Morning Report april 2nd

2016
Supervisor : Dimas, Kiki, Sani,
Rina, Lani, ari, ana
 Identity
Name : Ms. NN
Age : 20 th
Address : narmada , Lobar
Admitted : 4th april 2016
RM : 11-37-53
Diagnose : G1P0A0L0 38-39 weeks
S/L/IU head presentation with PROM
> 12 hours
Time Subjective Objective Assessm Planning
ent

13th april Patient come to NTB GH General status G1P0A0L0 Obs.

2016 referred from LIngsPar HC to GC : well 40-41 Mother
confirm the diagnosis of GCS : E4V5M6 weeks and fetal
02.25 G1P0A0H0 38-39 weeks S/L/IU BP : 110/70 mmHg S/L/IU well being
head presentation, mother PR : 80 bpm head Obs.
and fetal in good condition RR : 20 tpm presentati Progress
Patient didnt confessed T : 36,6 0C on with of labor
abdominal pain, water leak PROM > Inj.
out from her womb (+) since Eye : anemis (-/-), ikteric 12 hours Ampicilin
7 da ys a go (27-03-20146, (-/-) + 1 gr iv / 6
bloody slim (-), FM (+) Cor : S1S2 single, M (-), gestation hours
History : DM (-), HT (-), G (-) al DM co to
Asthma (-) Pulmo : Vez (+/+), Whz hypertens GP pro
Family history : DM (-), HT (-) (-/-), Rh (-/-) ion CTG, GP
Abdomen : striae advice : If
LMP : 9 7 2015 gravidarum (+), linea CTG
EDD : 16 04 2016 nigra (+), scar (-) reactive,
Extremity : pro
ANC history : 8X at narmada Upper : oedem (-/-), induction
PHC warm (+/+) oxy drip
Last ANC : 14-03-2016, BP : Lower : oedem (-/-), CIE family
110/70 mmHg, BW : 686kg, warm (+/+)
UK : 35 weeks, UFH : 297 cm,
Presentation : head Obstetrical Status
L1 : breech
USG History : 2x. Last USG at L2 : back at right
SPOg (2-04-2016) L3 : head
Result : fetal S/L/IU head L4 : 4/5
Time Subjective Objective Assessm Planning
ent

Familiy planning history : - VT : -, eff : -, amnion

Next family planning : - (+), head presentation,
denom unclear, HI,
Obstetrical history : impapable small part of
I. This fetus/ umbillical cord

Chronologist 4th april 2016 PS : 3

(08.00) Cervix Dilatation : 0
S/ Cervix length : 0
Patient came to Lingsar PHC Cervix position : 0
confessed water laked from Station : 1
her womb Cervix Consistency : 2

O/ PE : seems normal
GC : well Spina ischiadica : not
GCS : E4V5M6 prominent
BP : 110/70 mmHg Os coxygeus : mobile
PR : 80 bpm Arcus pubis : >90o
RR : 20 tpm
T : 36,0C Lab result :
HB : 13,7 g/dL
UFH : 31 cm HCT : 39,3 %
EFW : 3100 gr WBC : 10,23 x 103/uL
L1 : breech PLT : 373 x 103/uL
L2 : back at left BT : 245
L3 : head CT : 645
L4 : 4/5 HbsAg : (-)
UC : - Proteinuria : -
Time Subjective Objective Assessm Planning
ent
VT : not administer

A/
G1P0A0H0 40-41 weeks S/L/IU
head presentation, mother
and fetal in good condition
(diagnosis confirmation)

P/
-
Time Subjective Objective Assessm Planning
ent
21.30 HIS : - Pematangan
FHB : 12-12-12 serviks

16.00 HIS : 3x10~30 Latent 12 tpm

FHB : 12-12-12 Phase
+ History
GC : well of ROM
GCS : E4V5M6
BP : 140/90 mmHg
PR : 84 bpm
RR : 20 tpm
T : 36,5 0C

VT. 3 cm, eff 25%, head

presentation, H1, denom
unclear, impapable small
part of fetus/umbillical cord
16.30 HIS : 4x10~35 16 tpm
FHB : 11-12-11

17.00 HIS : 4x10~35 20 tpm

FHB : 12-12-12

17.30 HIS : 4x10~35 24 tpm

FHB : 12-12-11
CTG
Time : 18.30 WITA
(03 09 2014)