Scribd Logo
Importer

Bienvenue sur Scribd !

  • Gemelli

    Transféré par

    Darling Sevenfoldism Synyster
    22 vues4 pages
    Mrs. F, a 26 year old woman, was referred to the hospital at 21:00 on August 1st, 2012 with G2P1A0L1 at 37-38 weeks gestation with twins in a head down, head presentation position. She reported abdominal pain and her water had broken earlier that day. On examination, she was in the latent phase of labor with a cervical dilation of 3 cm. She was admitted for observation of her labor progress. By August 2nd at 05:00, her abdominal pain was less frequent but labor had arrested at 6 cm dilation. She received IV fluids and a ultrasound was planned for that morning to assess the status of the twins and labor.

    Description originale:

    Titre original

    266766629-Gemelli.pptx

    Copyright

    © © All Rights Reserved

    Formats disponibles

    PPTX, PDF, TXT ou lisez en ligne sur Scribd

    Avez-vous trouvé ce document utile ?

    Ce contenu est-il inapproprié ?

    Signaler ce document
    Mrs. F, a 26 year old woman, was referred to the hospital at 21:00 on August 1st, 2012 with G2P1A0L1 at 37-38 weeks gestation with twins in a head down, head presentation position. She reported abdominal pain and her water had broken earlier that day. On examination, she was in the latent phase of labor with a cervical dilation of 3 cm. She was admitted for observation of her labor progress. By August 2nd at 05:00, her abdominal pain was less frequent but labor had arrested at 6 cm dilation. She received IV fluids and a ultrasound was planned for that morning to assess the status of the twins and labor.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PPTX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    22 vues4 pages

    Gemelli

    Transféré par

    Darling Sevenfoldism Synyster
    Mrs. F, a 26 year old woman, was referred to the hospital at 21:00 on August 1st, 2012 with G2P1A0L1 at 37-38 weeks gestation with twins in a head down, head presentation position. She reported abdominal pain and her water had broken earlier that day. On examination, she was in the latent phase of labor with a cervical dilation of 3 cm. She was admitted for observation of her labor progress. By August 2nd at 05:00, her abdominal pain was less frequent but labor had arrested at 6 cm dilation. She received IV fluids and a ultrasound was planned for that morning to assess the status of the twins and labor.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PPTX, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 4

    Case Report

    Identity
    Name : Mrs. F
    Age : 26 years old
    Address : Sesela, Gunung Sari, Lombok Barat.
    RM : 049779
    Hospitalization : August 1st 2012 at 21.00 WITA
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
    01/08/ Patient was referred from Gunung General Status G2P1A0L1 37-38 • Observe mother and
    2012 Sari PHC with G2P1A0L1 37 weeks GC : well weeks G/L-L/IU fetal well being.
    L/IU head presentation, mother and BP : 120/80 mmHg head presentation - • Observe progress of
    21.00
    fetal condition well with latent phase PR : 84 bpm head presentation, labor.
    1st stage of labor and gemelli. RR : 24 bpm latent phase 1st • Skin test (-), injection
    Patient confessed abdominal pain & T : 36,7oC stage of labor with Ampicillin 1g/IV.
    water came out from her womb since history rupture of • DM co GP; GP consult
    Eye : anemis (-/-), icteric (-/-)
    05.00 (01/08/2012). Bloody slim (+). membrane. to SPV. Advice :
    Cor : S1S2 single regular, murmur (-),
    FM (+). observation.
    gallop (-).
    History of HT (-), DM (-), asthma (-).
    Pulmo : vesikuler (+/+), wheezing (-/-),
    ronkhi (-/-).
    LMP : 15/11 /2011 Abdomen : scar (-), striae (+), linea
    EDD : 22 /08 /2012 nigra (+).
    Extremity : edema (-/-), warm acral
    History ANC : > 4x at Posyandu (+/+).
    Last ANC : 30/07/2012
    USG : 2x at NTB GH Obstetric Status
    Last USG : 30/08/2012 L1 : breech & breech
    Result : Gemelli, head presentation- L2 : back on the left side & right side
    head presentation, placenta fundus L3 : head & head
    gr III, amnion enough, 35-36 weeks. L4 : 4/5
    I : EFW 2551 g, EDD 04/09/2012 UFH : 42 cm
    II : EFW 2511 g, EDD 12/09/2012 UC : 2x10’~ 25 “
    FHB : I. 11-11-12 (136 bpm)
    History of family planning : injection 3 II. 12-12-11 (140 bpm)
    months
    Next family planning : injection 3
    VT : Ø 3 cm, eff 50%, amnion (-),
    months clear, head palpable, denominator
    unclear, ↓HI, impalpable small part /
    Obstetric History : umbilical cord.
    1. ♀, aterm, spontan, 3600 gram,
    midwife, live, 8 years old.
    2. This
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
    Chronologist at Gunung Sari PHC (01/08/2012) : Lab Evaluation :
    Hb : 9,5 g/dl
    19.40
    RBC : 3,39 M/dl
    S : Patient with pregnancy 9 months confessed HCT : 29,7 %
    abdominal pain that spread to the frank and WBC : 8,93 K/dl
    water come out from her womb, leaked. FM (+). PLT : 333 K/dl
    O: HbSAg : (+)
    GC : well
    BP : 110/80 mmHg
    PR : 80 bpm
    RR : 18 bpm
    T : 36,7°C
    UFH : 40 cm
    UC : 3x10’~30’’
    FHB I : 140 bpm
    FHB II : 136 bpm
    VT : Ø 3 cm, eff 25%, amnion (+), leaked, head
    palpable ↓HI, denominator unclear, impalpable
    small part / umbilical cord.
    A:
    G2P1A0L1 37 weeks L/IU head presentation,
    mother and fetal condition well with latent phase
    1st of labor and gemelli.
    P:
    • CIE patient and family
    • Refer to NTB GH
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
    02/08 Abdominal pain came and relieved GC : well G2P1A0L1 37-38 weeks • Observe mother and
    /2012 UC : 4x10’~ 40 “ G/L-L/IU head fetal well being.
    FHB : I. 11-11-12 (136 bpm) presentation - head • Observe progress of
    01.00
    II. 11-11-11 (132 bpm) presentation, active labor with partograf.
    phase 1st stage of labor
    VT : Ø 6 cm, eff 50%, amnion (-), with history rupture of
    clear, head palpable, denominator membrane.
    LOA, ↓H-II, impalpable small part /
    umbilical cord.

    05.00 Abdominal pain came less GC : well G2P1A0L1 37-38 weeks • Observe mother and
    frequently UC : 2x10’~ 30 “ G/L-L/IU head fetal well being.
    FHB : I. 11-11-12 (136 bpm) presentation - head • Rehydration RL:D5 2:1
    II. 11-12-12 (140 bpm) presentation, arrested • Dm consult to SPV.
    active phase 1st stage Advice : pro USG in this
    VT : Ø 6 cm, eff 50%, amnion (-), of labor (dystocia 6 cm) morning.
    clear, head palpable, denominator with history rupture of
    LOA, ↓H II+, impalpable small part / membrane.
    umbilical cord.

    Vous aimerez peut-être aussi