakm's test !SG

#nitring" $,s) 5em"erat're

e@er2 ho'rs $,s) Patient in EI

for &4 ho'rs andthen mo@e to n'rsingroom

Therap$"

Am"i*i++in inJ) 1 gr/ho'rs *ontin'edwith am"i*i++in ora+3


4/29


Lab %17&0'&2016("H>6 131#>C6 44;HC56 3=)*+" 13,2' %-(PL56 &0H,sAg6 -.


5/29


+hrnlg$ at arma/a P+%1'&0'&2016("S"Patient *onfessed a,domina+ "ain(. sin*e 0&)00 1/04/&01. water+eaked (. M (. ,+ood2 s+ime -.

O"General statusGC 6 we++Cons*io'sness6 CM>P 6 1&0/70 mmHgP# 6 70 ""m## 6 &0 r"m5 6 3 C)

L1 6 ,ree*h

L& 6 ,a*k on right sideL3 6 headL4 6 4/!H 6 &4 *m!C6 &6 (. 140 t"m

E56 F 1*m eff & amnion -. head"a+"a,+e Hsma++ "art or'm,i+i*a+ *ord 'n"a+"a,+e)

A"G1P0A0L0 33-34 weeks S/L/!head "resentation with P#$M %1&ho'rs ( "reterm)

P"- E6 #L &7 d"m)- Skin test am"i*i++in -.)- nJ) Am"i*i++in 1gr/E


6/29


00)30 Confessed a,domina+ "ain (. General statusGC 6 we++Cons*io'sness6 CM>P 6 1&0/70 mmHgP#6 7 t"m##6 17 t"m56 3?C

G1P0A0L0 33-34weeks S/L/! head"resentation withP#$M)

$,s) 5em"erat'ree@er2 ho'rs

$,s) Patient in EIfor &4 ho'rs andthen mo@e to n'rsingroom

Am"i*i++in inJ) 1 gr/ho'rs *ontin'edwith am"i*i++in ora+3P 6 1&0/70 mmHgP#6 7 t"m##6 17 t"m56 3?C

G1P0A0L0 33-34weeks S/L/! head"resentation withP#$M)


7/29


8/29


9/29


10/29

Remaining a!e

"ame : "y. S

Age : #2 year! old

Addre!! : Bima Admitted : 1!t April 2016

RM :$%61-


11/29

T4#5 S*5+T45 O*5+T45 ASS5ST#5T PLA4G

01/04/ &0110)00

Patient referred from >ima GH withG1P0A0L0 3-3 weeks S/L/! head"resentation with o,s) e,ris e* H with

"+a*enta "re@ia tota+is) 5he "atient *onfessed*o'gh and d2s"nea sin*e & da2s ago) e@ersin*e da2s ago) 5here is no a*ti@e ,+eedingfrom her wom,) A,domina+ "ain -. water+eaked from her wom, -. ,+ood2 s+ime -.M (.)

:o histor2 of M H5 and asthmaHistor2 of fami+26 M -. H5 (. motherasthma -.

LMP6 -86 -

G96 -

Histor2 of A:C6 &< at PHCLast res'+t 1&/1&/&01.6 >P 110/;0 mmHgG9 17 weeks !H & finger ,e+ow 'm,i+i*'sH> (.

General status"GC6 moderateGCS6 84EM

>P6 130/70 mmHgH#6 77 ,"m88" 36 9&min56 30C

82e 6 anemis -. i*teri* -.5hora< 6Cor 6 S1S& sing+e reg'+er m'rm'r -. ga++o" -.Pulm " esi:uler %;&;(, &>(,8n:hi %;&;(.

A,domen 6 s*ar -. striae (. +inea nigra -.e"igastri* tenderness (.86 1&-1&-1& 144 ,"m.T" >

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris

- e* @ira+ infe*tion

!# planing"iagnostik C>C >5 C5 PP5 AP55

C5G !SG ns"e*'+o

5hera"2 $,s mother K feta+ we++ ,eing $,ser@ation ,+eeding H>

>P e@er2 ho'rs E #L

!# c GP, GP c SP, SPa/ice %1&0'&16("- La,) 5est

- Para*etamo+ 3


12/29


Histor2 of !SG6 3< at S")$GLast res'+t 1/04/1.>P6 34-3 w

AC6 33-34 wHC6 33-34 wL6 3 w896 &)44& g86 4/0/1Cor" ant P+a*enta *o@ering entire $! grade

Amnion eno'gh

Histor2 of fami+2 "+anning6 -:e


13/29


+hrnlg$ at *ima G

01&'&2016

S" Patient *ame to >ima GH refered from PHC after*onfessed fe,ris sin*e &/3/1.)

O"GC6 we++GCS6 84EM>P6 100/0 mmHgH#6 7= ,"m

A" G1P0A0H0 3-3 weeks S/L/! with "+a*enta "re@iatota+is ( o,s) e,ris e* H

P"- Co Cardio+ogist- o !SG 6 &=/03/1- Cons'+t nterna &7/03/1.- Am+odi"ine & GH

27&03&2016- nJ) Ceftria


14/29


14)00 2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 10/70 mmHgH#6 7& ,"m##6 40

56 3;

0

C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris

- e* @ira+ infe*tion

$& 4 +"m $,s mother K feta+ we++ ,eing

SP isite " La,) 5est e@er2 &-3 da2s f d2"sne' sti++ (. Con*'+t Cardio+ogist


>P6 10/70 mmHgH#6 7& ,"m##6 3756 3;0C 6 11-11-1& 13& ,"m.!C6 -


1)00 2s"ne' ((.A*ti@e ,+eeding from her wom, -.

>P6 140/70 mmHgH#6 7; ,"m##6 4056 3=0C 6 1&-13-1& 147 ,"m.!C6 -

5ho 6 rh (/(. whee -/-.

M "+anning 6 Pro 8CG Pro 5horaks "hoto $,s mother K feta+ we++ ,eingM *o GP GP ad@i*e 6 A** to 8CG A** to thoraks "hoto

1) &0 9 5A 6Patient mo@e to #adio+og2st La, and do the thoraks"hoto) #es'+t is 6C5# % 0 *ardiomega+2

M P+anning 6 Co Cardio+ogist Co P'+mo+ogistGP ad@i*e 6- A** to *o *ardio+ogist


15/29


1;)00 2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 140/70 mmHgH#6 7& ,"m##6 3056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris- e* @ira+ infe*tion (e*om") Cordis


1;)30 Cardio+ogist ad@i*e 6- nJ) Lasi< 1 < 1 am"


>P6 130/70 mmHgH#6 74 ,"m##6 &756 30C 6 11-11-1& 13& ,"m.!C6 -


1=)00 2s"ne' ((.A*ti@e ,+eeding from her wom, -. >P6 140/70 mmHgH#6 77 ,"m##6 3&56 3;10C 6 11-11-1& 13& ,"m.!C6 -


&0)00 2s"ne' ((.A*ti@e ,+eeding from her wom, -.

>P6 130/70 mmHgH#6 7 ,"m##6 30T" 37,?0+! " 1'>1@>1@ %176 bpm(!C6 -

$& 4 +"m $,s mother K feta+ we++ ,eing Para*etamo+ ta, 00 mg "o

&1)00 2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 140/70 mmHgH#6 70 ,"m##6 &756 3;40C 6 1&-13-1& 147 ,"m.!C6 -



16/29


&&)00 2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 140/70 mmHgH#6 7& ,"m##6 3056 3;0C

6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris- e* @ira+ infe*tion (

e*om") Cordis



>P6 130/70 mmHgH#6 74 ,"m##6 &756 30C 6 11-11-1& 13& ,"m.!C6 -


&4)00 2s"ne' (.A*ti@e ,+eeding from her wom, -. >P6 140/70 mmHgH#6 77 ,"m##6 &56 3;10C 6 11-11-1& 13& ,"m.!C6 -


0&/04/&01.0)00

2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 130/70 mmHgH#6 77 ,"m##6 &456 370C 6 1&-1&-1& 144 ,"m.!C6 -



1&)00 2s"ne' (.A*ti@e ,+eeding from her wom, -.

>P6 130/70 mmHgH#6 77 ,"m##6 &456 370C 6 1&-1&-1& 144 ,"m.!C6 -



17/29



>P6 130/70 mmHgH#6 77 ,"m##6 &456 3;70C 6 1&-1&-13 147 ,"m.!C6 -


$,s mother K feta+ we++ ,eing >ed rest 4nterna"

bs ebris P+T tab 391 +ar/ilgist" Lasi9 191 Amp


>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 30C 6 1&-1&-1& 144 ,"m.!C6 -

$,s $& $,s mother K feta+ we++ ,eing >ed rest

03/04/&010)00


>P6 130/70 mmHgH#6 74 ,"m##6 &456 370C 6 13-1&-1& 147 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris-; e* @ira+ infe*tion (e*om") Cordis

$,s $& $,s mother K feta+ we++ ,eing >ed rest Pro *o *ardio+ogist tommorow


>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 3;0C 6 1&-1&-1& 144 ,"m.

!C6 -



>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 3;0C 6 1&-1&-1& 144 ,"m.!C6 -



18/29



>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 30C 6 1&-1&-1& 144 ,"m.!C6 -



04/04/&010)00


>P6 130/70 mmHgH#6 74 ,"m##6 &456 370C 6 13-1&-1& 147 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris-7 e* @ira+ infe*tion (e*om") Cordis

$,s $& $,s mother K feta+ we++ ,eing >ed rest Pro *o *ardio+ogist this morning


>P6 1&0/70 mmHgH#6 77 ,"m

##6 &456 3;0C 6 1&-1&-1& 144 ,"m.!C6 -

$,s $& $,s mother K feta+ we++ ,eing

>ed rest


>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 3;0C 6 1&-1&-1& 144 ,"m.!C6 -



>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 30C 6 1&-1&-1& 144 ,"m.!C6 -



0/04/&010)00


>P6 130/70 mmHgH#6 74 ,"m##6 &456 370C 6 13-1&-1& 147 ,"m.!C6 -


$,s $& $,s mother K feta+ we++ ,eing >ed rest Cardio+ogist ad@i*e6

Lasi< 1 am"/hari Sto" digoiso"ro+o+ 1 < ta, Pro e*ho tomorrow


19/29



>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 3;0C

6 1&-1&-1& 144 ,"m.!C6 -



>P6 1&0/70 mmHgH#6 77 ,"m##6 &456 3;0C 6 1&-1&-1& 144 ,"m.!C6 -



>P6 1&0/70 mmHgH#6 77 ,"m

##6 &456 30C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta

"re@ia tota+is ( o,s fe,ris-; e* @ira+ infe*tion (e*om") Cordis

$,s $& $,s mother K feta+ we++ ,eing

>ed rest

0/04/&010)00


>P6 130/70 mmHgH#6 74 ,"m##6 &456 370C 6 13-1&-1& 147 ,"m.!C6 -


$,s $& $,s mother K feta+ we++ ,eing >ed rest Pro e*ho toda2

0;/04/&01

0)00

2s"ne' (.

A*ti@e ,+eeding from her wom, -.

>P6 130/70 mmHg

H#6 77 ,"m##6 &456 3;0C 6 13-1&-1& 147 ,"m.!C6 -

G1P0A0L0 3-3 weeks

S/L/! with "+a*enta"re@ia tota+is ( o,s fe,ris-= e* @ira+ infe*tion (e*om") Cordis

Patient *o'+d go home


20/29


07/04/&0107)00

Patient *ome ,a*k again to :5> GH*onfessed that there is ,+ood that+eaked o't from her @agina sin*e thismorning at 0)00 95A a,domina+

"ain -. water +eaked o't from herwom, -. M (.)

>P6 1&0/70 mmHgH#6 =0 ,"m##6 &&56 3;0C

6 1&-1&-1& 144 ,"m.!C6 -ns"e*'+o6 F -. tiss'e -. a*ti@e,+eeding -. "ortio +i@ide (.

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( e*om")Cordis

Hos"ita+ied $,s) Mother and feta+ we++ ,eing C5G 8CG M *o to GP GP *o to SPE ad@i*e6

Hos"ita+ied $,ser@e the "atient Co to *ardio+ogist

Cardio+ogist ad@i*e6 Patient *o'+d go home Contin'ed the thera"2 from *ardio+ogist

Mo@e the "atient to Segara Anak #oom

0=/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &&

56 3;0

C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeksS/L/! with "+a*enta"re@ia tota+is ( e*om")

Cordis

$,s mother K feta+ we++ ,eing >ed rest S'ggest mother to eat and drink

17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -



10/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m

##6 &056 370C 6 1&-1&-1& 144 ,"m.!C6 -


"re@ia tota+is ( e*om")Cordis

$,s mother K feta+ we++ ,eing >ed rest

S'ggest mother to eat and drink

17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -




21/29


11/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 3;0C

6 1&-1&-1& 144 ,"m.!C6 -


$,s mother K feta+ we++ ,eing >ed rest S'ggest mother to eat and drink SPE ad@i*e6

Pro C-se*tion need rest

S'ggest mother to eat and drink Cardio+ogist ad@i*e6

Pro 8*ho Sto" 'osemide and >iso"ro+o+ Contin'e the thera"2 from $>GN:

17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 =0 ,"m##6 &056 30C 6 1&-1&-1& 144 ,"m.!C6 -



13/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 370C 6 1&-1&-1& 144 ,"m.!C6 -


$,s mother K feta+ we++ ,eing >ed rest S'ggest mother to eat and drink Pro C-se*tion at 1=/04/&01


22/29


17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 3;0C

6 1&-1&-1& 144 ,"m.!C6 -



14/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 1756 370C 6 1&-1&-1& 144 ,"m.!C6 -



17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m

##6 &056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -





1/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 =0 ,"m##6 1756 30C 6 1&-1&-1& 144 ,"m.!C6 -



17)00 Com"+aint -. >P6 1&0/70 mmHg

H#6 77 ,"m##6 &056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeks

S/L/! with "+a*enta"re@ia tota+is ( e*om")Cordis

$,s mother K feta+ we++ ,eing

>ed rest S'ggest mother to eat and drink


23/29


1/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &056 3;0C

6 1&-1&-1& 144 ,"m.!C6 -



17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &&56 370C 6 1&-1&-1& 144 ,"m.!C6 -



1;/04/&010)00

Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m

##6 &056 3;0C 6 1&-1&-1& 144 ,"m.!C6 -





17)00 Com"+aint -. >P6 1&0/70 mmHgH#6 77 ,"m##6 &&56 370C 6 1&-1&-1& 144 ,"m.!C6 -



17/04/&01

0)00

Com"+aint -. >P6 1&0/70 mmHg

H#6 77 ,"m##6 &056 370C 6 1&-1&-1& 144 ,"m.!C6 -

G1P0A0L0 3-3 weeks

S/L/! with "+a*enta"re@ia tota+is ( e*om")Cordis

$,s mother K feta+ we++ ,eing

>ed rest S'ggest mother to eat and drink Pr +>sectin at 1B&0'&2016


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Morning Report 18 April 2016 (KPD)

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