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Morning Report

20 April 2016
SPV : dr., SpOG
DM : Amy, Ana, Bella, Brian,
Vita

Case 1

Name : Mrs. SA
Age : 32 years old
RM : 57-71-33
Address : Kediri, Lombok Barat
Admitted : 20th April 2016

Time
17th
April
2016
23.00

Subject
Patient referred from Meninting
PHC with G1P0A0L0 33-34
weeks S/L/IU head presentation
with PROM >12 hours + preterm.
Patient confessed water leaked
from her womb (+) since 02.00
(15/04/2016), abdominal pain (+)
since 02.00 (16/04/2016), bloody
slime (-), FM (+).
History of DM (-), HT (-), asthma
(-), allergy (-).
LMP : 25 / 08 / 2015
EDD : 01 / 06 / 2016
GW : 33-34 week
History ANC : 7x at Posyandu
Last ANC: 22-03-2016,
Result GW 28-29 weeks, BP :
110/80 mmHg, BW: 49,7 kg,
head presentation, UFH: 26cm,
FHB (+), edema (-).
History of USG : History of family planning: Next family planning: Obstetric history:
1. This

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 90 tpm
RR: 20 tpm
T: 36,6C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on right side
L3 : head
L4 : 4/5
UFH : 25 cm
EFW : 2170 gr
FHB: 12-12-12
UC : 1 x 10 ~ 15
VT : 1 cm, eff 10%, amnion
(-), head presentation, HI,
denominator unclear, small
part or umbilical cord
unpalpable.

Assessment
G1P0A0L0 33-34
weeks S/L/IU head
presentation with
PROM.

Planning

Diagnostic:
CBC
LED
Urinalysis
Lakmus test
USG

Monitoring:
Obs. Temperature
every 6 hours
Obs. Patient in VK
for 24 hours, and
then move to nursing
room
Therapy:
Ampicillin inj. 1 gr/6
hours, continued
with ampicillin oral
3x500gr for 7 days.
Dexamethasone IM
2x6mg every 12
hours for 2 days.
DM co to GP, GP co
to SPV, SPV advice:
Conservative
treatment.
Antibiotic
Dexamethasone
Nifedipine 3x10mg
Pro-USG

Time

Subject

Object
Lab (17/04/2016):
HB: 13,1
RBC: 4,47
HCT: 39,6
WBC: 13,24 ()
PLT: 250
HbsAg: (-)

Assessment

Planning

Time

Subject
Chronology at Narmada PHC
(14/04/2016):
S:
Patient confessed abdominal pain
(+) since 02.00 (15/04/2016), water
leaked (+), FM (+), bloody slime (-)
O:
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg,
PR : 80 ppm,
RR : 20 rpm,
T : 36 C.
L1 : breech
L2 : back on right side
L3 : head
L4 : 4/5
UFH : 24 cm
UC: 2x10~20
FHB: (+) 140 tpm
VT: 1cm eff 25%, amnion (-), head
palpable, HI, small part or
umbilical cord unpalpable.
A:
G1P0A0L0 33-34 weeks S/L/IU
head presentation with PROM >12
hours + preterm.
P:
- IVFD: RL 28 dpm.
- Skin test ampicillin (-).
- Inj. Ampicillin 1gr/IV

Object

Assessment

Planning

Time
00.30

Subject
Confessed abdominal pain (+)

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 86 tpm
RR: 18 tpm
T: 36,5C

Assessment
G1P0A0L0 33-34
weeks S/L/IU head
presentation with
PROM.

Planning
Obs. Temperature
every 6 hours
Obs. Patient in VK
for 24 hours, and
then move to nursing
room
Ampicillin inj. 1 gr/6
hours, continued
with ampicillin oral
3x500gr for 7 days.
Dexamethasone IM
2x6mg every 12
hours for 2 days.
Moved to VK teratai

18/04/
2016
06.00

Confessed abdominal pain (+)

General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 86 tpm
RR: 18 tpm
T: 36,5C

G1P0A0L0 33-34
weeks S/L/IU head
presentation with
PROM.

Remaining Case

Name
: Ny. S
Age : 32 years old
Address
: Bima
Admitted : 1st April 2016
RM
:576149

TIME

SUBJECTIVE

01/04/ 2016
10.00

Patient referred from Bima GH with


G1P0A0L0 35-36 weeks S/L/IU head
presentation with obs. Febris ec DHF with
placenta previa totalis. The patient confessed
cough and dyspnea since 2 days ago. Fever
since 5 days ago. There is no active bleeding
from her womb. Abdominal pain (-), water
leaked from her womb (-), bloody slime (-),
FM (+).
No history of DM, HT, and asthma
History of family: DM (-), HT (+) mother,
asthma (-)
LMP: EDD: GW: History of ANC: 2x at PHC
Last result (12/12/2015): BP 110/70 mmHg,
GW 18 weeks, UFH 2 finger below umbilicus,
FHB (+)

OBJECTIVE
General status:
GC: moderate
GCS: E4V5M6
BP: 130/80 mmHg
HR: 88 bpm
RR: 36 x/min
T: 360C
Eye : anemis (-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur -), (gallop -)
Pulmo : vesikuler (+/+), wheezing (-/-),
Ronkhi (+/+).
Abdomen : scar (-), striae (+), linea nigra (-)
epigastric tenderness (+)
Extremity : edema (-/-), warm acral (+/+)
Obstetrical status:
L1: breech
L2: back on left side
L3: head presentation
L4: 5/5
UFH: 28 cm
EFW: 2480 gram
UC: FHB: 12-12-12 (144 bpm)
VT: -

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU
with
placenta
previa totalis + obs febris
D-5 ec viral infection

PLANNING
DM planing:
Diagnostik
CBC, BT, CT, PPT, APTT
CTG
USG
Inspeculo
Therapy
Obs mother & fetal well being
Observation bleeding, FHB,
BP every 6 hours
IVFD RL
DM co GP, GP co SPV, SPV
advice (1/04/16):
- Lab. Test
- Paracetamol 3x500 mg PO
(K/P)
- Consult Interna
- If patient is well dyspnea
(-) moved to Segara Anak
Co Internist, advice :
- obs. Febris ec viral infection
- Paracetamol tab 3 x 500 mg
if needed
- CIE family about the patience
condition

TIME

SUBJECTIVE
History of USG: 3x at Sp.OG
Last result (1/04/16)
BPD: 34-35 w
AC: 33-34 w
HC: 33-34 w
FL: 36 w
EFW: 2.442 g
EDD: 4/05/16
Corp ant Placenta covering entire OUI grade III
Amnion enough
History of family planning: Next family planning: Obstetrical history:
I.
This

OBJECTIVE
Lab: (01/04/16)
HB: 10,0 g/dl
RBC: 3,87 M/dl
WBC: 7,77 K/dl
PLT: 170 K/dl
PPT : 12,2
APTT : 27.2
Lab at Prodia ( 31/03/16)
Dengue IgG (-)
Dengue IgM (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
Chronology at Bima GH
01/4/2016
S: Patient came to Bima GH refered from PHC after
confessed febris since (26/3/16).
O:
GC: well
GCS: E4V5M6
BP: 100/60 mmHg
HR: 89 bpm
A: G1P0A0H0 35-36 weeks S/L/IU with placenta previa
totalis + obs. Febris ec DHF
P:
-

Co Cardiologist
Do USG : 29/03/16
Consult Interna (28/03/16)
Amlodipine 2x10 mg
Refer to NTB GH

27/03/2016
- Inj. Ceftriaxon 2 x 1
- Inj. Ranitidin 2 x 1
- Inj. Dexamethason 2 x 6 mg
- Vit. C 2 x 400 mg
- PCT Infus 4 x 1
- Kaltrofen sup 3 x 1
- RL 12 kolf
- NaCl1 kolf
- Drip MgSO4 4 gr 2 fl : RL 500 cc

OBJECTIVE

ASSESTMENT

PLANNING

TIME
14.00

SUBJECTIVE
Dyspneu (+)
Active bleeding from her womb (-)

OBJECTIVE
BP: 150/80 mmHg
HR: 82 bpm
RR: 40
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU with placenta
previa totalis + obs febris
D-5 ec viral infection

PLANNING
-

O2 4 lpm
Obs mother & fetal well being

SPV visite :
- Lab. Test every 2-3 days
- If dypsneu still (+) Concult Cardiologist

15.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 150/80 mmHg


HR: 82 bpm
RR: 38
T: 36,70C
DJJ : 11-11-12 (132 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

16.00

Dyspneu (++)
Active bleeding from her womb (-)

BP: 140/80 mmHg


HR: 87 bpm
RR: 40
T: 36,90C
DJJ : 12-13-12 (148 bpm)
UC: -

DM planning :
- Pro ECG
- Pro Thoraks photo
- Obs mother & fetal well being
DM co GP, GP advice :
- Acc to ECG
- Acc to thoraks photo

Tho : rh (+/+), wheez (-/-)


16. 20 WITA :
Patient move to Radiologyst Lab and do the thoraks
photo. Result is :
CTR > 50 % cardiomegaly
DM Planning :
- Co Cardiologist
- Co Pulmologist
GP advice :
- Acc to co cardiologist

TIME
17.00

SUBJECTIVE
Dyspneu (+)
Active bleeding from her womb (-)

OBJECTIVE
BP: 140/80 mmHg
HR: 82 bpm
RR: 30
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU
with
placenta
previa totalis + obs febris
D-5 ec viral infection +
Decomp. Cordis

PLANNING
-

O2 4 lpm
Obs mother & fetal well being

17.30, Cardiologist advice :


- Inj. Lasix 1 x 1 amp

18.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 84 bpm
RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

19.00

Dyspneu (++)
Active bleeding from her womb (-)

BP: 140/80 mmHg


HR: 88 bpm
RR: 32
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

20.00

Dyspneu (++)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 86 bpm
RR: 30
T: 37,80C
DJJ : 14-15-15 (176 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being
Paracetamol tab 500 mg po

21.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 140/80 mmHg


HR: 80 bpm
RR: 28
T: 37,40C
DJJ : 12-13-12 (148 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

TIME

SUBJECTIVE

OBJECTIVE

22.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 140/80 mmHg


HR: 82 bpm
RR: 30
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

23.00

Dyspneu (+)
Active bleeding from her womb (-)

24.00

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU
with
placenta
previa totalis + obs febris
D-5 ec viral infection +
Decomp. Cordis

PLANNING
-

O2 4 lpm
Obs mother & fetal well being

BP: 130/80 mmHg


HR: 84 bpm
RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

Dyspneu (+)
Active bleeding from her womb (-)

BP: 140/80 mmHg


HR: 88 bpm
RR: 26
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

(02/04/2016)
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 88 bpm
RR: 24
T: 35,80C
DJJ : 12-12-12 (144 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

12.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 88 bpm
RR: 24
T: 35,80C
DJJ : 12-12-12 (144 bpm)
UC: -

O2 4 lpm
Obs mother & fetal well being

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-6 ec viral infection +
Decomp. Cordis

TIME
18.00

SUBJECTIVE
Dyspneu (+)
Active bleeding from her womb (-)

OBJECTIVE
BP: 130/80 mmHg
HR: 88 bpm
RR: 24
T: 37,80C
DJJ : 12-12-13 (148 bpm)
UC: -

24.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

03/04/2015
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 84 bpm
RR: 24
T: 36,80C
DJJ : 13-12-12 (148 bpm)
UC: -

12.00

Dyspneu (+)
Active bleeding from her womb (-)

18.00

Dyspneu (+)
Active bleeding from her womb (-)

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU
with
placenta
previa totalis + obs febris
D-6 ec viral infection +
Decomp. Cordis

PLANNING
-

Obs mother & fetal well being


Bed rest
Interna:
obs febris
PCT tab 3x1
Cardiologist:
Lasix 1x1 Amp

Obs O2
Obs mother & fetal well being
Bed rest

Obs O2
Obs mother & fetal well being
Bed rest
Pro co cardiologist tommorow

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-7 ec viral infection +
Decomp. Cordis

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

24.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-7 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest

04/04/2015
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 84 bpm
RR: 24
T: 36,80C
DJJ : 13-12-12 (148 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-8 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest
Pro co cardiologist this morning

12.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

18.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

24.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-7 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest

05/04/2015
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 84 bpm
RR: 24
T: 36,80C
DJJ : 13-12-12 (148 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-8 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest
Cardiologist advice:
- Lasix 1 amp/hari
- Stop digoxin
- Bisoprolol 1 x tab
- Pro echo tomorrow

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

12.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

18.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

Obs O2
Obs mother & fetal well being
Bed rest

24.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 24
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-7 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest

06/04/2015
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 84 bpm
RR: 24
T: 36,80C
DJJ : 13-12-12 (148 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-8 ec viral infection +
Decomp. Cordis

Obs O2
Obs mother & fetal well being
Bed rest
Pro echo today

07/04/2016
06.00

Dyspneu (+)
Active bleeding from her womb (-)

BP: 130/80 mmHg


HR: 88 bpm
RR: 24
T: 36,70C
DJJ : 13-12-12 (148 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + obs febris
D-9 ec viral infection +
Decomp. Cordis

Patient could go home

TIME
08/04/2016
08.00

SUBJECTIVE
Patient come back again to NTB GH
confessed that there is blood that
leaked out from her vagina since this
morning at 06.00 WITA, abdominal
pain (-), water leaked out from her
womb (-), FM (+).

OBJECTIVE
BP: 120/80 mmHg
HR: 90 bpm
RR: 22
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: Inspeculo: (-), tissue (-), active
bleeding (-), portio livide (+)

ASSESTMENT
G1P0A0L0 35-36 weeks
S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

PLANNING

Hospitalized
Obs. Mother and fetal well being
CTG
ECG
DM co to GP, GP co to SPV, advice:
- Hospitalized
- Observe the patient
- Co to cardiologist
Cardiologist advice:
- Patient could go home
- Continued the therapy from cardiologist
Move the patient to Segara Anak Room

09/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 22
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

10/04/2015
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

11/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink
SPV advice:
- Pro C-section next week
- Reconsult to cardiologist

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 22
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

12/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink
Cardiologist advice:
- Pro Echo
- Stop Fuosemide and Bisoprolol
- Continue the therapy from OBGYN

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 90 bpm
RR: 20
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

13/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink
Pro C-section at 19/04/2016

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

14/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 18
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

15/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 90 bpm
RR: 18
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

16/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 22
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

17/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 22
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink

18/04/2016
06.00

Complaint (-)

BP: 120/80 mmHg


HR: 88 bpm
RR: 20
T: 36,80C
DJJ : 12-12-12 (144 bpm)
UC: -

G1P0A0L0 35-36 weeks


S/L/IU
with
placenta
previa totalis + Decomp.
Cordis

Obs mother & fetal well being


Bed rest
Suggest mother to eat and drink
Pro C-section at 19/04/2016

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