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Morning Report

September, 1th 2015

Supervisor:dr. Gede made punarbawa, Sp.OG(!

"M #aga:rian

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Morning Reportseptember 1th 2015

Case Resume$ORM%&&%'OR

0

%)*O&OG+S

&%'OR

1. G4P3A0L3 38-39 weeks S/L/IU, head

presentation with 1

st

 stae o! "a#or "atentphase and histor$ o! % Se&tion 10 $ears ao'. G1P0A0L0 '(-'8 weeks S/L/IU head

presentation

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-ase 1

$ame : Mrs. $urhaani%ge : /1 ears od%ddress : %mpenan

%dmitted : 1032015$o. RM : 5440/

G4P3A0L3 38-39 weeks S/L/IU, headpresentation with 1st stae o! "a#or

"atent phase and histor$ o! % Se&tion 10

$ears ao

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)I*+ SU+%)I+ +%)I+ ASS+SS*+) PLAIG

31/08/'01

0.3 wita

Patient &a2e to e2eren&$depart2ent o! ) G&on!essed a#ot a#do2ina"pain spread to the !"ank 567sin&e 03.00 531/08/'017, water"eaked ot !ro2 her wo2# 5-7#"ood$ s"i2567, * 567.

istor$ o! * 5-7, ) 5-7,asth2a 5-7 and a""er$ 5-7.

L*P : !oret+ : -

istor$ o! A% : ;< at SpGLast res"t: 508/08/'017

P n&"ear 

istor$ o! USG : ;<, at SpGLast : 08/08/'01=es"t : + 0(/09/'01

istor$ o! !a2i"$ p"annin:In>e&tion 3 2onthse<t !a2i"$ p"annin : *?

#stetri& istor$:I. Ater2/Po"indes/2idwi!e/3(

00 /1 $ears/2a"e/"i@eII. Ater2/) G/S%/3(00

/10 $ears/!e2a"e/"i@eIII. Ater2/)

G/2idwi!e/3(00 /4$ears/!e2a"e/"i@e

I. )his

Genera" statsG% : we""&ons&iosness: %*P : 110/(0 22P=: 88 #p2==: '0 #p2): 3;,;%

Lo&a" stats+$e : an 5-/-7, i&t 5-/-7P"2o : @es 56/67, rh 5-/-7, wh5-/-7%or : S1S' sin"e re"ar, 25-7, 5-7

 A#d : striae ra@idar2 567,"inea nira 567, s&ar 5-7

+<t : ede2a 5-/-7, war2 a&ra"56/67.

#stetri& statsL1 : #ree&hL' : #a&k on the riht sideL3 : headL4 : 4/U: 30 &2

+? : '94 r U% : 1<10B C'0D : 11-1'-1') : E ' &2, e!! 0F, a2nion567, head presentation, I,deno2inator n&"ear, notpa"pa#"e s2a"" part H2#i"i&a" &ord

G4P3A0L3 38-39weeks S/L/IU, headpresentation with 1st stae o! "a#or "atentphase and histor$ o!% Se&tion 10 $earsao

* p"annin:ianosti& : %%,

#sA, ), %))herap$ :*onitorin : S 2other,

U%, , o#ser@ationproress o! "a#or 

%I+ : %I+ 2other and!a2i"$ a#otdianosti& p"anninand therapeti&p"annin

08.00* &o to GP &o to SP#ser@ation proress

o! "a#or 

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Laboratory (31/08/2015 05.57):: 10.( /d"=%: 3.(%): 3'. F?%: 8.8(PL): '19#sA: non rea&ti@e) : 1B4D%) : B00D

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09.3 *other &on!essed a#ota#do2ina" pain

Genera" statsG% : we""&ons&iosness: %*P : 100/(0 22P=: 84 #p2==: '0 #p2): 3;,8%

U% : 3<10B C3D : 1'-1'-13) : E 4 &2, e!! 0F, a2nion567, head presentation, I,deno2inator =A, not pa"pa#"es2a"" part H 2#i"i&a" &ord

G4P3A0L3 38-39weeks S/L/IU,head presentationwith 1st stae o!"a#or a&ti@e phaseand histor$ o! %Se&tion 10 $earsao

* p"annin:ianosti& : -)herap$ :*onitorin : S 2other,

U%, , o#ser@ationproress o! "a#or withpartoraph

%I+ : sest 2otherto "a$down at the "e!tside

13.3 *other &on!essed a#ota#do2ina" pain Genera" statsG% : we""&ons&iosness: %*P : 100/(0 22P=: 9' #p2==: '1 #p2): 3;,(%

U% : 3<10B C30D : 10-10-11

) : E &2, e!! 0F, a2nion567, head presentation, I,deno2inator =A, not pa"pa#"es2a"" part H 2#i"i&a" &ord

G4P3A0L3 38-39weeks S/L/IU,head presentationwith pro"oned 1st stae o! "a#ora&ti@e phase andhistor$ o! %Se&tion 10 $earsao

* p"annin:ianosti& : %)G)herap$ : pro

a2nioto2$*onitorin : S 2other,

U%, , %I+ :sest 2other to"a$down at the "e!tside

* &o to GP &o to SP Ad@i&e : a2nioto2$,

rehidration

 A2nioto2$ was doneat 13,4

=ehidration with =L : ': 1

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14. *other want to #earin down Genera" statsG% : we""&ons&iosness: %*P : 110/(0 22P=: 9' #p2==: '0 #p2): 3;,(%

U% : 4<10B C4D : 1'-1'-13

Sin o! 'nd stae o! "a#or 567 :&rownin, ans pressre,openin o! @"@a, #"in o!perine2

) : not per!or2

G4P3A0L3 38-39weeks S/L/IU,head presentationwith 'nd stae o!"a#or and histor$ o!% Se&tion 10 $earsao

* p"annin:ianosti& : -)herap$ : -*onitorin : S 2other,

U%, %I+ : sest 2other

to #earin down

%ond&t 2other to#earin down

 At 1.00 a#$ was#orn, !e2a"e, A-S (-9,3000 , L 1 &2, %34 &2, ans 567&onenita" ano2a"$ 5-7

a#$ roo2in in

P"a&enta was #orn&o2p"ete"$ at 1.'

o the 2anae2ent o!4th stae o! "a#or 

1(.30 G% : we""&ons&iosness: %*P : 130/90 22P=: 84 #p2==: '0 #p2): 3;.4%U% : we""U : ' !iners #e"ow 2#i"i&a"U : not 2easred

 A&ti@e #"eedin 5-7

' hors postpart2

* p"annin:ianosti& : -)herap$ : -*onitorin : S 2other,

U%, U%I+ : sest 2other

to eat and drink

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01/09/'010(.00

G% : we""&ons&iosness: %*P : 110/(0 22P=: 84 #p2==: '0 #p2): 3;.'%

U% : we""U : ' !iners #e"ow 2#i"i&a"U : not 2easred

 A&ti@e #"eedin 5-7

1 da$ post part2 * p"annin:ianosti& : -)herap$ : -*onitorin : S 2other,

U%, U%I+ : sest 2other

to eat and drink

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.. Thank

 You ..