PowerPoint Presentation

Morning ReportSeptember, 10th 2014Supervisor:Dr. Agus Thoriq, SpOG

DM Jaga:Faisol, Santi, LalaMorning ReportSeptember 4th 2014Case ResumeNORMAL LABOR0PATHOLOGIES LABORG1P0A0L0 19-20 weeks/S/IUFD/IUCase 1Name: Mrs. NAge: 37 years oldAddress: Telagawaru, LobarAdmitted: 09-09-2014No. RM: 10-53-79G1P0A0L0 19-20 weeks/S/IUFD/IUTimeSubjectObjectAssessmentPlanning09-09-201410.00Patient come to NTB GH, referred from spesialist with G1P0A0L0 19-20 weeks IUFD.

Patient confessed abdominal pain since 1 weeks ago, bloody came out from her vagina (+), water came out from her womb (-) and FM (-) since 2 days ago.

No history of DM, HT, asthma.

LMP : 23-04-2014EDD : 30-01-2015

History ANC : 2x at PolindesLast ANC : 09-09-2014result: BP : 110/70, FHB (-)General statusGC : wellGCS: CM (E4V5M6)BP : 120/80 mmHgHR: 80 x/mRR: 20 x/mT: 36,8 C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema (-/-), warm (+/+)

Obstetric statusUFH: as high as umbilicus

UC : (-)FHB : (-)

VT: (-)G1P0A0L0 19-20 weeks S/IUFD/IUCo to SPV, adv: induction with misoprostol 4x50 g

TimeSubjectObjectAssessmentPlanningHistory of USG : 3x at specialist. Last USG: 9-9-14G1P0A0L0 16-18 weeks/IUFD

History of family planning : -Next family planning : -

History of obstetric :This

Lab (3/09/2014):HGB = 11.8 g/dlRBC = 3.65 K/ulWBC = 7.98 M/ulHCT = 34,0 %PLT = 219 M/ulHBsAg = (-)BT = 215CT = 600

TimeSubjectObjectAssessmentPlanning10.15-GC: wellBP: 120/80 mmHg HR: 78 bpm T 360C RR 16 x/mUC: -FHB: -Insertion of misoprostol 50 g (I)16.15-GC: wellBP: 120/80 mmHg HR: 78 bpm T 360C RR 16 x/mUC: -FHB: -Insertion of misoprostol 50 g (II)18.00Patient confessed abdominal painGC: wellBP: 110/80 mmHg HR: 78 bpm T 360C RR 18 x/mUC: 1x/10 ~ 15FHB: -Obs. inpartu22.15Patient confessed abdominal painGC: wellBP: 110/80 mmHg HR: 78 bpm T 360C RR 18 x/mUC: 1x/10 ~ 15FHB: -Insertion of misoprostol 50 g (III)6TimecSubjectObjectAssessmentPlanning01.15Mother confessed abdominal pain mor frequently and wants to bearing downUC: 3x/10 ~ 40FHB: (-)Inspection: opening vulva (+), bulging of perineum (+), pressure of anus (+)Abortus insipienConduct labor

19.15Death conceptus was born, female, 200 gram,21.20GC: well GCS: E4V5M6BP: 110/70 mmHg PR: 80x/m RR: 20x/m T: 37 0CUC: (+) wellUFH : 2 finger above simfisisActive bleeding: (-)UO: +Lokea rubra (+)Abortus completeObservation mother and baby well beingSuggest mother to eat and drinkSuggest mother to mobilization7TimecSubjectObjectAssessmentPlanning01.15GC: well GCS: E4V5M6BP: 110/70 mmHg PR: 80x/m RR: 20x/m T: 37 0CUC: (+) wellUFH : 2 finger above simfisisActive bleeding: (-)UO: 400 ccLokea rubra (+)todayContinue medication