New Patient: - Patient Prior Patient: 1 Patient

New patient
Prior patient
:
:
- patient
1 patient
1. Mrs. N, 29 yo, G3P1A1

Dx: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head
Presentation
Plan
: - Spontaneous Vaginal Delivery
Follow Up at 8 AM
Present state:
Sens : Alert Anemis (-)
BP : 180/ 120 mmHg Icteric (-)
HR : 90 x/I Sianosis (-)
RR : 24 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head
: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)
Neck: in normal limit

Thorax : Respiratory sound : Vesiculer
Additional sound
: Wheezing(-)/(-), Rhonki (-)/(-)
Extremity : pretibial edema (+), KPR/APR : (+)/(+) N
Obstetrical State
Abdomen
: Symetrically enlarged
Fundal height
: 3 fingers above umbilical
Stretch part : Right

Lowest part : Head
Contraction : 3x20/10
Micturition
: via catheter 60 cc/ hour
Vaginal Examination : Not done, Baloon catheter was inflated at

OUI with RL 500cc as ballast from previous duty team
Dx
: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation
Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minutes (maintenance dose)
IVFD RL+ oxitoxin 5IU 4drips/minute titrate 4 drips/minute every 15 minutes, maximum
40drips/ minute.
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning : C-Section
Report to Supv. Dr. Melvin N.G Barus, M.Ked(OG), Sp.OG ACC
Follow Up at 4 PM
Present state:
T : 37 C Edema (-)
Localized St :
Head

Additional sound
Obstetrical State
Abdomen
Fundal height

Lowest part : Head
Micturition
Vaginal Examination : Baloon catheter was detached, cervix

sacral, 3cm, effacement 40%, Amniotic membrane (+).
Dx
Therapy:
Indwelling Catheter
40drips/ minute.
Planning : C-Section
Follow Up at 8 PM
Present state:
T : 37 C Edema (-)
Localized St :
Head

Additional sound
Obstetrical State
Abdomen
Fundal height

Lowest part : Head
Micturition
Vaginal Examination : Cervix sacral, 3cm, effacement 40%,

Amniotic membrane (+).
Dx
Therapy:
Indwelling Catheter
40drips/ minute.
Planning : Spontaneous Vaginal Delivery
Follow Up at 10 PM
Present state:
T : 37 C Edema (-)
Localized St :
Head

Additional sound
Obstetrical State
Abdomen
Fundal height

Lowest part : Head
Micturition

Dx
Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minute (maintenance dose)
IVFD RL 20 drops/ minute
Planning : Spontaneous Vaginal Delivery
Report to Supv. Dr. dr. M. Fidel Ganis Siregar M.Ked(OG), Sp.OG ACC
Follow Up at 08 AM
Present state:
T : 37 C Edema (-)
Localized St :
Head

Additional sound
Obstetrical State
Abdomen
Fundal height

Lowest part : Head
Contraction : (-)
Micturition

Dx
Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minute (maintenance dose)
IVFD RL 20 drops/ minute
Planning
: Spontaneous Vaginal Delivery
THANK YOU
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
Oxytoxin
5IU
08.00
CM
180/12
0
90
24
37,5
50
10 mg
4 gtt/i
08.15
CM
160/11
0
88
20
37,5
50
8 gtt/I
08.30
CM
150/10
0
88
20
37
50
12 gtt/I
08.45
CM
150/10
0
86
20
37
50
16 gtt/I
09.00
CM
150/12
0
90
20
37,5
50
20 gtt/I
09.15
CM
160/11
0
88
20
37,5
50
24 gtt/I
09.30
CM
150/10
0
88
20
37
50
28 gtt/I
09.45
CM
150/10
0
86
20
37
50
32 gtt/I
10.00
CM
180/12
0
90
20
37,5
50
10.15
CM
160/11
0
88
20
37,5
50
10 mg
36 gtt/I
40 gtt/I
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
11.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
11.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
11.30
CM
150/10
0
100
20
37
50
40 gtt/I
11.45
CM
150/10
0
90
20
37
50
40 gtt/I
12.00
CM
150/12
0
90
24
37,5
50
40 gtt/I
12.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
12.30
CM
150/10
0
100
20
37
50
20 gtt/I 10
IU
12.45
CM
150/10
0
90
20
37
50
24 gtt/I 10
IU
13.00
CM
180/12
0
90
20
37,5
50
13.15
CM
180/11
0
88
20
37,5
50
10 mg
Oxytoxin
5IU
28 gtt/I 10
IU
32 gtt/I 10
IU
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
Oxytoxin
14.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
14.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
14.30
CM
150/10
0
100
20
37
50
40 gtt/I
14.45
CM
150/10
0
90
20
37
50
40 gtt/I
15.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
15.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
15.30
CM
150/10
0
100
20
37
50
40 gtt/I
15.45
CM
150/10
0
90
20
37
50
40 gtt/I
16.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
16.15
CM
150/11
0
88
20
37,5
50
40 gtt/I
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
17.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
17.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
17.30
CM
150/10
0
100
20
37
50
40 gtt/I
17.45
CM
150/10
0
90
20
37
50
40 gtt/I
18.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
18.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
18.30
CM
150/10
0
100
20
37
50
40 gtt/I
18.45
CM
150/10
0
90
20
37
50
40 gtt/I
19.00
CM
150/12
0
90
20
37,5
50
19.15
CM
150/11
0
88
20
37,5
50
10mg
Oxytoxin
40 gtt/I
40 gtt/I
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
Oxytoxin
20.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
20.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
20.30
CM
150/10
0
100
20
37
50
40 gtt/I
20.45
CM
150/10
0
90
20
37
50
40 gtt/I
21.00
CM
150/12
0
90
20
37,5
50
40 gtt/I
21.15
CM
160/11
0
88
20
37,5
50
40 gtt/I
21.30
CM
150/10
0
100
20
37
50
40 gtt/I
21.45
CM
150/10
0
90
20
37
50
40 gtt/I
22.00
CM
150/12
0
90
20
37,5
50
22.15
CM
150/11
0
88
20
37,5
50
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
Nifedipi
ne
23.00
CM
150/12
0
90
20
37,5
50
10mg
23.15
CM
160/11
0
88
20
37,5
50
23.30
CM
150/10
0
100
20
37
50
23.45
CM
150/10
0
90
20
37
50
00.00
CM
150/12
0
90
20
37,5
50
01.15
CM
160/11
0
88
20
37,5
50
01.30
CM
150/10
0
100
20
37
50
01.45
CM
150/10
0
90
20
37
50
02.00
CM
150/12
0
90
20
37,5
50
02.15
CM
150/11
0
88
20
37,5
50
Oxytoxin
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
03.00
CM
150/12
0
90
20
37,5
50
03.15
CM
160/11
0
88
20
37,5
50
03.30
CM
150/10
0
100
20
37
50
03.45
CM
150/10
0
90
20
37
50
04.00
CM
150/12
0
90
20
37,5
50
04.15
CM
160/11
0
88
20
37,5
50
04.30
CM
150/10
0
100
20
37
50
04.45
CM
150/10
0
90
20
37
50
05.00
CM
150/12
0
90
20
37,5
50
06.15
CM
150/11
0
88
20
37,5
50
Nifedipi
ne
10mg
Oxytoxin
Ocloc
k
Sens
Bp
HR
RR
Temp
UOP
07.00
CM
150/12
0
90
20
37,5
50
07.15
CM
160/11
0
88
20
37,5
50
07.30
CM
150/10
0
100
20
37
50
07.45
CM
150/10
0
90
20
37
50
08.00
CM
150/12
0
90
20
37,5
50
Nifedipi
ne
Oxytoxin

New Patient: - Patient Prior Patient: 1 Patient

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New patient

1. Mrs. N, 29 yo, G3P1A1

: - Spontaneous Vaginal Delivery

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

: 3 fingers above umbilical

Stretch part : Right

: via catheter 60 cc/ hour

Vaginal Examination : Not done, Baloon catheter was inflated at

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

: 3 fingers above umbilical

Stretch part : Right

: via catheter 60 cc/ hour

Vaginal Examination : Baloon catheter was detached, cervix

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

: 3 fingers above umbilical

Stretch part : Right

: via catheter 60 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

: 3 fingers above umbilical

Stretch part : Right

: via catheter 50 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

: 3 fingers above umbilical

Stretch part : Right

: via catheter 50 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

: Spontaneous Vaginal Delivery

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