Morning Report

Supervisor : dr. Made Mahayasa, Sp.OG

August 27th 2012

Medical Students :
Yan, Tari, Rona, Agung, Dani, DianVera, Rani CASE RESUME
NORMAL LABOR PATHOLOGY LABOR 1. G1P0A0L0 32 weeks/S/L/IU with eclampsia

CASE REPORT
Name
Age Address Admitted

: Mrs. A
: 20 years old : Duman, Lingsar Lobar : 21/08/2012 at 09.30

Diagnosis : G1P0A0L0 32 weeks/S/L/IU with Eclampsia

TIME 21/08 /2012 09.30

SUBJECTIVE Patient referred from Sigerongan GH with G1P0A0L0 32 weeks T/H/IU with eclampsia and unconcious. Patient has seizure 3x at home and 1x at PHC. History of rupture membrane (-), bloody slim (), abdominal pain (-), FM (+). History of DM (-), HT (-), asthma (-). in PHC. LMP : 13 12 - 2011 EDD : 20 9 - 2012 History ANC : > 4x at posyandu History USG : never History of family planning : (-) Next family planning : IUD Obstetric History : 1. This

OBJECTIVE General Status

ASSESSMENT G1P0A0L0 32 weeks /S/L/IU with eclampsia

PLANNING Observed mother and fetal well being. Continue MgSO4 dryp 6 g/IV, 28 tpm from PHC. DM consult to SPV, pro CS. Advice : prepare CS at 11.30 Skin test (-), injection Amphicilin 2 gram/IV.

GC : weak GCS : E2V2M5 BP : 150/110 mmHg PR : 132 bpm RR : 28 bpm T: 36,4C

Eye : anemis (-/-), icterus(-/-) Pulmo : vesicular (+/+), rhonki (-/-), wheezing (-/-). Cor : S1S2 single regular, murmur (-), gallop (-). Abdomen : striae gravidarum (+), linea nigra (+), scar (-). Extremity : edema (-/-), warm acral (+/+). Obstetric Status L1 : breech L2 : back on the right side L3 : head L4 : 5/5 UC : (-) FHB : 11.11.12 (136x/minute) VT : (-), fornix palpable, the lowest part of fetal still high.

TIME

SUBJECTIVE Chronologist (21/08/2012, in Sigerongan PHC): 08.00 S : Patient pregnant 8 months, came to PHC with confessed seizure since 23.00 wita, 3x at home, and seizure again 1x at PHC. O: BP : 150/110 PR : 132 bpm RR : 20 bpm T : 36,4C TFU: 25 cm His : (-) FHR : 11-11-12 (136 bpm) Head presentation. A : G1P0A0L0 32 weeks S/L/IU with eclampsia & unconcious. P: - Infuse RL + drip MgSO4 40% 28 tts/mnt - Bolus MgsSO4 40% 4 gram - Insert DC - O2 5 Liter/mnt - Referred at 09.00 wita - Drip flash 1 Lab from PHC: - HB: 10,8 gr % - Proteinuri (+++)

OBJECTIVE Lab Examination Hb = 13,6 g/dl RBC = 5,55 x 106/uL WBC = 16,7 x 103/uL PLT = 407 x 103/uL HCT = 46,8 HbSAg = (-) Protein urine = +3 GDS = 123 mg/dl SC = 0,9 Ureum = 45 SGOT = 54 SGPT = 32 BT = 2,15 CT = 600

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

12.00

CS began :
Baby was born (12.15) : Female. 1800 gram, 36 cm, AS 5-7. Hematoma retroplasenta (+). Anus (+), congenital anomaly (-). Placenta was born manual, complete. Bleeding 400 cc SPV advice : Dryp oxytocin 2 amp until 12 hours. Infuse MgSO4 until 24 hours post CS. Ampicillin 1 gram per 6 hours Transmit patient to ICU

TIME 14.30

SUBJECTIVE

OBJECTIVE BP : 150/110 mmHg PR : bpm RR : 28 bpm Temp : 37,2C UO : 300 cc UC : (+) UFH : 2 finger below umbilicus Active bleeding : (-) Lab : Hb = 14,8 g/dl RBC = 5,75 x 106/uL WBC = 18,52 x 103/uL PLT = 331 x 103/uL

ASSESSMENT 2 hours post CS

PLANNING - Observation vital sign, bleeding, and conciousness. - Continue medication - PRC transfussion 2 kolf

22/08/12 07.00

GC : weak BP : 150/100 mmHg PR : 92 bpm RR : 22 bpm Temp : 37,3C UO : 500 cc UC : (+) UFH : 2 finger below umbilicus Active bleeding : (-) Baby in NICU : PR : 146 bpm RR : 48 bpm T : 35,2OC

1 day post CS

- Observation vital sign, bleeding. - Continue medication - CIE mother to bed rest total.