20 april 2015 dgn peb dan edema paru-sinta

7/25/2019 20 April 2015 Dgn Peb Dan Edema Paru-sinta

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MORNING REPORT

April, 20th 2015Supervisor :dr. Edi Prasetyo Sp.OG

Medical Students :

Arif, Gde, Ryan, Jihan, Santya, Sinta, Yulisa, Ryan, Adi, Yuvita

CASE RESUME

NORMAL LABOR

PATHOLOGIC LABOR

GP!A"#! $! % $ &ee's S(#()* head presentation&ith Severe Pree'la+psia susp. Pul+onary

Oede+a fetal distress


2/16

CASE REPORT

Name : Mrs. S

Age : 33 years old Address : Sigerongan, Lingsar, West

Lombok

Admitted: April,20th201 !0".#$%


3/16

Time Subject Object Assessmet Pl!i"

April20th2015

-".$/0

Patient ca+e to 123 G4 refferedfro+ Si5eron5an P46 &ithGP!A"#! $! &ee's S(#()* &ithi+pendin5 ecla+psia &ith susp.Pul+onary oede+a. Patientconfessed 7reathlless since "8.""a+, headache -0, 7lurred vision -90,

vo+itted -90, epi5astric pain -90,seiure -90. Patient also confessed

A7do+inal pain -0 since !"."" p+-;


4/16

TIME S%&'ECTI(E O&'ECTI(E ASSESTMENT P#ANNING

Chr$$l$") i Si"er$"! P*C+20-0.-2015/

S+ p!tiet c!me t$ Si"er$"! P*Cith !b$mi!l p!i spre! t$ l!3sice 20400 160.62015/ ! !terl!3e $ut r$m her $mb 7/ sice0.400 206.62015/, et!l m$8emet

7/, c$u"h 7/ , bre!thlless 7/

O +GC + ell&P + 1.0-0 mm*GPR + 99:-mRR + .0:-mT + ;< C*=4 : ?c+

#; : 7reech#! : 7ac' on the ri5ht side# : head#$ : $(8#a7oratoriu+ :Proteinuria :

A+ GP!A"#! $! &ee's S(#()* &ithi+pendin5 ecla+psia &ith susp.

Pul+onary oede+a.

P+-)C=> R# 8""cc-Set to >6-3olus M5SO$ $"I $ 5r->rip M5SO$ $"I ? 5r on R# !/ dp+-Prepare to reffered to RS*P G4

#a7oratoriu+ !"("$(!";8 :43 : ;8, 5(d#R36 : $,$; u#462 : $!,< IP#2 : ;/! u#36 : ;/,$;Proteinuria :

>M co to GP pro2eraphy:

>rip M5SO$ $"I ?5r on R# !/ dp+

Set to do&ercatheter

pro E6G

Set O! +as' ;" lp+GP co to SPC:

Advice:6o to )nternist

)nternist advice :9A+lodipin ta7 ;" +5;@;9 =urose+id ;" +5( /

h9 6o to cardiolo5ist

6)E :K 2ell the result of

e@a+ination andcondition to +otherand her fa+ily


5/16


"


6/16


;".""

;"."

S6 7e5in

9 3a7y &as 7ornfe+ale, !/"" 5ra+,

3# $/ c+, 46 c+,anus -0, con5enitalano+aly -90, AS 98

;".;" Placenta &as 7orn+anually : co+plete,8"" 5r, 7leedin5 !8"

cc Monitorin5 :o7servation ! hourspost partu+ -vitalsi5n, active 7leedin5,*=4, *60

;".!8 Patient tranfser to)6* and 7a7ytransfer to 1)6*


7/16

TIME S%&'ECTI(E O&'ECTI(E ASSESSMENT P#ANNING

12400 G6S : E!C@M!3P : ;8"(;"" ++45PR : ;"" 7p+RR : !$ 7p+2 : ?,O6*6 : -0 &ell*=4 : ! fin5ers 7elo&

u+7ilicusActive 7leedin5 : -90*O : ;"" cc(hoursOperation &ound 5ood

! hours post S6 K O7served +other &ell 7ein5K O7served 7leedin5 CS +other

21-0.-2015

0


8/16

4

4

34

4

3

22


9/16

Parchmentdeep

cracking novessels

Full areola5-10 mm

bud

Formed &frrm instant

recoil Yellowumbilical

cord


10/16

!a"oralarge

minorasmall

#reasesover entire

sole

!ostl$ bald


11/16

4

4

4

4

4

4

24


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13/16

#u7chenco 6urve


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15/16


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%hank $ou

20 april 2015 dgn peb dan edema paru-sinta

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