MORNING REPORT May 19th 2012

Supervisor : dr. A Rusdhy HA, SpOG Medical Students : Nata, Yuyun, Ika, Novi

Case Resumes Normal labor: 1 Pathologic labor: G1P0A0L0 A/T/IUFD with eclampsia

Case Report
Mrs. N, 20 years old, from KLU GH on May 18th 2012 at 19.40 G1P0AoL0 A/S/IUFD head presentation with eclampsia

Time 18/05/12 19:40

Subject Patient was referred from Lombok Utara GH with G1P0A0L0 A/S/L/IU head presentation with eclampsia. History of seizure about >10x at home since 09.00 (18/05/12). 1x at Lombok Utara GH at 18.00 . Vomiting (+), nausea (+), febris (+) Family health history : DM (-), HT (-), asthma (-). LMP: forgot EDD: -

Object General status GC: weak Conciousness : somnolent GCS : E2VxM3 BP: 130/100 mmHg PR: 120 bpm RR: 28 t/m T: 40,6C UO: Local status Eye : an (-/-), ict (+/+) Pulmo: ves (+/+), rh (-/-), wh (-/-) Cor : S1S2 single regular M(-), G(-) Abd : strie gravidarum (+) Ext : edema (+/+) Patella reflex (+/+) Obstetric status L1: breech UFH : 31cm L2: back on the left side L3: head L4: 4/5 UC: (-) FHB: (-) VT : not done EFW: 3100 gr

Assessment G1P0A0L0 A/S/IUFD with eclampsia

Planning O2 5 lpm Infus RL drip MgSO4 40% 6gr 28 tpm (continue from Lombok Utara GH) Insert DC Observation mother well being Inj. Xilodela 2cc IM DM co to SPV pro SC, SPV advice stabilisation in ICU

History of ANC : >4x at PHC Last ANC: 10-05-2012 BP : 170/100 mmHg. Proteinurine +3 USG: History of family planning: (-) Next family planning : (-) Obstetric History: 1. This

Time

Subject

Object

Assessment

Planning

18/05 /12 18.30

Cronologist: S: Patient pregnant 9 months came to Lombok Utara GH with seizure since 09.00 (18/05/12). Nausea (+), Vomit (+), Febris (+). O: General status : weak Consciousness : CM BP: 190/140 mmHg PR: 120 bpm RR: 24 t/m T: 38,5C Protein urine : + 3 UC: (-) VT : A : G1P0A0L0 A/S/L/IU head presentation with eclampsia P: -RL 20 dpm -MgSo4 40 % 4 gram Bolus - MgSo4 40 % 6 gram drip in RL 28 dpm -Nifedipin sublingual Patient referred to NTB GH

Laboratorium : Hb : 15,8 Hct : 45,3 Rbc : 6,23 Wbc : 30,47 PLT : 330 SGOT : 80 SGPT : 88 Ureum: 47 Kreatinin : 1,8 GDS : 125 HbsAg : (-) BT : 2.15 CT : 6.10

Time 20.10

Subject Patient still nervous

Object BP: 100/70 mmHg PR: 100 bpm RR: 24 t/m T: 40,1C UC: (-) FHB: (-) BP: 100/70 mmHg PR: 96 bpm RR: 24 t/m T: 39 C UC: (-) FHB: (-)

Assessment G1P0A0L0 A/S/IUFD with eclampsia

Planning DM to GP, pro co to Sp.An to stabilisation in ICU

21.30

Patient still nervous

G1P0A0L0 A/S/IUFD with eclampsia

GP co Sp.An., pro ICU; Sp.An advice acc ICU & pro SC DM co to SPV pro SC; acc SC Prepare SC: - Test ampi (-), inj ampi 2 g IV SC began Male, W : 2500 gram, death, amnion cloudy & odor Congenital anomali : (-), Plasenta was born manually, complete Bleeding 450 cc

23.30

01.30

Unconsciousness

BP: 120/100 HR: 96 T: 38,5 RR: 20x UC : + well UFH : 2 fingers below umbilicus Active bleeding : UO : < 5cc/6 hours

2 hours post SC

Observe general condition and vital sign Observe active bleeding Observe uterus contraction Observe urine output

Time 19/05 /12 07.00

Subject Unconsciousness

Object GCS: E2VxM3 BP: 110/90 HR: 84 T: 37,2 RR: 13 UC : + well UFH: 2 fingers below umbilicus Active bleeding : (-) UO : 20 cc/12 hours

Assessment 1 day post SC

Planning Observe general condition and vital sign Observe active bleeding Observe uterus contraction Observe urine output