APBecPPP.ppt
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Transcript of APBecPPP.ppt
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8/19/2019 APBecPPP.ppt
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MORNING REPORT
8th August 2015
Supervisor : dr. I Made Putra Juliawan, SpOG
Medical Student:
Yande,Cinta
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• Name : Mrs. M
• !e : "" #ears old
• ddress : $atu %a#ar, %o&ar • dmitted : 't( u!ust )*+, ++.-
• No. M : +)+/0
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Time Subject Object Assesment Planning
0808201511!15
Patient re11ered 1rom Menintin!P2C wit( G)P+*%+ "34"0wee5s6S6%6I7 (ead presentation,mot(er and 1etal well &ein! 8con1irmation dia!nose. Patientcon1essed a&out &lood lea5ed
out 1rom (er wom& since )+.**9*06*'6)*+. &dominal pain 94.$lood# slim 94, ;M 98. M, andast(ma 1rom patient and (er1amil#.
%MP : ))4++4)*+-
?>> : )/4*'4)*+
2istor# o1 NC : +*@ at P2C%ast NC : '6'6+esult mot(er con1essed
&leedin! 1rom va!ina, $P +"*6/*,"34"0 wee5s, 7;2 "* cm, (eadpresentation, ;2$ 987SG : )@ at SpOG
%ast 7SG: '6'6+;etal S6%6I7 , 2ead presentation,plasenta at corpus posterior,aterm, ?;< ""+ !ram
2istor# o1 1amil# plannin! : 4Ne@t 1amil# plannin! : 4
O&stetrical (istor# :
+.term6 1emale6 spontan6midwi1e 6P2C 6 - #.o6 alive
GC : wellGCS : ?-AM3$P : ++*60* 2: '- &pm= : "0B C : )+ &pmGeneral Status :?#e : an 9464 , ict 9464
=(ora@ :C : S+S) sin!le re!uler, murmur 94,!allop 94.P : ves 868 , w( 9464. ( 9464
&domen : scar 94 , striae 98?@tremit# : edema 9464
O&stetrical status :%+ : &reec( 7;2 :
"+cm%) : &ac5 on t(e ri!(t side
%" : (ead%- : 6?;< : )/- !r 7C : 94;2 : +).+".+" 9+) &pmA= : not evaluated
%a& :2G$ : +),3$C : -,'2C= : "0,/
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Time Subject Object Assesment Planning
0808201508!00"ITA
#h$%n%l%gist in PMenintingS :Patient con1essed a&out &loodlea5ed out 1rom (er wom&since )+.** 9*06*'6)*+.
&dominal pain 94. $lood# slim94, ;M 98.
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Time Subject Object Assesment Planning
12!(0"ITA
$lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 94
Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : ') &pm : )* tpm
= : "3,/O
C7C : 94;2 : +).+).+" 9+-' &pmA= : not evaluated
G)P+*%+ "34"0wee5s6S6%6I7 (eadpresentation, wit(
P$ e.c plasentaprevia parsial.
• Pro 7SG, result :placenta previaparsial, aterm, e1w :""* !r.
• Pro C=G• Pro termination
pera&dominal wit(CS• Pro deliver# patient
to AD teratai
1)!00"ITA
$lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 98
minimal
Gene$al Status 'GC : wellGCS: ?-AM3
$P : ++*60* mm2!P : '3 &pm : )+tpm= : "3,' OC7C : 94;2 : +".+).+) 9+-' &pmA= : not evaluated
G)P+*%+ "34"0wee5s6S6%6I7 (eadpresentation, wit(
P$ e.c plasentaprevia parsial.
• C(ec5 C$C, $=6C=,2&S!
• Preparation 1or CS
• O&s mot(er 1etalwell &ein!.• O&servation &leedin!• CI? 1or 1amil#
plannin!
15!(0"ITA $lood lea5ed out 1rom (erwom& 94%ower a&dominal pain 98minimal
Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : '" &pm : )* tpm= : "3,/ OC7C : 94;2 : +).+).+) 9+--&pmA= : not evaluated
>eliver# patient to ODCito
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Time Subject Object Assesment Planning
1*!00"ITA
• CS was &e!un
1*!15"ITA
4$a was &orn, male,")** !ram, 2C: ")cm,$% + cm, 4S 0 and /,
anus 98, anomalicon!enital 94.
Plasenta was &ornmanual, complete.
1*!(5"ITA
CS ;inis(ed
18!(5"ITA
iEEiness 94
Gene$al Status 'GC : wellGCS: ?-AM3$P : +)*60* mm2!P : '3 &pm : )+ tpm= : "3,3 OC7;2 : ) 1in!er &elow um&ilical%oc(ea 98$leedin! 9* cc
) (ours post CS • O&serve mot(er well&ein!
• Su!!est mot(er to eatand drin5 i1 mot(er not1eel nausea or didintvomit
• Su!!est mot(er to doearl# mo&iliEation
• DI? mot(er 1or&reast1eedin!
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Time Subject Object Assesment Planning
0+0820150,!00"ITA
Operation wound pain 94 Gene$al Status 'GC : wellGCS: ?-AM3$P : ++*60* mm2!P : '- &pm : )+ tpm
= : "3,/O
C7;2 : ) 1in!er &elow um&ilical%oc(ea 98$leedin! 94
-ab.'GC : wellP : +-/ &pm : -' tpm= : "3,3OC
+ da# post CS • O&serve mot(er well&ein!
• Su!!est mot(er toeat and drin5
• DI? mot(er 1or&reast1eedin!
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