OUTWARD ROOM REPORT

DUTY ON : WEDNESDAY, MARCH 31st 2021

1. YUL, 26 yo Hospitalized: 28/03/21 Ratna 207.1 DJM
IC
S O A D P
X
Complain: Present state G1P0000 35 Weeks O Intervention :
Fever (+), BP : 110/70 mmHg 5 Days Single/Life 60 1. Join care with Internal
spontaneous P : 88 x/min + Obs Fever Day-6 medicine
bleeding (-) RR : 22 x/min ec Dengue A9
Tax : 37.4°C Infection Without 0 Target :
Labor pain (-), Warning Sign 2. Optimal care
watery vaginal General state
Eyes : anemic -/- Pdx:
discharge (-), Thorax : EFW : 2521 g Therapy :
fetal movement (+) Cor : S1S2 single, - SF 300 mg @ 12 hours IO
good. regular, murmur(-) Problem list: - Other therapy ~ Internal
Po : vesicular +/+, 1. Preterm Medicine
EDD: 03/06/21 rhonchi -/-,
wheezing -/- Pregnancy with Mx: Complain, Vital Sign, FHB
Extremities : Warm +/+ Dengue Infection
+/+ Without Warning CIE
Obstetric state Sign
Abdomen :
Uterine contraction (-)
FHB (+) 128 bpm

Vaginal :
Discharge (-)
 HOSPITALIZED OBSTETRIC COVID-19 CASES
DUTY ON : WEDNESDAY, MARCH 31st 2021
2. ADI, 27 yo Hospitalized: 28/03/21 Flamboyan 108 DJM
IC
S O A1 D P
X
Complain: Present state P2002 post CS day 1 O Intervention :
Post operative BP : 110/70 mmHg 60 1. Analgetics
P : 84 x/min + IUD acceptor
pain (+) minimal U0 2. Join care with
RR : 20 x/min + Confirmed COVID- pulmunologist
Cough (-), Tax : 36.6°C 19 (mild) 7.
Shortness of SpO2 : 98% on room 1 Target :
breath (-), Fever (-) air
Problem list: 3. VAS < 1
General state 4. Optimal care
1. Post operative
Eyes : anemic -/-
Thorax : Pdx: -
Cor : S1S2 single, Therapy :
regular, murmur(-) - IVFD RL 500 cc ~ 20 dpm
Po : vesicular +/+, - Paracetamol 500 mg @ 8
rhonchi -/-, hours PO
wheezing -/- - Other therapy ~
Extremities : Warm +/+ pulmunologist
+/+
Obstetric state Mx: Complain, Vital Sign,
Abdomen :
Fundal height 2 fingers Contraction, Bleeding
below umbilical
Contraction (+) CIE
Operation wound
treated well Pulmonologist
Pdx : -
Vaginal : Lochia (+)
Tx:
Swab PCR (31/03/21) - Zegavit 1 tab @ 24 hours PO
Positive
Thorax PA (31/3/21) :
- Pneumonia
- Cor normal
 HOSPITALIZED OBSTETRIC COVID-19 CASES
DUTY ON : WEDNESDAY, MARCH 31st 2021
1. HER, 26 yo Hospitalized: 28/03/21 Flamboyan 107 DJM
IC
S O A1 D P
X
Complain: Present state G1P0000 31 Weeks O Intervention :
Cough (+) BP : 110/70 mmHg 0 Day Single/Life 60 1. Conservative management
improved, P : 84 x/min U0 2. Join care with Internal
RR : x/min + Confirmed COVID- medicine and clinical
Shortness of Tax : 36.6°C 19 (moderate) 7. nutritionist
breath (-), Fever (-) SpO2 : 98% on NC + Mild Anemia (9.98) 1
2 lpm N-N Target :
Labor pain (-), + Hypokalemia (3.21) 3. Conserve pregnancy until
watery vaginal General state viable
Eyes : anemic -/- ec susp low intake 4. Optimal care
discharge (-), dd/ shift
fetal movement (+) Thorax :
Cor : S1S2 single, + Hypoalbuminemia Pdx:
good. regular, murmur(-) (2.60) ec low intake Therapy :
Po : vesicular +/+, - Conservative management
EDD: 03/06/21 rhonchi -/-, - Other therapy ~ Internal
wheezing -/- EFW : 1860 g Medicine
Extremities : Warm +/+
+/+ Problem list: Mx: Complain, Vital Sign,
Obstetric state 1. Preterm FHB
Abdomen :
Uterine contraction (-) Pregnancy with, CIE
FHB (+) 138 bpm Hypoalbuminemia,
Confirmed COVID-
Vaginal : 19 (moderate)
Discharge (-)
Bhayangkara Hospital
Swab I (26/03/21)
Positive
Swab II (27/03/21)
Positive