Morning Report 20 April 2016 (KII Memanjang)

7/25/2019 Morning Report 20 April 2016 (KII Memanjang)

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Morning Report

20 April 2016

Supervisor : dr.Agus Thoriq ,

SpOGDM : An, !el, !rin, Di"s,

#it


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$se 1

%"e : Mrs. S% Age : 21 &ers old

RM : '()(1)*+ Address : Sedu, o"-o !rt Ad"itted : 20thApril 2016


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Time Subject Object Assessment Planning

20th

April2016

23.00

Patient referred from Sedau PHCwith G1P0A0L0 40-41 weeksS/L/IU head resentation withro!on"ed se#ond sta"e of !a$or%Patient #onfessed a$domina!ain &'( sin#e 1)%00&1*/04/+01,( $!ood. s!ime &'(sin#e 0,%00 &+0/04/+01,( water!eaked from her wom$ &'( sin#e0%00 &+0/04/+01,( &'(%

Histor. of 2 &-( H3 &-( asthma&-( a!!er". &-(%

LP 0 / 0) / +015622 15 / 04 / +01,

G7 40-41 week

Histor. A8C ,9 at PHCLast A8C 11-0+-+01,:esu!t G7 ;0 weeks


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Lab $20%0&%2016'"H


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+0/04/+01,

14%00

(hronolog# at Se)au P*($20%0&%2016'"S"Patient #onfessed a$domina! ain&'(

O"

General statusGC we!!Cons#iousness C

$s% Si"n of !a$or 4 hours a"ain%


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+0/04/+01,

1%00

(hronolog# at Se)au P*($20%0&%2016'"S"Patient #onfessed a$domina! ain &''(

O"

General statusGC we!!Cons#iousness C

$s% Si"n of !a$or + hours a"ain%


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+0/04/+01,

+1%00

(hronolog# at Se)au P*($20%0&%2016'"S"-

O"General status

GC we!!Cons#iousness CH< 11-1+-11 &1;,(


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+0/04/+01,

++%00

(hronolog# at Se)au P*($20%0&%2016'"S"Confessed a$domina! ain &'(

O"General status

GC we!!Cons#iousness C


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01%;0 A$domina! ain &'( General statusGC we!!Cons#iousness C


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0,%00 8o #om!aint General statusGC we!!Cons#iousness C


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Re"ining $se

%"e : Mrs. M Age : /1 &ers old Address : A"penn

Ad"itted : April 1th, 2016 %o. RM : 12 (6 1



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1*/04/+01,1;%00 wita

Patient from o$stetri# o!.#!ini# withG1P0A0L0 41 weeks S/L/IU headresentation mother dan feta! in"ood #ondition% Patient #onfesseda$domina! ain &-( $!ood. s!ime&-( &'(

8o histor. of 2 H3 asthma&-(%LP 10-0)-+015622 1)-04-+01,G7 40-41 weeks

Histor. of A8C 11 9 at PHC and83< GHLast resu!t &1*/04/+01,(


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Pe!@i# S#ore Pe!@i# di!atation 1 #m 1Cer@i# !en"th + #m +Cer@i9 #onsisten#e soft +Cer@i9 osisition ost 0Station -+ 1

Total " 6

Lab"H


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Time Subjecti+e Objecti+e Assessment Planning

1,%0&%201613.30

Confessed &-( Genera! #ondition 7e!!GCS C

9.to#in dri started at dm

1&.00 Confessed &-( H9.to#in dri 1+ dm

1&.30 Confessed &-( H9.to#in dri 1, dm

1-.00 Confessed &-( H9.to#in dri +0 dm

1-.30 Confessed &-( H9.to#in dri +4 dm

16.00 Confessed &-( H9.to#in dri + dm

16.30 Confessed &-( H9.to#in dri ;+ dm

1.00 Confessed &-( H9.to#in dri ;, dm

1.30 Confessed &-( Genera! #ondition 7e!!GCS C


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1/.00 Confessed &-( H9.to#in dri 40 dm

1/.30 Confessed &-( H9.to#in dri 40 dm

1,.00 Confessed &-( H9.to#in dri 40 dm

1,.30 Confessed &-( H9.to#in started >9.to#in dri 40 dm

20.00 Confessed &-( H9.to#in dri 40 dm



21.30 Confessed &-( GC we!!GCS C &64E5,(


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23.30 A$domina! ain &'( GC we!!GCS C &64E5,(


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21%0&%201606.00

A$domina! ain &'( GC we!!GCS C &64E5,(


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Documents

Morning Report 20 April 2016 (KII Memanjang)