PEB Drip Dundee

Morning Report25 April 2014

Supervisor : dr. I Made Putra Juliawan, Sp.OG

Medical Students :Kiki, Ardi, Dandi

CASES RESUME

NORMAL LABOR

PATHOLOGY LABOR

1. G2P1A0L1 41-42 weeks S/L/IU with severe pre-eclampsia

Case Report

• Name : Mrs. S• RM : 537284• Age : 32 years old• Address : Aik Genit, Batu Layar• Admitted : 24 April 2014, 10.36

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING24/04/2014

10.36

WITA

Patient referred from Meninting PHC with G2P1A0L0 41-42 weeks S/L/IU head presentation, with severe preeclampsia. water came out from her womb (-), bloody slim (-), FM (+).No history of blurred vision, epigastric pain, nausea and vomit.No history of DM, HT, asthma.

LMP : 13/7/2013EDD : 20/4/2012

History of ANC : > 9x at PHCLast ANC : 23/04/2014History of USG : never

History of family planning : (-)Next family planning : IUD

Obstetrical History :I.Aterm, Spontan, 3300 gr, male 2 yoII.This

General Status :GC : wellBP : 160/100 mmHgPR : 84 bpmRR : 20 bpm T : 37,0OCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-),ronkhi (-/-).Abdomen : scar (-), striae gravidarum (+), linea nigra (+).Extremity : edema (+/+), warm acral (+/+).

PS : 5Prod urine : 50 cc

Obstetrical Status :L1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH : 30 cm EFW : 2945 gramUC : 3x/10’~15”FHB : 12-12-11 (140 bpm)VT : Ø -

G2P1A0L1 41-42 weeks S/L/IU with

severe preeclampsia

• Observation mother & fetal well being.

• Observation progress of labor.

• Bolus MgSO4 40% 4 gram

• DM co to GP, GP co to SPV, advice : continue therapy of severe

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNINGChronologist (24/04/2014)

08.30S : Patient came to PHC wants to check the pregnancy..O : GC : wellBP : 150/100 mmHgPR : 88 bpmRR : 20 bpm T : 36,8OCHead presentationUFH : 28 cm UC : -FHB : (+) 11-11-11 (132 x/min)VT : - Lab : protein urine (+) 4A : G2P1A0L1 41-42 weeks S/L/IU head presentation with severe preeclampsiaP : •Drip MgS04 6 g/IV (23.15)•Down Catheter

Pelvic Evaluation :Spina ischiadica not prominentOs coccygeus mobileArcus pubis > 90o

Pelvic Score : 5Cervix dilatation 1 cm : 1Cervix length 2 cm : 1Station H1 : 1Cervix consistency moderate : 1Cervix position mid : 1

Lab Examination : HGB : 12,8g/dl HCT : 36,,3 % RBC :4,38 M/uL WBC : 10,77 K/uLPLT : 235 K/uLHbSAg : (-)Protein urine : +3

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING12.25 - General Status :

GC : wellBP : 160/100 mmHgPR : 88 bpmRR : 22 bpm T : 36,8OCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-),ronkhi (-/-).Abdomen : scar (-), striae gravidarum (+), linea nigra (+).Extremity : edema (+/+), warm acral (+/+).


Obstetrical Status :UC : -FHB : 12-12-11 (140 bpm)VT : Ø -

• DM co to GP pro CTG, GP ad CTG

• Obs. Mother and fetal being

14.00 - - _ • DM co to GP resul CTG, GP co to SPV, SPV ad :

• Termination with oxy drip

• Re- CTG while inpartu

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING14.10 - General Status :




• RL + MgSO4 40% 4 gram 28 tpm

15.00 - - _ • Give D5% + oxy drip

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING15.00 - UC : -

FHB : 11-12-12 (140 bpm)

Flash IDrip oxytocin began 8

tpm15.30 - UC : -

FHB : 12-12-12 (144 bpm)

Drip oxytocin 12 tpm

16.00 - UC : -FHB : 12-12-12 (144 bpm)


16.30 - UC : -FHB : 12-12-11 (140 bpm)


17.00 - UC : -FHB : 12-12-13 (148 bpm)


17.30 - UC : -FHB : 11-11-11 (132 bpm)


18.00 Abdominal Pain and relieved

UC : 2 x 10’ ~ 10”FHB : 12-12-12 (132 bpm)


18.30 Abdominal pain came and relieved

UC : 2 x 10’ ~ 10”FHB : 11-11-11 (132 bpm)



UC : 2 x 10’ ~ 20”FHB : 11-11-11 (132 bpm)


TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING19.00 Abdominal Pain General Status :



• RL + MgSO4 40% 4 gram flash II

• Obs. Fetal and mother being

21.00 Abdominal PainObstetrical Status :UC : 2x10’~20”FHB : 12-12-12 (144 bpm)VT : Ø 1 cm eff 10 % amnion +, denom unclear

-

Laten phase of Labor

• Give D5% + oxy drip flas II

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING21.00 Abdominal Pain and

relievedUC : 2X10’~10”FHB : 11-12-12 (140 bpm)



UC : 2x10’~10”FHB : 12-12-12 (144 bpm)



UC : 2X10’~10”FHB : 12-12-12 (144 bpm)



-

UC : 2x 10’~10”FHB : 12-12-11 (140 bpm)



-

UC : 2x 10’~10”FHB : 12-12-13 (148 bpm)



-

UC : 2 X 10’~10”FHB : 11-11-11 (132 bpm)


25/4/2014

00.00

Abdominal Pain and relieved

UC : 2 x 10’ ~ 10”FHB : 12-12-12 (132 bpm)



UC : 2 x 10’ ~ 10”FHB : 11-11-11 (132 bpm)



UC : 2 x 10’ ~ 20”FHB : 11-11-11 (132 bpm)


TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING25/04/2014

01.00

Water leaked fom her womb (+)

General Status :GC : wellBP : 160/100 mmHgPR : 90 bpmRR : 20 bpm T : 36,9OCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-),ronkhi (-/-).Abdomen : scar (-), striae gravidarum (+), linea nigra (+).Extremity : edema (+/+), warm acral (+/+).

Obstetrical Status :UC : 2x10’~10”FHB : 12-12-12 (144 bpm)VT : Ø 2 cm eff 25 %, amnion (-)

• RL + MgSO4 40% 4 gram flash II

• Obs. Fetal and mother being

21.00 Abdominal PainObstetrical Status :UC : 2x10’~20”FHB : 12-12-12 (144 bpm)VT : Ø 1 cm eff 10 % amnion +, denom unclear , caput (+), head palpable ↓H1, Urine Prod : 1000cc

-

G2P1A0L1 41-42 wk, L/H/IU with

severe preeklampsia with failed oxy

drips

• DM co to GP pro CS, GP co to SPV, SPV ad: CS at 07.00 am

• Skin Test ampi (-)• Injection ampicillin• CIE family and

patient

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

07.00- CS began

Baby was born (7.28), male 3100 gram. AS 6-8. Anus (+). Congenital anomaly (-). -Amnion clear-Placenta was born Complete. Bleeding 300cc-Inserted IUD

-CS finished

07.35 Wound painGC : wellBP : 140/90 mmHgPR : 80 x/minuteRR : 20 x/minuteT : 36,7° C

UC : +UFH : 2 finger below umbilicusLActive bleeding : -UO : 100 cc/hours

Baby moved to NICU

2 hours post CS -Obs. Mother well being.- Suggest mother

to mobilisation.- Continue drip

MgSO4 40% 6 gram 28 tpm.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING09.35 Delivery wound pain GC : well

BP : 130/90 mmHgPR : 84 bpmRR : 20 bpm T : 36,8OCUC : (+) wellUFH : 2 fingers below umbilicusLochea rubra : (+)UO : 100 cc/hours

One day post partum

• Observed mother well being• Suggest mother to mobilisation, eat and drink, medication.

• Continue drip MgSO4 40% 6 gram 28 tpm.

PEB Drip Dundee

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