morning report 02 mei 2016 (oligohidramnion)
DESCRIPTION
obgynTRANSCRIPT
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
16/06/16(18.00)
Patient come to NTB GH referred from Praya GH with G1P0A0H0 A/S/L/IU with Severe Preeclampsia + Hypertiroid + elderly primigravida + Sinus Tachycardia. Patient confessed abdominal pain since 21.00 (15/06/16), Bloody slime (+) since 22.00 (15/06/16), FM (+), water leaked out from her womb (-). PatientPalpitation (+), sweating (-), tremor (-), weakness (-), Defecation and urination in normal range.History of Hypertiroid (+) since 17 yo, HT (+) since 4 year ago, DM (-), asthma (-) allergy (-)History of family (-)
History of medication: PTU and propanolol.History of Allergy: (-)
LMP : 01/09/2015EDD : 06/06/2016GW: 41-42 weeks
ANC history : 8x at PHCLast ANC : 10/06/2016Result : BP 140/70 mmHg, BW: 47kg, UFH: 28 cm, head presentation. USG history : 1x at SPOGLast : 13/03/16Result : G1P0A0 uk. 32 minggu T/H/IU+ hipertiroid + HDK + Primi tua primer
Family planning history :-Plan of family planning: IUD
General status :GC : wellConsciousness : CMBP : 180/110 mmHgPR : 100 bpmRR : 31 rpmT : 36,50C
Local StatusEye : pale (-/-), icteric (-/-), exofthalmus (+)Cor : S1S2 single regular, murmur (-), gallop (-)Pulmo : vesicular (+/+), ronchi (-/-), wheezing (-/-)Abdomen : striae gravidarum (-), scar (-)Extremity : edema (-/-), warm acral (+/+), tremor (-/-)
Obstetrical StatusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 31 cmEFW : 3100 gramUC : 2x10’~30”FHR : 11-12-11 (136 bpm)VT : ᴓ 3 cm, eff 25%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord
G1P0A0L0 41-42 weeks S/L/IU head presentation with Cronic Hypertension + Hyperthyroidism + elderly primigravida + inpartu latent phase first stage of labor
DM PlanningDiagnostic• CBC• UL• CTG• HbsAg• ECG• FT4, TSH
Therapy• Observation
progress of labor• Observe mother &
fetal well being• Suggest mother to
eat and drink• Suggest mother to
lay to to the left side.• CIE : CIE mother
and family about planning
• Pro consul interna
DM co to GP, GP co to SPV, advice : • Observation
Progress of labor• Nifedipine 3 x 10
mg
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Obstetric History:1. Ini
Pelvic ExaminationPromontorium unpalpableSpina ischiadica not prominentOs sacrum convexOs coccygeus mobileArcus pubis > 90
Laboratory (02/05/2016):HB: 13.9 g/dl RBC: 4,86 (10^6/uL)HCT: 41,0 %WBC: 9,17 (10^3/uL)PLT: 293 (10^3/uL)Ureum : 14Cr: 0,6SGOT: 49SGPT: 46HbsAg: non reactive
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16/06/2016 Chronology at Praya GH (16/06/2016)S :Patient referred from Langko PHC with G1P0A0 A/T/H + Hyperthyroid. Patient confess abdominal pain referred to flank since 17.00 (15/06/16). Water leaked out from her womb (-).O :GC : moderateConsciousness : CMBP : 160/100 mmHgPR: 80 bpmRR: 20 tpm
Obstetric statusUFH: 27 cmFHB : 144 bpm
VT : ᴓ 3 cm, eff 50%, amnion (+) head presentation, ↓H II.
A:G1P0A0L0 A/S/L with severe preeclampsia + Hyperthyroid + PTP +synus tachicardy
P:IVFD RL + MgSO4 40% 20 dpmBolus MgSO4 20% 4gr
Time Subject Object Assessment Planning
22.00 Abdominal pain (+++), FM (+)
General statusGC : wellBP : 180/110 mmHgPR: 100 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 11-12-11VT : ᴓ 4 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord
Active phase first stage of labor
Observation Progress of labor with WHO partograph
17/06/1602.00
Abdominal pain (++), FM (+)
General statusGC : wellBP : 170/100 mmHgPR: 104 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 12-12-12VT : ᴓ 6 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord
Protracted active phase first stage of labor
DM planning:Observation Progress of labor with WHO partograph
DM co to GP, GP co to SPV, SPV advice:Observation, if there is no progress, pro C-section
06.00 Abdominal pain (++), FM (+)
General statusGC : wellBP : 170/90 mmHgPR: 96 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 12-12-12VT : ᴓ 6 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord
Arrested active phase first stage of labor
DM Planning:Amniotomy
DM co to GP, GP co to SPV, SPV advice:Pro C section