Preterm Letsu 01 DESember 2014

8/9/2019 Preterm Letsu 01 DESember 2014

1/24

MORNING REPORT

30th November 2014

Supervisor : dr. H. Agus Thoriq, SpOG

Medical Students:Anies, Ida, Aan


2/24

Case 2

• a!e : ". #

• Age : $% "o

• Adress : Gunung sari

• o. &M: ''(%)*

• Ad!itted :+(th ove!er 2($-, ($.((a!

• iagnose : G$/(A(0( S101I +-3+'4ee5s reech presentation 4ith secondphase o6 laor


3/24

Time Subjective Objective Assesment Planning

30/11

/2014

01.00

wita

Patient reffered from Gunung sari PHC

with G1P0A0L0 S/L/! 34"3# wee$s

%ree&h 'resentation with se&ond 'hase of

(a%or. Patient &onfess a%domina( 'ain

s'read to her f(an$ sin&e 1).30 wita

*2)/11/14+, water (ea$ed out from her

-agina *"+, %(ood s(im *"+, *+.

Histor of *"+, HT *"+ and Asthma *"+

LP 4"4"2014

11"1"2014

Histor of A5C 67 at Po(indes

Last A5C *14"11"2014+

8esu(t 9P :100/;0, P8:< T:3=,; 88:<

Histor of !SG ".

Histor of fami( '(anning "

5e7t fami( '(anning "

>%stetr Histor1.This

General status :

?GC we((

?9P 130/;0 mmHg

?88 247/mnt

?P 667/mnt

?T 3;,#@ Ces an *"/"+ i$t *"/"+Cor S1S2 8eg Sing(e

*"+ G *"+Pu(mo -es /.wh "/", ro

"/"A%domen s&ar *"+, striae

*+7tremit warm*+,

oedema *"+

Obstetric status L1 %ree&hL2 head on right sideL3 headL4 #/#!H 13&m, 1## gr

!C 47/10@"2#BH8 14"13"13 *1;0 %'m+

T D &om'(ete, eff. 100

E, Amnion *+, %re&h

'a('a%(e H7 ,

denominator un&(ear,

'a('a%(e sma(( 'art of

feta( *the hands+

G1P0A0L0 S/L/! 34"3#

wee$s %ree&h 'resentation

se&ond 'hase of (a%or

• >%s. mother and

feta( we(( %eing

• &onsu(t to GP &o

to SP o%ser-ation

of (a%or

• >%ser-ation

'rogress of (a%or• oti-ation mother

to eat and drin$


4/24

Time Subjective Objective Assesment Planning

Chronologist : at Gunung sari /HC:

S1 patient 8 !onth pregnant con6essado!inal pain since $%.(( 4ita

9281$$1$-, water (ea$ed out from her

-agina *"+, %(ood s(im *"+, *+.

O1

GC: 4ell,

;/: $$(1%(, /: *$ p!, &&:2$ p!, T:+),% C

0$ : reech

02: ac5 on the right side

0+ : Head

0- : -1'

1$(?3+'@

T: B co!plete, e. $(( D, A!nion9E, rech palpale 7HII,deno!inator unclear, palpales!all part o6 6etal 9the hands

A1G$/(A(0( S101I +(3+$ 4ee5s reechpresentation 4ith inpartu signsecond phase o6 laor

/1 in6or! consent and reered to T;GH

La%

HG9 11,3

H&t 33

89C 4,2=

9C 1#,1=

P(t 1)1

9T2@00B

CT#@00B

H%sAg *"+


5/24

Time S O A P

01.20 Patient &onfessed a%domina( 'ain more !C 47/10@"40BH8 12"12"13 *146%'m+

Se&ond 'hase of (a%or " >%s mother and feta(

we((%eing

" >%ser-ation 'rogress

of (a%or

" oti-ation mother to

eat and drin$

01.40 other want to %earing down >n ins'e&tion

Pressure of anus, %u(ging of

'erineum, o'ening of -u(-a

Se&ond 'hase of (a%or Condu&t (a%or

*01.44+ 9a% was %orn

s't %ra&ht, fema(e,

9 22#0 gram, 9L 4=

&m, A"S #"=, anus *+,&ongenita( anoma( *"+

01.#0 Third 'hase of (a%or P(asenta was %orn

&om'(ite

9(eeding 1#0&&

Perineum inta$

03.#0 GC we(((

9P 120/60 mmHgP8 667/minute

88 207/minute

T 3;,=C

!H 3 finger %e(ow

um%i(i&us

!C good

9(eeding 30&&

2 hours 'ost 'artum • >%ser-ation genera(

status and -ita( signmother

• oti-ation mother to

%reast feeding


eat and drin$


6/24

S O A P

01"12"

2014

0=.00

GC we((

9P 110/60 mmHg

P8 )27/minute

88 207/minute

T 3;,#@C

!C good!H 3 finger %e(ow

um%i(i&us

A&ti-e %(eeding *"+

9a% in 5C!

P8 1367/minute

88 407/minute

TF 3=@C

1st da 'ost 'artum • >%ser-ation genera(

status and -ita( sign

mother


%reast feeding

•

oti-ation mother toeat and drin$


wa($ing


7/24


8/24


9/24

• COTOH /AA ;AFI 0AI


10/24

2

0

2

2

1

1

8


11/24

/osture 9+


12/24

Square 4indo4 9(


13/24

Ar! recoil 9+


14/24

/opliteal angle 9-


15/24

Scar6 sign 9+


16/24

Hell to ear 92


17/24

S5in 9$


18/24

0anugo 9$


19/24

/lantar sur6ace 9(


20/24

;reast 92


21/24

#"e1 #ar 9+


22/24

Genitals 92


23/24

1

0

1

2

3

2

9


24/24

Documents

Preterm Letsu 01 DESember 2014