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    Fellixeby Elninothetorres
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    Ny. Siti Fatimah, a 39 year-old housewife from Lamongan, presented to the hospital complaining of contractions for 5 hours accompanied by bleeding mucus. On examination, she was found to be 38-39 weeks pregnant with severe preeclampsia, a blood pressure of 170/92, and the baby in a head down position ready to deliver. Labs showed elevated blood counts. She was assessed as a gravid woman at 38-39 weeks with severe preeclampsia. Her treatment plan included monitoring, IV fluids, antihypertensive medications, and a magnesium sulfate drip and injection to prevent seizures from preeclampsia.

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    Ny. Siti Fatimah, a 39 year-old housewife from Lamongan, presented to the hospital complaining of contractions for 5 hours accompanied by bleeding mucus. On examination, she was found to be 38-39 weeks pregnant with severe preeclampsia, a blood pressure of 170/92, and the baby in a head down position ready to deliver. Labs showed elevated blood counts. She was assessed as a gravid woman at 38-39 weeks with severe preeclampsia. Her treatment plan included monitoring, IV fluids, antihypertensive medications, and a magnesium sulfate drip and injection to prevent seizures from preeclampsia.

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    6 views8 pages

    Morning Report

    Uploaded by

    Fellixeby Elninothetorres
    Ny. Siti Fatimah, a 39 year-old housewife from Lamongan, presented to the hospital complaining of contractions for 5 hours accompanied by bleeding mucus. On examination, she was found to be 38-39 weeks pregnant with severe preeclampsia, a blood pressure of 170/92, and the baby in a head down position ready to deliver. Labs showed elevated blood counts. She was assessed as a gravid woman at 38-39 weeks with severe preeclampsia. Her treatment plan included monitoring, IV fluids, antihypertensive medications, and a magnesium sulfate drip and injection to prevent seizures from preeclampsia.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 8

    Morning Report

    24 November 2015

    Identity

    Name: Ny. Siti fatimah

    Age : 39 yo

    Addres: Lamongan

    Occupation : Housewife

    Religion : Islam

    Married : 1 year

    MRS : 14 desember 2015

    Anamnesis

    Chief complaint: kenceng-kenceng

    RPS : Patient complaint kenceng2 5 hours before patient came to the


    hospital, accompanied with bleeding mucus or clear liquid. Patient also
    complaint sometimes heartburn, headache -, blurred vission-, nausea & vomit
    -, leg edem -

    RPD : HT+, DM-, gastritis , fluor albus-

    R.obs : the third pregnant

    R.ANC : > 4x in midwife dan Sp.OG

    R.mens : HPHT 6 Maret 2015, TP 18 Desember 2015, reguler mens cycle/ 2830 day/ 5 day/ dysminorhhea +-

    Physic Examination

    Vital sign BP : 170/92 , P : 113, RR : 20, T : 36,7

    General

    K/L : a-/i-/c-/d-

    Thorax : sim+, retP V/V, Rh -/-, Wh -/C S1 S2 single, g-, m-

    Abdomen : Gravid, operation scars-

    Extremity : a-/i-/e+ tungkai bawah

    St.Obstetri
    L1

    : TFU 32cm, teraba bulat lunak, kesan bokong

    L2

    : Puka, 134x/m

    L3

    : teraba bulat keras, kesan kepala, sudah masuk PAP

    L4

    : 3/5 konvergen

    Vt

    obs : -

    Lab examination

    Eritrosit 4,42 Leukosit 9,9 trombosit 321

    Hb : 11,6

    LED : 80/94

    MCHC 32,4

    Limposit 18,8

    MCV 81,00

    Basofil 3,3

    eosinopil 3,7 MPV 4

    GDA 107 Neutropil 69,0

    Hct 35,8 RDW 12

    Sk : 0,5 urea 14

    SGOT 15 SGPT 17

    UL : protein +2

    MCH 26,2

    monosit 5,2

    BT 1,3
    CT 6,00

    Assesement

    G3 P2002 A000 Gr 38-39 Week TH + Severe Preeclampsia

    Therapy

    NST

    DK

    Inf RL/D5 16 tpm

    Nifedipin 3x100

    Methyldopa 2x500

    Inj.SM 5gr 20% dalam 25cc iv dlm 15 mnt + SM 10gr IM 40%


    dalam 25cc

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