Morning Report

05 April 2016

SPV : dr. Ario

DM : Amy, Ana, Bella, Brian,
Martina
CASES RESUME

Normal -
Labor
Pathology 1. G1P0A0L0 38-39 weeks S/L/IU head
presentation with PROM <12 hours
2. G2P1A0L1 29-30 weeks S/L/IU head
presentation with imminent premature labor
3. G4P2A1L2 41-42 weeks/S/L/IU head presentation
with PROM >12 hours
4. Mass ec. Abscess tubaovarial + moderate
anemia

Remaint 1. G1P0A0L0 35-36 weeks S/L/IU with placenta

Patient previa totalis + obs febris D-9 ec viral infection
 Case 1
Name : Mrs. YS
Age : 25 years old
RM : 57-63-49
Address : Butukliang - Loteng
Admitted : 5th April 2016
 Time Subject Object Assessment Planning
5th April Patient referred from General status G1P0A0L0 38-39 Diagnostic:
2016 Independent practice midwive GC : well weeks S/L/IU head CBC, HbsAg,
with G1P0A0L0 38-39 weeks Consciousness: CM presentation with PTT/APTT, CTG
16.15 S/L/IU head presentation with BP : 120/80 mmHg PROM <12 hours. Inspekulo
PROM < 12 hours. Patient PR: 80 tpm Lakmus test
confessed water leaked out from RR: 21 tpm USG
her womb (+) since 11.00 (05-04- T: 36,5C
2016), abdominal pain (-), bloody
slime (-), FM (+). Local status Monitoring:
Eye : palor -/-, icteric -/- Obs. Temperature
History of DM (-), HT (-), asthma Cor : S1S2 single reguler, every 4 hours.
(-). murmur (-), gallop (-). Obs. Sign of labor
Family history: DM (-), HT (-), Pulmo : vesikuler (+/+), for 12 hours.
asthma (+). wheezing (-/-),
ronkhi (-/-). Therapy:
LMP : 09 / 07 / 2015 Abdomen : scar (-), striae (+), Inj. Ampicillin 2gr IV
EDD : 16 / 04 / 2016 linea nigra (+). Ampicillin tab
GW : 38-39 week Extremity : edema (+/+), warm 3x500gr.
acral (+/+). Pro termination with
History ANC : 6x at Sp.OG oxytocin drip
Last ANC: 06-03-2016, Obstetric status
Result GW 32 weeks, BP : 90/60 L1 : breech DM co to GP, GP co to
mmHg, BW: 87 kg, head L2 : back on right side SPV, SPV advice :
presentation, lower extremity L3 : head Obs. Mother and
edema. Lab: PU (-), HIV (-), L4 : 1/5 fetal well being for
Random blood glucose 133,5 UFH : 30 cm 12 hours
EFW : 2945 gr Pro termination with
History of USG : 4x at Sp.OG FHB: 12-12-12 oxytocin drip
Last USG: 21-03-2016 UC : - tomorrow.
Result S/L/IU head presentation,
37 weeks, EFW 3000gr, EDD VT : 1 cm, eff 10%, amnion
11/04/2016 (-), head presentation,
denominator unclear, HI,
History of family planning: - small part or umbilical cord
Next family planning: implant unpalpable.
Time Subject Object Assessment Planning
Obstetric History: Pelvic Score = 5
1. This Dilatation of cervix : 1
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1

Lab (05/04/2016):
HB: 11,1
RBC: 3,93
HCT: 39
WBC: 7,85
PLT: 270
PT: 12,2
APTT: 30,2
HbsAg: (-)
 Time Subject Object Assessment Planning
05/04/2 Chronology at Independent
016 practice midwive

13.00 S:
Patient confessed water leaked
out from her womb since 09.00
(05/042016)

O:
GC : well
Consciousness: CM
BP : 110/70 mmHg,
PR : 84 ppm,
RR : 20 rpm,
T : 36,5 C.
Extremity: edema on the lower
extremity (+/+)

UFH : 34cm
UC: (-)
FHB: (+) 136 tpm
VT: 1cm eff 10%, amnion (-),
head still high, small part or
umbilical cord unpalpable.

HB: 8,6 %
PU: (-)

A:
G1P0A0L0 40 weeks S/L/IU with
PROM.

P:
IVFD: RL flash I 28 dpm
Ampicillin 1gr
 Time Subject Object Assessment Planning
18.00 Confessed (-) General status G1P0A0L0 38-39 DM co to GP, GP co
GC : well weeks S/L/IU head to SPV, SPV advice:
BP : 120/80 mmHg presentation with Obs. Sign of labor.
PR: 84 tpm PROM <12 hours. Pro termination with
RR: 20 tpm oxytocin drip
T: 36,7C tomorrow morning.

UC : (-) Patient moved to VK

FHB : 11-12-12 teratai

20.00 Confessed abdominal pain (+) General status Inj. Ampicillin 1gr/IV
GC : well Obs. temperature.
BP : 120/80 mmHg Obs. Sign of labor
PR: 84 tpm
RR: 20 tpm
T: 36,6C

UC : 2x10~10
FHB : 11-12-12
VT : 2 cm, eff 25%, amnion
(-) clear, head presentation,
denominator unclear, HI,
small part or umbilical cord
unpalpable.

00.00 Confessed abdominal pain (+) General status G1P0A0L0 38-39 Obs. Mother and
GC : well weeks S/L/IU head fetal well being.
BP : 130/80 mmHg presentation with Obs. Temperature.
PR: 83 tpm PROM > 12 hours CTG
RR: 20 tpm
T: 36,7C DM co to GP, GP co
to SPV, SPV advice:
UC : 2x10~15 Pro termination with
FHB : 12-13-12 oxytocin drip at
VT : 2 cm, eff 25%, amnion 05.00.
(-) clear, head presentation, Obs. Sign of labor.
denominator unclear, HI,
 Time Subject Object Assessment Planning
04.00 Mother confessed abdominal General status G1P0A0L0 38-39 Obs mother and fetal
pain (+) GC : well weeks S/L/IU head well being
BP : 110/60 mmHg presentation with CIE family about the
PR: 86 tpm PROM >12 hours condition and theraphy
RR: 22 tpm
T: 36C

UC : 2x10~15
FHB : 11-12-12
VT : 2 cm, eff 25%, amnion
(-) clear, head presentation,
denominator unclear, HI,
small part or umbilical cord
unpalpable.

05.00 Abdominal pain (+) UC : 2x10~15 Start Oxytocin drip

FHB : 11-12-12 Flash I 8 dpm
Obs mother and fetal
well being

05.30 Abdominal pain (+) UC : 2x10~15 Oxytocin drip 12 dpm

FHB : 11-11-12 Obs mother and fetal
well being
06.00 Abdominal pain (+) UC : 2x10~30 Oxytocin drip 16 dpm
FHB : 11-12-12 Obs mother and fetal
well being
06.30 Abdominal pain (+) UC : 2x10~30 Oxytocin drip 20 dpm
FHB : 12-12-12 Obs mother and fetal
well being
07.00 Abdominal pain (+) UC : 2x10~30 Oxytocin drip 24 dpm
FHB : 12-12-12 Obs mother and fetal
well being
 Case 2
Name : Mrs. AR
Age : 23 years old
Address : Midang, Gunung Sari
Admitted : April 05th, 2016
No. RM : 09 20 31
 Time Subject Object Assessment Planning

05/04/2016 Patient come to NTB GH by General condition : Well G2P1A0L1 29-30 DM planning:
07.00 wita herself confessed abdominal pain GCS : CM weeks S/L/IU head Diagnostic:
since 03.00 am (05/04/2016), BP : 110/70 mmHg presentation with CBC, HbSAg
bloody slime (+) since 07.00 am HR : 84 bpm imminent premature CTG
(05/04/2016), water leaked out RR : 20 bpm labor USG
from her womb (-), fetal Temp : 37C
movement (+).
Local status Therapy:
No history of DM, HT, asthma(-). Eye : an (-/-), ict (-/-) Obs mother and fetal
History of family: DM (-), HT (-), Pulmo: ves (+/+), rh (-/-), wh well being
asthma (-). (-/-) Tocolytic: nifedipin 10
History of gynecology: Cor : S1S2 single regular mg p.o. 2 times per hr
endometriosis(+) since 1 years m(-), g(-) for 2 h and continue per
ago and uterus bicornu Abd : striae gravidarum (-), 8 hrs until UC (-)
linea nigra (+), scar (-) Corticosteroid:
LMP : 12-09-2015 Ext : warm (+/+) edema (-/-) dexamethasone 6 mg/
EDD: 19-06-2016 12 hrs IM
GW: 29-30 weeks Obstetrical status:
L1 : Breech
History of ANC : 5 x at doctor L2 : Back on the left side DM co to GP,, GP co to
clinic L3 : Head SPV, advice:
No result L4 : 4/5 Nifedipine 3 x 10 mg
UFH : 21 cm Dexamethason
History of USG : 3 x at doctor EFW: 1550 gr 6mg/12h
clinic UC : 2x10 ~ 20 Pro USG
Last result: (21/03/2016) FHB 11-12-12 (140 x/m)
Fetal S/L/IU head presentation, VT: 2 cm, eff 25%,
EFW: 1005 gr amnion (+) ,head palpable,
denominator unclear , HI,
History of Family planning : - small part of fetal not
Next Family Planning : Implant palpable
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Obstetrical History. Laboratory exam (05/04/2016):

I. Aterm/male/2600 gr/ HGB: 9,9
pervaginam/GH/ 2 yo/ L RBC: 3,92
II. This HCT: 31,1
MCV: 79,3
MCH: 25,3
MCHC: 31,8
WBC: 12,57
PLT: 299
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

08.00 Abdominal pain (+) UC : 2x 10-20 Nifedipine tablet10 mg

FHB : 12-13-12 Dexamethason 6 mg

09.00 Abdominal pain (+) UC : 2x 10-20

FHB : 13-12-12

10.00 Abdominal pain (+) UC : 2x 10-15

FHB : 13-12-13

11.00 Abdominal pain (+) UC : 2x 10-15

FHB : 12-12-13
12.00 Abdominal pain (+) UC : 2x 10-10
FHB : 13-12-13
13.00 Abdominal pain (+) UC : 1x 10-20 USG Result Fetal S/L/IU head
FHB : 13-12-13 presentation, male
28w2d , EFW 1168 gr
Amnion clear enough

14.00 Abdominal pain (+) UC : 1x 10-10

FHB : 12-12-13

15.00 Abdominal pain (+) UC : 1x 10-10

FHB : 13-13-13

16.00 Abdominal pain (+) UC : 1x 10-10 Nifedipine tablet10 mg

FHB : 13-13-13
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

17.00 Abdominal pain (+) UC : 1x 10-10

FHB : 12-13-12
18.00 Abdominal pain (+) UC : 1x 10-10
FHB : 13-12-12

19.00 Abdominal pain (-) UC : -

FHB : 13-12-13

20.00 Abdominal pain (-) UC : - Dexamethason 6 mg

FHB : 12-12-13
21.00 Abdominal pain (-) UC : -
FHB : 13-13-12

22.00 Abdominal pain (-) UC : -

FHB : 12-13-12

23.00 Abdominal pain (-) UC : -

FHB : 13-12-12

24.00 Abdominal pain (-) UC : - Nifedipine tablet10 mg

FHB : 13-12-13

04.00 Abdominal pain (-) UC : -

FHB : 12-12-13

06.00 Abdominal pain (-) UC : -

FHB : 13-13-12
 Case 2
Name : Mrs. ES
Age : 29 years old
RM : 57-63-27
Address : Dompu
Admitted : 5th April 2016
 Time Subject Object Assessment Planning
5th April Patient referred from Dompu GH General status Mass ec. Abscess Diagnostic:
2016 with Peritonitis generalisata ec GC: moderate tubaovarial + CBC, ESR, USG,
perforation uteri ec GCS: E4V5M6 moderate anemia Rontgen BOF,PP
09.00 hemotomiopetra ec post SC. BP: 130/80 mmHg test
Patient confessed abdominal HR: 88 bpm
pain (+) and solid mass in the RR: 36 x/min Dd : Monitoring:
lower quadrant since 2 years T: 360C Ectopic Pregnancy Obs. VS and urine
ago. Abdominal pain was felt Endometriosis output
continuously and increased every Local status
time the liquid leaked out from Eye : pallor -/-, icteric -/- Therapy:
her womb. The liquid Cor : S1S2 single regular, Antibiotic
characteristic was white like an murmur (-), gallop (-).
abscess, smells (+), blood (-). Pulmo : vesicular (+/+), DM co to GP, GP
The mass was solid-elastic, wheezing (-/-), Rhonchi (-/-). advice:
mobile (+), pain (+). Patient Abdomen : scar (+), mass (+), Acc to CBC
confessed that she never had her tenderness (+), distention (-) Acc to rontgen BOF
menstruation since 3 years ago. Extremity : edema (-/-), warm
accrual (+/+)
No history of DM, HT, and
asthma
History of family: DM (-), HT (+)
mother, asthma (-)

History of medicine : control post

SC at Sp. OG till she was
referred to NTB GH.

History of family planning :

injection 3 months

Obstretrical history :
1. 9month/male/3000
g/PHC/D/53 day
Time Subject Object Assessment Planning
Obstretrical Status :
Abdomen
I : distension (-), mass (+) at
hypogastric region, 15 x 10 cm
A : intestinal contraction (+)
normal
P : mass (+) at hypogastric region
about 1 finger below the
umbilical, solid-elastic, mobile
(+), clear border, fundus uteri
impalpable, tenderness (+).
P : timpani (+) at 4 quadrant but
dim (+) at hypogastric reg.

Inspekulo : Fluxes (-), livide (-),

erotion (-), active bleeding (-),
fluor albus (+) from the OUI,
smells (+).

VT: (-), Fluxes (-), vagina and

portio is slippery, AP/CD normal,
slinger pain (-), mass (-),
tenderness (+)

Lab (05/04/2016):
HB : 7,9 g/dl
PLT : 327/L
WBC : 8,43/L
RBC : 3,30 x 106
HCT : 22,8 L
LED : 27 mm/jam
 Time Subject Object Assessment Planning
09.00 Patient go to
radiology lab to do
Rontgen BOF

The result is:

Meteorismus with
sentinel loop (local
distention of
intestinal on the
upper right
abdomen).
There is not image
of ileus obstruction,
perforation, and
pneumo peritoneum.

09.30 GP co to SPV, SPV

advice:
Pro USG
11.00 Mass ec. Abscess Patient go to
tubaovarial + Radiology lab to do
moderate anemia USG, and the result
is:
Mass (+) at supra
VU and superior
fundus uteri
11x7,5cm
Susp. Abscess
Pro CT-scan lower
abdomen with
contrast
 Time Subject Object Assessment Planning

11.30 GP advice:
Ceftriaxone 2 gr/day
Paracetamol 1 gr/
8hour
Pro transfusion PRC
1 kolf/day

12.30 PP test (-)

14.00 General status Mass ec. Abscess SPV visite, and

GC: well tubaovarial + advice:
GCS: E4V5M6 moderate anemia Infuse RL 500cc 10
BP: 100/80 mmHg dpm
PR: 88 bpm Inj. Ceftriaxone
RR: 18 x/min 2x1gr/IV
T: 370C Inj. Metronidazole
HB: 7,9 3x500gr/IV
Check LED
Pro co to Surgent

14.15 GP co to Surgent,
Surgent advice:
Continue treatment
as the obgyn
procedure.
Move patient to
nifas.
 Time Subject Object Assessment Planning
21.00 Confessed (-) General status Mass ec. Abscess Obs. Temperature
GC: well tubaovarial + and abdominal pain
GCS: E4V5M6 moderate anemia
BP: 100/80 mmHg
PR: 84 bpm
RR: 20 x/min
T: 370C

06.00 Confessed (-) General status Obs. Temperature

GC: well and abdominal pain
GCS: E4V5M6
BP: 100/70 mmHg
PR: 88 bpm
RR: 17 x/min
T: 35,70C
 Case 3
Name : Mrs. S
Age : 33 yo
Adress : Lingsar, West of Lombok
Admitted : April, 05th 2016 13.50( WITA)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

05/04/2 Patient reffered from Sigerongan General Status G4P2A1L2 41-42 DM planning:
016 PHC with G4P2A1L2 41-42 GC : well weeks/S/L/IU head - Diagnostik : CBC,
01.50 weeks/S/L/IU head presentation with presentation with HbSAg
Consciusness : CM
PROM >12 hours. Patient confessed BP : 120/80 mmHg PROM >12 hours - CTG
water leaked out from her womb PR : 84 bpm - Theraphy:
since 4 days ago (01/04/2016) at inj,. Ampicillin 1g IV
RR : 16 bpm
10.00 WITA, Abdominal pain (-), T : 36,5oC Pro termination with
bloody slim (-), FM (+). induction oksitosin drip
Eye : anemis (-/-)icteric (-/-) Observation mother &
No history of DM, HT, asthma. fetal well being.
Cor : S1S2 single reguler, M (-), G (-)
Observe temperature/4
LMP : 18-06-2015 Pulmo : vesikuler (+/+), wheezing (-/-), hr
EDD : 25-03-2016 ronkhi (-/-).
GW : 41-42 weeks Abdomen : scar (-), striae (+).
Extremity : edema (-/-), warm acral (+/ DM co GP pro
History of ANC : 11x at PHC +) induction,
Last ANC : 11/03/2013
Result GW 41-42 weeks, BP : Obstetrical Status GP co to SPV pro
130/80 mmHg, BW: 52 kg, UFH: 30 L1 : breech induction, SPV acc
cm, head presentation, FHB (+) L2 : back on the right side induction oxytocin.
L3 : head CIE patient and family
History of USG : - L4 : 4/5
UFH : 30cm
History of family planning : inj 3 EFW : 2945 g
month UC : -
Next family planning : IUD FHB : 12-12-12 (144 bpm)
VT : 1 cm, eff 25%, amnion (-),head
Obstetrical History : palpable H I, denominator unclear,
I. Aterm/Female//MW/spontaneou impalpable small part / umbilical cord.
sly/3500gr
II. Aterm/Female/MW/Spontaneou
sly/2500gr
III. Abortus/4 months
IV. This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist at Sigerongan PHC: Pelvic Score: 5
. (05/04/16) Dilataion of serviks: 1
Length of servix: 1
09.00 S : patient 10 month pregnancy Consistency: 1
came to Sigerongan PHC confessed Posisiton: 1
water leaked out from her womb Station: 1
since 4 days ago (01/04/2016) at
10.00, FM (+).

O :
GC : well
BP : 130/80 mmHg
PR : 84 bpm
RR : 18 tpm
Temp : 36,8OC
UFH : 32 cm,
EFW : 3255 g
UC : 1x10 ~20
FHB : 12-12-11 (140 bpm)
VT: 0 cm

A : G4P2A1L2 41-42
weeks/S/L/IU head presentation
with PROM >12 hours

P:
Amoxicilin 500 mg tab
co to doctor advice :
Refrred to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.30 Abdominal pain (+) UC : - Patient move to VK

FHB : 12-11-12 (144 bpm) teratai

15.00 Abdominal pain (+) UC : - Dryp oxy began 8 dpm

FHB : 12-12-12 (144 bpm)

15.30 Abdominal pain (+) UC : 2x/10~10 Dryp oxy 12 dpm

FHB : 11-12-12 (140 bpm)

16.00 Abdominal pain (+) UC : 2x/10~20 Dryp oxy 16 dpm

FHB : 11-11-12 (136 bpm)

16.30 Abdominal pain (+) UC : 2x/10~20 Dryp oxy 20 dpm

FHB : 11-12-12 (140 bpm)

17.00 Abdominal pain (+) UC : 2x/10~25 Dryp oxy 24 dpm

FHB : 11-11-12 (136 bpm)

17.30 Abdominal pain (+) UC : 3x/10~30 Dryp oxy 28 dpm

FHB : 11-12-11 (136bpm)

17.50 Abdominal pain (++) UC : 3x/10~35 Dryp oxy 32 dpm

FHB :11-12-12 (140bpm)
VT : 4 cm, eff 90%, amnion (-),
head palpable H II, denominator
unclear, impalpable small part /
umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
18.05 Abdominal pain (+++) UC : 4x/10~40 2nd stage of labor + DM Planning: Resusitation
Mother want to bearing down FHB :9-9-10 (112 bpm) fetal bradikardi Intrauterine
Head apears at vulva
Bulging of perineum DM co to GP, GP co to SPV
Open vulva
Pressure of anus Conducted mother to bearing
down
Baby was born at 18.40,
female, spontan, AS 6-8, 3000
gram, 50 cm, Anus (+),
congenital anomaly (-)

18.35 Third stage of labor Placenta was born

spontaneously, complete.

20.40 Confessed (-) General status 2 hours post partum. Move the patient to Segara
GC : well Anak.
BP : 130/90 mmHg
PR: 80 tpm
RR: 16 tpm
T: 36,8C
UFH : 2 fingers below umbilicus
Active bleeding (-)
Baby
HR : 142 x/m
RR : 41 x/m
T: 36.6 C

06/04/ Confessed (-) General status 1st day post partum Obs. Mother and fetal well
2016 GC : well being.
06.00 BP : 130/90 mmHg Suggest mother to eat and
PR: 86 tpm drink.
RR: 20 tpm Suggest mother to move
T: 36,7C freely
UFH : 2 fingers below umbilicus Breast feed the baby.
Active bleeding (-)
4

21
4

3
19
Kurva Lubchenco
 Case 4
Name : Ny. S
Age : 32 years old
Address : Bima
Admitted :1st April 2016
RM :576149
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

01/04/ 2016 Patient referred from Bima GH with General status: G1P0A0L0 35-36 weeks DM planing:
10.00 G1P0A0L0 35-36 weeks S/L/IU head GC: moderate S/L/IU with placenta Diagnostik
presentation with obs. Febris ec DHF with GCS: E4V5M6 previa totalis + obs febris CBC, BT, CT, PPT, APTT
placenta previa totalis. The patient confessed BP: 130/80 mmHg D-5 ec viral infection CTG
cough and dyspnea since 2 days ago. Fever HR: 88 bpm USG
since 5 days ago. There is no active bleeding RR: 36 x/min Inspeculo
from her womb. Abdominal pain (-), water T: 360C
leaked from her womb (-), bloody slime (-), FM Therapy
(+). Eye : anemis (-), icteric (-) Obs mother & fetal well being
Thorax : Observation bleeding, FHB, BP
No history of DM, HT, and asthma Cor : S1S2 single reguler (murmur -), (gallop -) every 6 hours
History of family: DM (-), HT (+) mother, Pulmo : vesikuler (+/+), wheezing (-/-), IVFD RL
asthma (-) Ronkhi (+/+).
Abdomen : scar (-), striae (+), linea nigra (-) DM co GP, GP co SPV, SPV
LMP: - epigastric tenderness (+) advice (1/04/16):
EDD: - Extremity : edema (-/-), warm acral (+/+) - Lab. Test
GW: - - Paracetamol 3x500 mg PO
Obstetrical status: (K/P)
History of ANC: 2x at PHC L1: breech - Consult Interna
Last result (12/12/2015): BP 110/70 mmHg, L2: back on left side - If patient is well dyspnea
GW 18 weeks, UFH 2 finger below umbilicus, L3: head presentation (-) moved to Segara Anak
FHB (+) L4: 5/5
UFH: 28 cm Co Internist, advice :
EFW: 2480 gram - obs. Febris ec viral infection
UC: - - Paracetamol tab 3 x 500 mg
FHB: 12-12-12 (144 bpm) if needed
VT: - - CIE family about the patience
condition
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

History of USG: 3x at Sp.OG Lab: (01/04/16)

Last result (1/04/16) HB: 10,0 g/dl
BPD: 34-35 w RBC: 3,87 M/dl
AC: 33-34 w WBC: 7,77 K/dl
HC: 33-34 w PLT: 170 K/dl
FL: 36 w
EFW: 2.442 g PPT : 12,2
EDD: 4/05/16 APTT : 27.2
Corp ant Placenta covering entire OUI grade III
Amnion enough Lab at Prodia ( 31/03/16)
Dengue IgG (-)
History of family planning: - Dengue IgM (-)
Next family planning: -

Obstetrical history:
I. This
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
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
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
14.00 Dyspneu (+) BP: 150/80 mmHg G1P0A0L0 35-36 weeks - O2 4 lpm
Active bleeding from her womb (-) HR: 82 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 40 previa totalis + obs febris
T: 36,70C D-5 ec viral infection SPV visite :
DJJ : 12-12-12 (144 bpm) - Lab. Test every 2-3 days
UC: - - If dypsneu still (+) Concult Cardiologist

15.00 Dyspneu (+) BP: 150/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 82 bpm - Obs mother & fetal well being
RR: 38
T: 36,70C
DJJ : 11-11-12 (132 bpm)
UC: -

16.00 Dyspneu (++) BP: 140/80 mmHg DM planning :

Active bleeding from her womb (-)
HR: 87 bpm - Pro ECG
RR: 40 - Pro Thoraks photo
T: 36,90C - Obs mother & fetal well being
DJJ : 12-13-12 (148 bpm) DM co GP, GP advice :
UC: - - 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 SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
17.00 Dyspneu (+) BP: 140/80 mmHg G1P0A0L0 35-36 weeks - O2 4 lpm
Active bleeding from her womb (-) HR: 82 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 30 previa totalis + obs febris
T: 36,70C D-5 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis 17.30, Cardiologist advice :
UC: - - Inj. Lasix 1 x 1 amp

18.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 84 bpm - Obs mother & fetal well being
RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

19.00 Dyspneu (++) BP: 140/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 32
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

20.00 Dyspneu (++) BP: 130/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 86 bpm - Obs mother & fetal well being
RR: 30 - Paracetamol tab 500 mg po
T: 37,80C
DJJ : 14-15-15 (176 bpm)
UC: -

21.00 Dyspneu (+) BP: 140/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 80 bpm - Obs mother & fetal well being
RR: 28
T: 37,40C
DJJ : 12-13-12 (148 bpm)
UC: -
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
22.00 Dyspneu (+) BP: 140/80 mmHg G1P0A0L0 35-36 weeks - O2 4 lpm
Active bleeding from her womb (-) HR: 82 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 30 previa totalis + obs febris
T: 36,70C D-5 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis
UC: -

23.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 84 bpm - Obs mother & fetal well being
RR: 28
T: 36,60C
DJJ : 11-11-12 (132 bpm)
UC: -

24.00 Dyspneu (+) BP: 140/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 26
T: 37,10C
DJJ : 11-11-12 (132 bpm)
UC: -

(02/04/2016) Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - O2 4 lpm
06.00 Active bleeding from her womb (-) HR: 88 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris
T: 35,80C D-6 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis
UC: -

12.00 Dyspneu (+) BP: 130/80 mmHg - O2 4 lpm

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24
T: 35,80C
DJJ : 12-12-12 (144 bpm)
UC: -
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
18.00 Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - Obs mother & fetal well being
Active bleeding from her womb (-) HR: 88 bpm S/L/IU with placenta - Bed rest
RR: 24 previa totalis + obs febris - Interna:
T: 37,80C D-6 ec viral infection + obs febris
DJJ : 12-12-13 (148 bpm) Decomp. Cordis PCT tab 3x1
UC: - - Cardiologist:
Lasix 1x1 Amp

24.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,60C
DJJ : 12-12-12 (144 bpm)
UC: -

03/04/2015 Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
06.00 Active bleeding from her womb (-) HR: 84 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,80C D-7 ec viral infection + - Pro co cardiologist tommorow
DJJ : 13-12-12 (148 bpm) Decomp. Cordis
UC: -

12.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

18.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
24.00 Dyspneu (+) BP: 120/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
Active bleeding from her womb (-) HR: 88 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,60C D-7 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis
UC: -

04/04/2015 Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
06.00 Active bleeding from her womb (-) HR: 84 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,80C D-8 ec viral infection + - Pro co cardiologist this morning
DJJ : 13-12-12 (148 bpm) Decomp. Cordis
UC: -

12.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

18.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2

Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

24.00 Dyspneu (+) BP: 120/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
Active bleeding from her womb (-) HR: 88 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,60C D-7 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis
UC: -

05/04/2015 Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
06.00 Active bleeding from her womb (-) HR: 84 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,80C D-8 ec viral infection +
DJJ : 13-12-12 (148 bpm) Decomp. Cordis
UC: -
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
12.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2
Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm) Cardiologist advice :
UC: - Pro echo tomorrow
Inj. Lasix 1 amp/12 hour
18.00 Dyspneu (+) BP: 120/80 mmHg - Obs O2
Active bleeding from her womb (-) HR: 88 bpm - Obs mother & fetal well being
RR: 24 - Bed rest
T: 36,70C
DJJ : 12-12-12 (144 bpm)
UC: -

24.00 Dyspneu (+) BP: 120/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
Active bleeding from her womb (-) HR: 88 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,60C D-7 ec viral infection +
DJJ : 12-12-12 (144 bpm) Decomp. Cordis
UC: -

06/04/2015 Dyspneu (+) BP: 130/80 mmHg G1P0A0L0 35-36 weeks - Obs O2
06.00 Active bleeding from her womb (-) HR: 84 bpm S/L/IU with placenta - Obs mother & fetal well being
RR: 24 previa totalis + obs febris - Bed rest
T: 36,80C D-8 ec viral infection + - Pro echo today
DJJ : 13-12-12 (148 bpm) Decomp. Cordis
UC: -