Morning Report Khodijah

Duty ReportMonday , June 12nd 2015 Supervisor on duty: Dr. dr. Sarma N. Lumbanraja, M.Ked(OG), SpOG.K Duty Team: 1. Dr. Juhriani Malahayati 2. Dr. Irliansyah Putra 3. Dr. Isnayu 4. Dr. Irfan Hamidi 5. Dr. Ria Suci 6. Dr. Ryan Andrian 7. Dr. Dwi Fenny Amir Obstetric dan Gynecology Department Faculty of Medicine of USU/ RSUP HAM 2015 Inj. Mrs.Inj. MgSO4 40% 12 gram  maintenance dose . 29 years old. MgSO4 20% 4 gram  loading dose . Dexamethasone 10 – 10 – 5 – 5 gram (48 hours) .1. K.Inj. G4P3A0 Dx : IUFD + MG + IUP (28-30) gw + preeclampsia BERAT+ partial HELLP syndrome Planning : . PATIENT 1 . 1.00 a. History of water from vagina (-).m. K. history of nausea and vomiting (-) history of blood from vagina (-).admitted at Adam Malik Hospital at August 30th 2015. Headache (-). 03.. housewife wife of Mr. E . . History of hypertension before pregnancy (-). Mrs. blurred vision (-). History of abdominal pain (-) . The characteristic of fever is intermitten and get little better with antipyretic. moslem. moslem . with : CC E : Decreased of consciousness (alloanamnesis) : Experienced by the patient since this morning. G4P3A0. 29 years old. history of fever (+) since 3 days ago. History of hypertension on the previous pregnancy (-). Defecation and micturition normal.40 yo. 2500 gram. This pregnancy . Midwife. clinic. 2 yo. Midwife. Hypertension (-). clinic. Midwife. PSP. clinic. PSP.aterm. ♀. 12 yo. ♂ . 3500 gram. healthy 2. ? gram. ♂ . 6 yo. asthma (-) Previous medical hist: HPHT : Unclear TTP : Unclear ANC : Midwife 5 x Hystory of pregnancy : 1.Previous ilness: Diabetes (-). healthy 3.aterm. PSP. healthy 4. aterm. icteric (-)/(-) Neck : in normal limit Thorax : Respiratory sound Additional sound : Vesiculer : Wheezing(-)/(-).2°C Edema : ( -) Proteinuria : +3 Localized State : Head : Conj Palpebra inferior anemic ( -)/(-).Vital Sign Cons BP Pulse RR Temp : apatis Anemic : (-) : 180/100 mmHg Icteric : (-) : 94x/i Cyanosis : (-) : 28 x/i Dypsnoe : (+) : 36. Rhonki (-)/(-) . Obstetrical state • Abdomen • Fundal Height • Teregang • Terbawah • Movement • His • FHR • VT : : : : : : assymetricaly enlarged 3 fingers above umbilical right head ::: Servix closed • Dx : IUFD + MG + IUP (28-30) gw + preeclampsia BERAT+ partial HELLP syndrome . Lumbanraja.Inj. SpOG. MgSO4 40% 12 gram  maintenance dose .Inj.Inj.Ked(OG).K  Acc . MgSO4 20% 4 gram  loading dose . Sarma N. M. Dexamethasone 10 – 10 – 5 – 5 gram (48 hours) – Report to supervisor Dr.• Planning: . dr. 9 gr/dl N: 12-14/gr/dl Leukocyte : 34.6-1.6.9 mg/dl N : 3.2 C= 14 S • TT : 29.000/u Ad Random Glucose : 30 mg/dl N: < 200 mg/dl • APT : 129.000-400.8 % N: 36.8 S • Ureum : 14.2 mg/dl • Natrium : 128 mg/dl N : 135-155 mg/dl • Kalium : 6.0-42.LABORATORY FINDINGS on 30/08/2015 Hb : 14.0/% Platelet : 52 /mm3N:150.3 N : 0.5.5 C = 17.8 C= 33.5 mg/dl • Klorida : 85 mg/dl N : 96-106 mg/dl .5 S • PT : 65.87 N : 10-50 mg/dl • Creatinin : 1.23 /mm3N: 4000-11000/uL Hematocrit : 45. • USG belum ada . 69 cm • HC 28.69 cm • FL 5. head presentation • FM (-).22 cm • Placenta corpus anterior • Amnion fluid : MVP = 4 Kesan : IUFD + IUP (29-30) gw + Head presentation . FHR (-) • BPD 7.USG TAS • Single fetus.31 cm • AC 25. THANK YOU .