MORNING REPORT
MORNING REPORTJuly 1st, 2015Resident :Gol/Cep/Til/Dof
Chief:dr. TAW
Supervisor :dr. Eka SpOG1EMERGENCY ROOM:1
DELIVERY ROOM Physiological Delivery:4Pathological Delivery
Pervaginam:-Perabdominam:12IdentityMrs. H/ 34 y.o/ 9 y.o.e/
HousewifeMr. M/ 40 y.o/12 y.o.e/Tire repairmanMarried 1x, 11
yearsAddress: Jl. Yulius Usman VI / 391, KratonAdmission 1-7-2015
at 07.00 am
3Patient reffered PKM Ngempit with chief complain fluid excess
from birth canal4SUBJECTIVES(30/6/15) 05.00 pm patient complaint
fluid excess from birth canal stay at hom
(1/7/15) 06.00 am fluid excess from birth canal more excessive
patient went to PKM Ngempit suggested to RSUD
Bangil.5SUBJECTIVESHistory of PregnancyPremature/2000 gr/
Spontaneously delivery/ Midwife/M/10 y.o/LAterm/3000 gr/CS dt
Transverse lie/ Mitra Husada Hospital/F/4 y.o/L3.This pregnancy
ANC :Midwife 5x (last controlled 24-12-13) LMP ~ 38-39
weeksContraception : 3 months injection, stop 1 year
agoOBJECTIVESBH:153 cm, BW :72 kgGA :Good, CMBP:BP :110/70 mmHg, PR
:82 x/m RR:20 x/mTax:36,6CTrect:36,8CHead : Conj. an -/- , ict -/-
Thorax: C/ S1-2 single murmur (-) P/ RH WH Abd : FU 32 cm,
longitudinal lie U FHR 152 bpm , EFW : 3100 gr, uterinecontraction
(+) rare, scar pfanenstiel (+)7OBJECTIVESGE : amniotic fluid flow
(+)Insp:amniotic fluid flow from OUE (+) amniotic fluid pooling at
posterior fornixlacmus test : (+)VT : 1 cm, eff 25%, HI, amniotic
membrane (-) greenish, head presentation, denominator ~ difficult
to evaluate, pelvic measurement ~ wnl8LABORATORYCBC
:15.440/14,2/40,3/239.000PTT/APTT: 10,4 (12,0) / 21,3
(25,9)9NSTBaseline:150 bpmVariability: < 15
bpmAcc:(-)Dcc:(+)
Patologic CTGUSG Fetal intrauterin S/L, head Below BPD: 92,0
(37w5d)AC: 338 (37w5d)FL: 73,2 (37w3d)EFW: 3326 grAFI: 3,5Placenta
implanted at fundusMaturation grade IIINuchal cord 2x
AssessmentG3P1102Ab000 gr 38-39 weeks S/L+ PROM >12 hours+
Previous CS+ Fetal Compromised
12PlanningPDx: PTx: Intra Uterine rescucitation -O2 10 lpm ,
NRBM -Mother left lateral recumbent Proposed to termination with CS
cito + post placental IUD Tocolitic : kaltrofen supp II CS
Preparation : IVFD RL 1000 cc Insert DC Tx Inj : Ceftriaxon Inj 1
gr(iv) skin test Ranitidin Inj 1Amp (iv) Metoclopramide Inj 1 Amp
(iv)Register to Operating room, Blood preparationPMo: observation
vital sign, subjective complain, FHRPEd : CIE / informed
consentC/Supervisor --------------------- Acc dr.Eka,SpOG
13July 1st, 2015 at 08.00 am Male baby born3300 gr / 49 cm/AS :
7-9OUTCOMETERIMA KASIH
