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New Patient: - Patient Prior Patient: 1 Patient

This document contains multiple patient notes and observations for a 29 year old pregnant patient (G3P1A1) who is 28-30 weeks gestation with a head presenting fetus. The patient was initially admitted with a diagnosis of preeclampsia, gestational hypertension, and gestational diabetes. The notes document the patient's vital signs, fetal position and contractions, treatment including IV magnesium sulfate and nifedipine, and plans for delivery over the course of several days. The patient's condition was stable with controlled blood pressure and contractions. Delivery was planned vaginally but did not occur during the observation period.

Uploaded by

Benny Harmoko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
131 views29 pages

New Patient: - Patient Prior Patient: 1 Patient

This document contains multiple patient notes and observations for a 29 year old pregnant patient (G3P1A1) who is 28-30 weeks gestation with a head presenting fetus. The patient was initially admitted with a diagnosis of preeclampsia, gestational hypertension, and gestational diabetes. The notes document the patient's vital signs, fetal position and contractions, treatment including IV magnesium sulfate and nifedipine, and plans for delivery over the course of several days. The patient's condition was stable with controlled blood pressure and contractions. Delivery was planned vaginally but did not occur during the observation period.

Uploaded by

Benny Harmoko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 29

New patient

Prior patient

:
:

- patient
1 patient

1. Mrs. N, 29 yo, G3P1A1


Dx: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head
Presentation
Plan

: - Spontaneous Vaginal Delivery

Follow Up at 8 AM
Present state:
Sens : Alert Anemis (-)
BP : 180/ 120 mmHg Icteric (-)
HR : 90 x/I Sianosis (-)
RR : 24 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit


Thorax : Respiratory sound : Vesiculer
Additional sound

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

Obstetrical State
Abdomen

: Symetrically enlarged

Fundal height

: 3 fingers above umbilical

Stretch part : Right


Lowest part : Head
Contraction : 3x20/10
Micturition

: via catheter 60 cc/ hour

Vaginal Examination : Not done, Baloon catheter was inflated at


OUI with RL 500cc as ballast from previous duty team

Dx

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minutes (maintenance dose)
IVFD RL+ oxitoxin 5IU 4drips/minute titrate 4 drips/minute every 15 minutes, maximum
40drips/ minute.
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning : C-Section
Report to Supv. Dr. Melvin N.G Barus, M.Ked(OG), Sp.OG ACC

Follow Up at 4 PM
Present state:
Sens : Alert Anemis (-)
BP : 150/ 100 mmHg Icteric (-)
HR : 90 x/I Sianosis (-)
RR : 20 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit


Thorax : Respiratory sound : Vesiculer
Additional sound

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

Obstetrical State
Abdomen

: Symetrically enlarged

Fundal height

: 3 fingers above umbilical

Stretch part : Right


Lowest part : Head
Contraction : 4x30/10
Micturition

: via catheter 60 cc/ hour

Vaginal Examination : Baloon catheter was detached, cervix


sacral, 3cm, effacement 40%, Amniotic membrane (+).

Dx

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minutes (maintenance dose)
IVFD RL+ oxitoxin 10IU 4drips/minute titrate 4 drips/minute every 15 minutes, maximum
40drips/ minute.
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning : C-Section
Report to Supv. Dr. Melvin N.G Barus, M.Ked(OG), Sp.OG ACC

Follow Up at 8 PM
Present state:
Sens : Alert Anemis (-)
BP : 150/ 100 mmHg Icteric (-)
HR : 88 x/I Sianosis (-)
RR : 24 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit


Thorax : Respiratory sound : Vesiculer
Additional sound

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

Obstetrical State
Abdomen

: Symetrically enlarged

Fundal height

: 3 fingers above umbilical

Stretch part : Right


Lowest part : Head
Contraction : 3x20/10
Micturition

: via catheter 60 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,


Amniotic membrane (+).

Dx

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minutes (maintenance dose)
IVFD RL+ oxitoxin 10IU 4drips/minute titrate 4 drips/minute every 15 minutes, maximum
40drips/ minute.
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning : Spontaneous Vaginal Delivery
Report to Supv. Dr. Melvin N.G Barus, M.Ked(OG), Sp.OG ACC

Follow Up at 10 PM
Present state:
Sens : Alert Anemis (-)
BP : 150/ 110 mmHg Icteric (-)
HR : 88 x/I Sianosis (-)
RR : 20 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit


Thorax : Respiratory sound : Vesiculer
Additional sound

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

Obstetrical State
Abdomen

: Symetrically enlarged

Fundal height

: 3 fingers above umbilical

Stretch part : Right


Lowest part : Head
Contraction : 2x20/10
Micturition

: via catheter 50 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,


Amniotic membrane (+).

Dx

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minute (maintenance dose)
IVFD RL 20 drops/ minute
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning : Spontaneous Vaginal Delivery
Report to Supv. Dr. dr. M. Fidel Ganis Siregar M.Ked(OG), Sp.OG ACC

Follow Up at 08 AM
Present state:
Sens : Alert Anemis (-)
BP : 150/ 100 mmHg Icteric (-)
HR : 88 x/I Sianosis (-)
RR : 20 x/I Dyspnoe (-)
T : 37 C Edema (-)
Localized St :
Head

: Conj Palpebra inferior anemis ( -)/(-), icteric (-)/(-)

Neck: in normal limit


Thorax : Respiratory sound : Vesiculer
Additional sound

: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : pretibial edema (+), KPR/APR : (+)/(+) N

Obstetrical State
Abdomen

: Symetrically enlarged

Fundal height

: 3 fingers above umbilical

Stretch part : Right


Lowest part : Head
Contraction : (-)
Micturition

: via catheter 50 cc/ hour

Vaginal Examination : Cervix sacral, 3cm, effacement 40%,


Amniotic membrane (+).

Dx

: PEB+ KJDK+ MG+ KDR(28-30)wga+ Head Presentation

Therapy:
Indwelling Catheter
IVFD RL + MgSO4 40 % ( 30 cc, 12 gr) 14 drips/minute (maintenance dose)
IVFD RL 20 drops/ minute
Nifedipine 10 mg every 30 minutes if BP > 160/110 mmHg, with maximum dose 120 mg/ 24
hours, and with maintenance 4 x 10 mg
Planning

: Spontaneous Vaginal Delivery

THANK YOU

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

Oxytoxin
5IU

08.00

CM

180/12
0

90

24

37,5

50

10 mg

4 gtt/i

08.15

CM

160/11
0

88

20

37,5

50

8 gtt/I

08.30

CM

150/10
0

88

20

37

50

12 gtt/I

08.45

CM

150/10
0

86

20

37

50

16 gtt/I

09.00

CM

150/12
0

90

20

37,5

50

20 gtt/I

09.15

CM

160/11
0

88

20

37,5

50

24 gtt/I

09.30

CM

150/10
0

88

20

37

50

28 gtt/I

09.45

CM

150/10
0

86

20

37

50

32 gtt/I

10.00

CM

180/12
0

90

20

37,5

50

10.15

CM

160/11
0

88

20

37,5

50

10 mg

36 gtt/I
40 gtt/I

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

11.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

11.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

11.30

CM

150/10
0

100

20

37

50

40 gtt/I

11.45

CM

150/10
0

90

20

37

50

40 gtt/I

12.00

CM

150/12
0

90

24

37,5

50

40 gtt/I

12.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

12.30

CM

150/10
0

100

20

37

50

20 gtt/I 10
IU

12.45

CM

150/10
0

90

20

37

50

24 gtt/I 10
IU

13.00

CM

180/12
0

90

20

37,5

50

13.15

CM

180/11
0

88

20

37,5

50

10 mg

Oxytoxin
5IU

28 gtt/I 10
IU
32 gtt/I 10
IU

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

Oxytoxin

14.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

14.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

14.30

CM

150/10
0

100

20

37

50

40 gtt/I

14.45

CM

150/10
0

90

20

37

50

40 gtt/I

15.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

15.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

15.30

CM

150/10
0

100

20

37

50

40 gtt/I

15.45

CM

150/10
0

90

20

37

50

40 gtt/I

16.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

16.15

CM

150/11
0

88

20

37,5

50

40 gtt/I

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

17.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

17.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

17.30

CM

150/10
0

100

20

37

50

40 gtt/I

17.45

CM

150/10
0

90

20

37

50

40 gtt/I

18.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

18.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

18.30

CM

150/10
0

100

20

37

50

40 gtt/I

18.45

CM

150/10
0

90

20

37

50

40 gtt/I

19.00

CM

150/12
0

90

20

37,5

50

19.15

CM

150/11
0

88

20

37,5

50

10mg

Oxytoxin

40 gtt/I
40 gtt/I

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

Oxytoxin

20.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

20.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

20.30

CM

150/10
0

100

20

37

50

40 gtt/I

20.45

CM

150/10
0

90

20

37

50

40 gtt/I

21.00

CM

150/12
0

90

20

37,5

50

40 gtt/I

21.15

CM

160/11
0

88

20

37,5

50

40 gtt/I

21.30

CM

150/10
0

100

20

37

50

40 gtt/I

21.45

CM

150/10
0

90

20

37

50

40 gtt/I

22.00

CM

150/12
0

90

20

37,5

50

22.15

CM

150/11
0

88

20

37,5

50

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

Nifedipi
ne

23.00

CM

150/12
0

90

20

37,5

50

10mg

23.15

CM

160/11
0

88

20

37,5

50

23.30

CM

150/10
0

100

20

37

50

23.45

CM

150/10
0

90

20

37

50

00.00

CM

150/12
0

90

20

37,5

50

01.15

CM

160/11
0

88

20

37,5

50

01.30

CM

150/10
0

100

20

37

50

01.45

CM

150/10
0

90

20

37

50

02.00

CM

150/12
0

90

20

37,5

50

02.15

CM

150/11
0

88

20

37,5

50

Oxytoxin

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

03.00

CM

150/12
0

90

20

37,5

50

03.15

CM

160/11
0

88

20

37,5

50

03.30

CM

150/10
0

100

20

37

50

03.45

CM

150/10
0

90

20

37

50

04.00

CM

150/12
0

90

20

37,5

50

04.15

CM

160/11
0

88

20

37,5

50

04.30

CM

150/10
0

100

20

37

50

04.45

CM

150/10
0

90

20

37

50

05.00

CM

150/12
0

90

20

37,5

50

06.15

CM

150/11
0

88

20

37,5

50

Nifedipi
ne

10mg

Oxytoxin

Ocloc
k

Sens

Bp

HR

RR

Temp

UOP

07.00

CM

150/12
0

90

20

37,5

50

07.15

CM

160/11
0

88

20

37,5

50

07.30

CM

150/10
0

100

20

37

50

07.45

CM

150/10
0

90

20

37

50

08.00

CM

150/12
0

90

20

37,5

50

Nifedipi
ne

Oxytoxin

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