Sie sind auf Seite 1von 35

FETOMATERNAL WARD

REPORT
Monday, October 4th
2015

Residents :

1. dr. Donny Mega Surya


2. dr. R.A.Dewi Utari
3. dr. Paul Alwin Khoman

Department of Obstetrics and Gynecology


Medical Faculty Universitas Sumatera Utara
Adam Malik General Hospital
2015

Ward Patients
patients

Mrs. R, 24 yo, G1P0A0


Diagnosis
: Severe Pre-eclampsia + PG + IUP (32-34) wga +
Head Presentation +
Live Fetus
Supervisior: dr. Hotma P Pasaribu, Mked(OG), Sp.OG
Resident in charge: dr. Donny
Planning :
- Expectant Management
- Evaluate vital signs, fetal heart rate, contraction and signs of
impending eclampsia
Mrs. H, 30 yo, G1P0A0
Diagnosis
: Severe oligohidramnios + PG + IUP (28-30) wga
+ Live Fetus
Supervisior: dr. Melvin NG Barus, Mked(OG), Sp.OG
Resident in charge: dr. Ajeng
Planning :
- Amniofusion

Mrs. R, 22 yo, P2A0


Diagnosis
: Post Active Phase III management + Post
Spontaneous Vaginal Delivery + PD 1 + Anemia
Supervisior: dr., Risman F Kaban, Mked(OG), Sp.OG
Resident in charge: dr. Paul
Planning :
- 5 Bags PRC Transfussion (2 bags per day)

Follow up Saturday, 3rd of October 2015 08.00 am


Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 140/100 mmHg

Icteric

: (-)/(-)

HR

: 84 times/minute

Cyanosis

RR

: 24 times/minute

Dyspnea: (-)

Temperature

: 37 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : Middle of Proccesus xyphoideus to Umbilicus ( 25 cm)
Streched part : Right
Lower part
: Head
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 152 x/i

Dx
: Severe Pre-eclampsia + PG + IUP (32-34) wga + Head
Presentation +
Live Fetus
Th/
-IVFD RL + MgSO4 40% 30 cc 14 gtt/i
-Inj. Dexamethasone 6 gr/12 h
-Nifedipine tab 4x10 mg, if BP 180/110 mmHg give Nifedipine
10 mg/30 minutes (max 120 mg/24 hours)
Plan:
-Expectant Management
-Evaluate vital signs, fetal heart rate, contraction and signs of
impending eclampsia

Follow up Sunday, 4th of October 2015 08.00 am


Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 130/70 mmHg

Icteric

: (-)/(-)

HR

: 96 times/minute

Cyanosis

RR

: 17 times/minute

Dyspnea: (-)

Temperature

: 36,2 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : Middle of Proccesus xyphoideus to Umbilicus ( 25 cm)
Streched part : Right
Lower part
: Head
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 140 x/i

Dx
: Severe Pre-eclampsia + PG + IUP (32-34) wga + Head
Presentation +
Live Fetus
Th/
-IVFD RL + MgSO4 40% 30 cc 14 gtt/i
-Inj. Dexamethasone 6 gr/12 h
-Nifedipine tab 4x10 mg, if BP 180/110 mmHg give Nifedipine
10 mg/30 minutes (max 120 mg/24 hours)
Plan:
-Expectant Management
Evaluate vital signs, fetal heart rate, contraction and signs
of impending eclampsia

Follow up Monday, 5th of October 2015 08.00 am


Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 150/90 mmHg

Icteric

: (-)/(-)

HR

: 85 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 36,6 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : Middle of Proccesus xyphoideus to Umbilicus ( 25 cm)
Streched part : Right
Lower part
: Head
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 148 x/i

Dx
: Severe Pre-eclampsia + PG + IUP (32-34) wga + Head
Presentation +
Live Fetus
Th/
-IVFD RL 20 gtt/I
-Nifedipine tab 4x10 mg, if BP 180/110 mmHg give Nifedipine
10 mg/30 minutes (max 120 mg/24 hours)
Plan:
-Expectant Management
Evaluate vital signs, fetal heart rate, contraction and signs
of impending eclampsia

03/10/15

04/10/15

Hb
Ht
Leu
PLT

Proteinuria Urinalysis : +3

: 12,7 gr/dL
: 36,5
: 13,91 /mm3
: 233000 /mm3

PT
: 12,8 (C 14 s)
APTT: 26,19 (C 33,5 s)
TT
: 20,5 (C 17,5 s)
INR : 0,9
Fibrinogen: 375
D-Dimer: 1700
Random blood glucose: 95 mg/dL
Ureum
: 57,35 mg/dL
Creatinine: 1,35 mg/dL
Na
K
Cl
Proteinuria

: 131 mEq/L
: 4,8 mEq/L
: 103 mEq/L
Urinalysis : +4

Follow up Friday, 2nd of October 2015 08.00 am


Chief Complaint: Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 110/80 mmHg

Icteric

: (-)/(-)

HR

: 80 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 36,5 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : 1 finger above navel
Streched part : Ballotement (+)
Lower part
: Ballotement (+)
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 148 x/i

Dx

Th/
Plan:
-

: Severe oligohidramnios + PG + IUP (28-30) wga + Live


Fetus

IVFD RL 20 gtt/i
Inj. Ceftriaxone 1 gr/12 h
Inj. Dexamethasone 6 mg / 12 hr
Nifedipine tab 3 x 10 mg
Pocari sweat 2 L / day

Amniofusion
Evaluate vital signs, fetal heart rate, contraction

02/10/15
Hb
Ht
Leu
PLT

: 10 gr/dL
: 31,4
: 12620 /mm3
: 176000 /mm3

PT
: 15,2 (C 14 s)
APTT: 31,9 (C 33,5 s)
TT
: 12,5 (C 17,5 s)
INR : 1,08
Random blood glucose: 89 mg/dL
Ureum
: 15 mg/dL
Creatinine: 0,3 mg/dL
Na
K
Cl

: 140 mEq/L
: 3,3 mEq/L
: 105 mEq/L

Follow up Saturday, 3rd of October 2015 08.00 am


Chief Complaint: Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 120/60 mmHg

Icteric

: (-)/(-)

HR

: 86 times/minute

Cyanosis

RR

: 16 times/minute

Dyspnea: (-)

Temperature

: 36,7 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : 1 finger above navel
Streched part : Ballotement (+)
Lower part
: Ballotement (+)
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 140 x/i

Dx

Th/
Plan:
-

: Severe oligohidramnios + PG + IUP (28-30) wga + Live


Fetus

IVFD RL 20 gtt/i
Inj. Ceftriaxone 1 gr/12 h
Inj. Dexamethasone 6 mh/12 hr
Nifedipine tab 3 x 10 mg
Pocari sweat 2 L / day

Amniofusion
Evaluate vital signs, fetal heart rate, contraction

Follow up Sunday, 4th of October 2015 08.00 am


Chief Complaint: Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 120/65 mmHg

Icteric

: (-)/(-)

HR

: 84 times/minute

Cyanosis

RR

: 18 times/minute

Dyspnea: (-)

Temperature

: 36,7 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : 1 finger above navel
Streched part : Ballotement (+)
Lower part
: Ballotement (+)
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 142 x/i

Dx

: Severe oligohidramnios + PG + IUP (28-30) wga + Live


Fetus

Th/
-

IVFD RL 20 gtt/i
Inj. Ceftriaxone 1 gr/12 h
Inj. Dexamethasone 6 mh/12 hr
Nifedipine tab 3 x 10 mg
Pocari sweat 2 L / day

Plan:
-

Amniofusion
Evaluate vital signs, fetal heart rate, contraction

Follow up Monday, 5th of October 2015 08.00 am


Chief Complaint: Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 120/70 mmHg

Icteric

: (-)/(-)

HR

: 82 times/minute

Cyanosis

RR

: 18 times/minute

Dyspnea: (-)

Temperature

: 36,4 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Symmetrically Enlarged
Fundal Height : 1 finger above navel
Streched part : Ballotement (+)
Lower part
: Ballotement (+)
Fetal Movement
: (+)
Uterine contraction : (-)
FHR
: 145 x/i

Dx

: Severe oligohidramnios + PG + IUP (28-30) wga + Live


Fetus

Th/
-

IVFD RL 20 gtt/i
Inj. Ceftriaxone 1 gr/12 h
Inj. Dexamethasone 6 mh/12 hr
Nifedipine tab 3 x 10 mg
Pocari sweat 2 L / day

Plan:
-

Amniofusion
Evaluate vital signs, fetal heart rate, contraction
USG Confirmation

Follow up Monday, 5th of October 2015 08.00 am


Chief Complaint: Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 120/70 mmHg

Icteric

: (-)/(-)

HR

: 80 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 36,5 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic +/+,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit


Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Localised State :
Abdomen
: Laxed , Peristaltic (+)
Fundal Height : 1 finger below navel, contraction strong
Vaginal Bleeding
: (-)
Micturition
: (+) via catheter, UOP +/- 50 cc/hour, clear
Defecation
: (-) , flatus (+)

Dx

: Post Active Phase III management + Post Spontaneous


Vaginal Delivery + PD 1 + Anemia

Th/
-

IVFD RL 20 gtt/i
Inj. Ceftriaxone 1 gr/12 h

Plan:
-

Transfuse 5 bags PRC (2 bags PRC have been transfused)

04/10/15
Hb
Ht
Leu
PLT

: 4,8 gr/dL
: 15,8
: 16480 /mm3
: 193000 /mm3

PT
: 16,6 (C 14,1 s)
APTT: 31,3 (C 33,8 s)
TT
: 16,5 (C 17,2 s)
INR : 1,19
Random blood glucose: 374 mg/dL
Ureum
: 13,1 mg/dL
Creatinine: 0,49 mg/dL
Na
K
Cl

: 140 mEq/L
: 3,3 mEq/L
: 105 mEq/L

THANK YOU