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MORNING REPORT

August, 30th 2014

SUPERVISOR : dr. Agus Thoriq, SpOG

! : S"#ti, A$u, Ri", %u&i

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MORNING REPORTAUGUST, 4TH 2014

'ASE RESU!E

(OR!A) )A*OR 1

PAT+O)OGIES)A*OR

1. G2P1A0L1 36-37 weeks/S/L/IU head presentation wPR! " 12 ho#rs

2.

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CASE 1

Name : Mrs. N

Age : 23 years oldAddress : LangkoL!ngsarAdm!""ed : 2#$%2$1&No. RM : 113'('

G2PA0L0 36-37 weeks/S/L/IU head

presentation with PR! " 12 ho#rs

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Time Subject Object Assessment Plan

2$-0%-201&11.20

Patient 'a(e to )*+ G,reered Sieronan P,with G2P1A0L1 36-37weeks /S/L/IU headpresentation with PR!" 12 ho#rs

Patient 'onessed water

'o(e o#t ro( her ainasin'e 2%-0%-201& 11.00.She didnt 'onessa4do(ina5 pain 45oods5i( - and 8! 9.

,istor o :! - ,* -asth(a -.

L!P ; 1&-12-2013> k U8,; 27'( head presentation.

General status

G ; we55GS; ! !6+P ; 120/%0 ((,,R; %% =/(RR; 22 =/(*; 36> @

Local statusU8,; 2$ '($=/(in

G2P1A0L1 36-37 weeks/S/L/IU headpresentationwith PR! "12 ho#rs

4s. !otheta5 we55

:! 'o to *G and /6 h GP

:oin * InB.a(pi 1

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,istor o USG ;-,istor o a(i5 p5annin ;inBe'tion 3 (onths)e=t a(i5 p5annin ;inBe'tion 3 (onth

,istor o o4stetri' ;1. Preter(/ 2600/ (a5e/

(idwie/ )*+ G,/ &ears o5d/ 5ie2. *his

?* ; C 1 '( e. 0 D a(nion -'5ear head pa5pa45e ,I deno(#n'5ear #npa5pa45e s(a55 part oet#s/ #(4i5i'a5 'ord

PS ;eri' di5atation 0 '( ; 0eriks 5enth & '(; 1

'eriks 'onsisten' sot; 2eriks position posterior; 0Station , I; 1*ota5; &

Lab:

,G+ E 122.$ /d5R+ E &22 F/#5+ E 1362 !/#5,* ; 366 DPL* E 2>2 !/#5

,+sA E -

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Chronologist : at Sigerongan PHC (02-0-

20!" 0#$%0&

S : Patient 'onessed 5ank pain and a4do(ina5pain sin'e esterda . +5ood s5i( - ater'o(e o#t ro( her aina 9 sin'eesterda 8! 9.

O : G ; we55ons ; !

+P ; 100/%0((,,R ; %0=/(RR ; 20=/(* ; 36U8, ; 27'(L1 ; 4ree'hL2 ; 4a'k on the 5et sideL3 ; headL& ; &/>8,+ ; 1&&=/(

U ; -?* ; C 1'( e 2>D a(nion 9 head

pa5pa45e ,I #npa5pa45e s(a55 part o et#s/#(4i5ika5 'ord

A : G2P1A0L1 36 weeks/S/L/IU with PR!

P ; a(o= 1 = >00 (Reered to )*+ G,

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Time Subject Object Assessment Plann

o *G to GPSP? ad; ind#drip o= > IU

I< patient anind#'tion

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Time Subject Object Assessment

1&.00 U ; -8,+ ; 11-12-12 1&0=/(in

Start d

1&.30 U ; -8,+ ; 11-11-12 136=/(in

1>.00 A4do(ina5 pain U -

8,+ ; 12-11-11 136=/(in

1>.30 A4do(ina5 pain U ; 2 = 10 30H8,+ ; 11-11-12 136 =/(inC > '( e. >0 D a(nion - '5ear headpa5pa45e ,I deno( #n'5ear #npa5pa45es(a55 part o et#s/ #(4i5i'a5 'ord

16.00 A4do(ina5 pain U ; 3 = 10 2>H8,+ ; 12-12-12 1&& =/(in

16.30 A4do(ina5 pain U ; 3 = 10 30H8,+ ; 12-11-12 1&0 =/(in

17.00 !other want to 4earindown

U ; & = 10 &0H8,+ ; 12-13-12 1&% =/(inInspe'tion ; openin o #5a 4#5in operine#( press#re o an#s

2nd o 5a4or

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Time Subject Object Assessment Plannin

17.2> +a4 was 4orn. (ra(. &% '( AS 9. onenita5 an

17.30 U ; we55

U8, ; 2 iner 4e55ow #(4i5i'#s

3rd o 5a4or P5a'enta was 4or

o(p5ete. >0+5eedin 2


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1$.30 G; we55 'ons;!6 +P; 110/70 ((, PR; %2=/( RR; 20=/( *; 36> 0 U; 9 we55 U8,; 2 iners 4e5ow #(4i5i'#s

2 ho#rs post part#( 4seratio4ein S#est (

30-0%-

201&07.00

G; we55 'ons;!6

+P; 110/70 ((, PR; %&=/( RR; 20=/( *; 36& 0 U; 9 we55 U8,; 2 iners 4e5ow #(4i5i'#s A'tie 45eedin; - Lokea r#4ra 9

1 da post post part# 4sered

S#est ( s#est ( S#est (

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CASE 2

Name : Mrs. ES

Age : 2% years oldAddress : S)m*a+aAdm!""ed : 2#$%2$1&No. RM : 113'3%

G1P$A$L$ 3% +eeks,G,LL,I- ead/resen"a"!onead /resen"a"!on

+!" a0"!e /ase o la*or


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2$-0%-201&10.30

Patient 'o(e to )*+ G,reered +ranrea P, withG1P0A0L0 9/-3$ weeks G/L-L/IU.Patient 'onessed a4do(ina5pain sin'e 2%-0%-1& 22.00water 'o(e o#t ro( heraina - sin'e 1&-0%-201&01.00 45ood s5i( 9 2$-0%-

1& 03.00 and 8! 9.

,istor o :! - ,* -asth(a -.

L!P ; &-12-2013

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j j

,istor o USG ; 1 ti(esLast USG; 30 J#5i 201&Res#5t; G1P0A0L0 e(e5i.

,istor o a(i5 p5annin ;-)e=t a(i5 p5annin ;inBe'tion 3 (onths

,istor o o4stetri' ;I. *his

?* ; C 6 '( e. 60 D a(nion -'5ear head pa5pa45e ,I deno(#n'5ear #npa5pa45e s(a55 part oet#s/ #(4i5ika5 'ord

Pe5i' e=a(ination;Pro(ontori#( #npa5pa45eSpina is'hiadi'a not pro(inents 'o''e#s (o4i5e

Ar'#s p#4i' " $0 deree

PS ;eri' di5atation > '( ; 2eriks 5enth 3 '(; 1eriks 'onsisten' (i5d ; 1eriks position posterior; 0Station , I; 1

*ota5; >

Lab:,G+ E 12.& /d5R+ E &20 F/#5+ E 13.7& !/#5,* ; 30E7.0 DPL* E 26$ !/#5,+sA E -

Ti S bj t Obj t A t Pl

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Chronologist : at 'rangrea PHC (2-0-

20!" 02$00&

S : Patient 'onessed a4do(ina5 pain sin'e 2%-0%-1& 22.00 water 'o(e o#t ro( her ainasin'e 1&-0%-201& 01.00 45ood s5i( 92$-0%-1& 03.00 and 8! 9.

O : G ; we55ons ; !

+P ; 110/70((,,R ; %&=/(RR ; 20=/(* ; 36>L1 ; 4ree'h 4ree'hL2 ; 4a'k on the 5et and riht sideL3 ; headL& ; &/>U8, ; 33'(

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1&.30 A4do(ina5 pain U ; 3= 10 30H8,+ ; I 13-12-13 1&%/(in II 11-11-12 136=/(in?* ; C %'( e 7>D a(nion -head pa5pa45e ,I #npa5pa45es(a55 part o et#s/ #(4i5ika5 'ord.

Pro5on a'tie phase -4s. !other and4ein

-:! pro *G GP

res#5t is rea'tie

SP? SP? ada''e5erati

-4s. Proest

16.30 U ; 3= 10 30H

8,+ ; I 12-12-12 1&&=/(in II 12-11-11 136=/(in

-Start drip o=to'in

17.00 U ; & = 10 30H8,+ ; I 12-12-13 1&%=/(in II 11-12-12 1&0=/(in

= drip; 12

17.30 U ; & = 10 30H8,+ ; I 12-12-12 1&&=/(in

II 12-12-11 1&0=/(in

= drip; 16

1%.00 U ; & = 10 30H8,+ ; I 12-12-12 1&&=/(in II 12-12-11 1&0=/(in

= drip; 20

1%.30 U ; & = 10 &0H8,+ ; I 12-12-12 1&&=/(in II 12-12-11 1&0=/(in?* ; C $ '( e %0D a(nion-head pa5pa45e ,II #npa5pa45es(a55 part o et#s/ #(4i5ika5 'ord.

Pro5on a'tie phase = drip; 2&


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j j

1$.30 U ; & = 10 &0H

8,+ ; I 11-12-13 1&&=/(in II 12-13-12 1&%=/(in

= drip; 2&

20.30 !other wont to4earin down

U ; & = 10 &0H8,+ ; I 11-12-11 136=/(in II 12-12-12 1&&=/(inInspe'tion ; openin o #5a4#5in o perine#( press#re oan#s

2nd stae o 5a4or ond#'t (other down

20.>> 8ist 4a4 was 4or1>00 ra(. && '(

An#s 9. onano(a5

U8, ; 1 iner a4oe #(4i55i'#sU ; & = 10 &0H

8,+ ; I 11-12-11 136=/(in?* ; C $'( e $0D a(nion -head pa5pa45e ,II #npa5pa45es(a55 part o et#s/ #(4i5ika5 'ord.


Inspe'tion ; openin o #5a4#5in o perine#( press#re oan#s


21.30 Se'ond 4a4 we(a5e. 2600 ra(

>-. An#s 9. oano(a5


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1$.30 U ; & = 10 &0H8,+ ; I 11-12-13 1&&=/(in II 12-13-12 1&%=/(in

= drip; 2&


U ; & = 10 &0H8,+ ; I 11-12-11 136=/(in II 12-12-12 1&&=/(inInspe'tion ; openin o #5a

4#5in o perine#( press#re oan#s


20.>> 8ist 4a4 was 4or1>00 ra(. && '(

An#s 9. onano(a5

U8, ; 1 iner a4oe #(4i55i'#sU ; & = 10 &0H8,+ ; I 11-12-11 136=/(in?* ; C $'( e $0D a(nion -head pa5pa45e ,II #npa5pa45es(a55 part o et#s/ #(4i5ika5 'ord.

Se'ond 4a4 we(a5e. 1>00 ra(

7-$. An#s 9. ano(a5

1&.0> U ; we55

U8, ; 2 iner 4e55ow #(4i5i'#s

3rd o 5a4or P5a'enta was 4or

o(p5ete. >0+5eedin &

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UC : wellUFH : 1 finger bellow umbilicus

3rd of labor PlaceCo

!

#3.3 $C: well cons:%"&5'( !P: 1)* mmHg

P+: ,#-)m ++: #-)m : 3(/( C UC: 02 well UFH: 1 fingers below umbilicus !leeding 02

# ours post partum 4bserat 6uggest

6uggest

3898#1"*.

$C: well cons:%"&5'( !P: 11)* mmHg P+: 9"-)m ++: 19-)m

: 3(/" C UC: 02 well UFH: 1 fingers below umbilicus ctie bleeding: 082 ;o7ea rubra

1 da< post post partu 4bsered 6uggest suggest m 6uggest

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ay!/er")m*)an

4an!n "eram*a"dan ke0!l masakeam!lan

mr 29 agustus 2014

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