7/25/2019 Morning Report 14 April 2016 (Anemia Berat)

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Morning Report

03 April 2016

SPV : dr. , SpOG

DM : Amy, Bell, Brin,Mrtin, Vit

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!"e 1

#me : Mr". $

Age : %& yer" old

RM : '()6*)62 Addre"" : #rmd

Admitted : 1%t+April 2016

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Time Subject Object Assessment Planning

14th

April2016

13.50

Patient referred from NarmadaPHC with severe anemia. Patientconfessed languid and coldsweat since 11.00 (14-04-201!."he also confessed that hermenstrual had #een going for awee$% with a lots of #lood comingout from her wom# (&!.

'#dominal ain (-!% headache (-!.

Histor) of *+ (-!% H, (-!% asthma(-!% malignanc) (&! Ca +amaeamil) histor) *+ (-!% H, (-!%asthma (-!.

/+P 0 04 201

Histor) of "3 -

Histor) of famil) lanning -

#stetric Histor)1. +ale5mtraditional midwife

6000 grsontaneousalive.2. emale5mtraditional

midwife 6000grsontaneousalive

General status3C wellConsciousness C+P ! 140"#0 mm$gP7 5 tm77 1 tm, 6%8C

%&cal status9)e anemic &&% icteric --Cor "1"2single reguler%

murmur (-!% gallo (-!.Pulmo vesicular (&&!%whee:ing (--!%rhonchi (--!.

'#domen scar (-!% mass (-!.

9;tremit) edema (--!% warmaccrual (&&!.

t #eevaluated.

%ab '14"04"16(!H3? @%2 ()!7?C 4%00 (A!HC, 22%2 (A!B?C %6 (N!P/, 46 (!

7andom 3lucose test 1@5 (N!

"evere anemia &"us. '?

*iagn&stic! C?C Pro-"3

+&nit&ring! #s. #leeding

Therap,! Pro-P7C transfusion

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Time Subject Object Assessment Planning

-hr&n&l&g, at arma/a P$-'14"04"2016(!S!Patient confessed languid (&! andcold sweat since a wee$ ago%headache (&!.

O!3C moderateConsciousness C+?P 12050 mmHg%9)e anemic &&% icteric --Cor "1"2single reguler% murmur (-!%

gallo (-!.Pulmo vesicular (&&!% whee:ing(--!% rhonchi (--!.'#domen scar (-!% mass (-!.

9;tremit) edema (--!% warmaccrual (&&!.

A!"evere anemia

P!2 nasal 2lmD

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Time Subject Object Assessment Planning

1E.60 Confessed (-! General status3C wellConsciousness C+?P 16050 mmHgP7 5 tm77 20 tm, 6%@8C

#s. ?leeding Pro-P7C transfusion Pro-"3

+&e/ t& SegaraAna

1404201

0.00

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!"e 2

#me : Mr". -

Age : 1( yer" old

RM : '()6*)*% Addre"" : Sed

Admitted : 1%t+April 2016

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Time Subject Object Assessment Planning

14th

April2016

23.45

Patient referred from "edau PHCwith 31P0'0/0 6 wee$s "/Dhead resentation with latenthase first stage of la#or &edema vulva. Patient confesseda#dominal ain (&! since 16.00(1404201!% water lea$ed fromher wom# (-!% #lood) slime (-!%+ (&!.

Histor) of *+ (-!% H, (-!% asthma(&!.amil) histor) *+ (&!% H, (&!%asthma (&! grandmother.

/+P 2 0E 201@

9** 04 0@ 2013B 6-65 wee$

Histor) 'NC ; at Pos)andu/ast 'NC 01-04-201%7esult 3B 6 wee$s% ?P 100E0 mmHg% ?B $g% headresentation% H? (&!.

Histor) of "3 -

Histor) of famil) lanning -Ne;t famil) lanning -

#stetric Histor)1. ,his

General status3C wellConsciousness C+?P 1200 mmHgP7 120 tm77 20 tm, 6E%8C

%&cal status9)e anemic --% icteric --Cor "1"2single regular%

murmur (-!% gallo (-!.Pulmo vesicular (&&!%whee:ing (--!%rhonchi (--!.

'#domen scar (-!% striae (&!%

linea nigra (&!.9;tremit) edema (--!% warmaccrual (&&!.

Obstetric status/1 #reech/2 #ac$ on left side/6 head/4 4@

H 60 cm9B 254@ grH? 12-12-12C 2;10>F2@G

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Time Subject Object Assessment Planning

Pelic aminati&nPromontorium unala#le"ina ischiadica rominents sacrum conve;s cocc)geus mo#ile

'rcus u#is I 50

Pelic sc&re ! 3Cervi; dilatation 1Cervi; length 0Hodge 0Consistenc) 0Position 1

%ab '05"04"2016(!H? 5% ()!

7?C 4%2 ()!HC, 62%2 ()!B?C 1% (!P/, 4@0 (!H#s'g (-!

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Time Subject Object Assessment Planning

-hr&n&l&g, at Se/au P$-'14"04"2016(!S!Patient confessed a#dominalain (&! since 16.00(1404201!% water lea$ed fromher wom# (-!% #lood) slime (-!%edema cervi; (&!.

O!3C wellConsciousness C+?P 11050 mmHg%P7 4 ;m, 6%2 C77 20 ;m

H 60cmC 2;10>F20GH? 140 ;m

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Time Subject Object Assessment Planning

1@04201

01.00

Confessed a#dominal ain (&&&! 3C wellConsciousness C+?P 1200 mmHgP7 120 tm77 20 tm, 6E%8C

31P0'0/0 6wee$s "/D headresentation withlatent hase firststage of la#or &edema vulva

Patient m&e t& O-7TO

01.60 Confessed (-! 3C wellConsciousness C+?P 1200 mmHgP7 120 tm

77 20 tm, 6E%8C

,he #a#) was #orn+ale'-"FE-56000gr45cm

,he lacenta was #orncomletel).

#s. +other andfetal well #eing.

04.00 Confessed (-! 3C wellConsciousness C+?P 1200 mmHgP7 120 tm

77 20 tm, 6E%8C

?a#) (in NDC!H7 144;min77 40 ;min, 6. C

#s. +other and#a#) well #eing

+oved to "egara

'na$

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0.00 Confessed (-! G- ! 8ell-&nsci&usness! -+

?P 1200 mmHgP9! 120 tpm99! 20 tpm, 6E%8C

?a#) (in NDC!H7 144;min77 40 ;min, 6. C

+&bili:ati&n at an/ /rin

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