mr 2 mar 12
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Sabtu, 6 Oktober 2012MORNING REPORT
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PASIEN 1
Tgl. Masuk : 5 Oktober 2012
Jam : 20.00
DPJP : dr. RI, S.O!
"ama as#e$ : "%. S", &' t($ "ama suam# : T$. ), &' t($
*lamat : Soekar$o +atta
T : 1'0 -m
: 5& kg
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ANAMNESIS
) : erdara(a$ dar# /ala$ la(#r
Pas#e$ seora$g eremua$, &' ta(u$, !'P1*2gra#da 10 m#$ggu, data$g ke RSI de$ga$ kelu(a$utama erdara(a$ dar# /ala$ la(#r. Perdara(a$ suda(
d#rasaka$ se/ak 3 /am SMRSI, suda( &4 ga$t#embalut, dara( bergumalgumal. elu(a$d#serta# mulas ada erut bag#a$ baa( se/ak ' /amSMRSI. lek 789, mual 79, mu$ta( 79, keut#(a$ 79.
)S! Terak(#r : ' Oktober 2012, /a$#$ t#dakberkemba$g
*: t#dak ada kelu(a$
*: t#dak ada kelu(a$
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ANAMNESIS TAMBAHAN +P+T : 2& Jul# 2012
TTP :
R. Me$s : teratur, 23 (ar#, '5 (ar#
R. P"; : 14 ke S. O! R. : I)D ' ta(u$ %a$g lalu,
d#-oot & ta(u$ kemud#a$
RPD :
RP : a%a( as#e$ +T 789 R. Oeras# : S; ' ta(u$ %a$g lalu
!ol. Dara( : *
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R#a%at Obstetr#
Perkawinan
LamaKehamilan
Pemolong
JenisKelamin
BBL m!rSekarang
Kea"aanSekarang
In#er$al
1 & bula$ S. O! *bortus
1 bula$ S. O! eremua$
&200 gr ' ta(u$ Se(at & bula$
1 2 bula$ S. O! *bortus & ta(u$
1 +am#l #$# 1 ta(u$
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eadaa$ umum: ba#k, ;M
TT= : TD : 110>?0 mm+g
" : 6 4>m$tR : 2'4>m$t
S : &6,50;
PEMERIKSAAN %ISIK
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STATS GENERALIS
eala : ko$/.a$em#s >, sklera #kter#k>
T(ora4 : -or : J S1@S2, reg, murmurA
ulmo: =S ka@k#, R( >, B( > *bdome$ : datar Ckstrem#tas : oedem 8>8, akral (a$gat ,
;RT2
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M%oma uter#
&IAGNOSIS KERJA
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LABORATORIM
+b : 12,6 g>dl
+t: &?,5F
mm&
Trombos#t : 2?6rb>mm&
Cr#tros#t : ',2 /t>mm&
asoEl : 0,& F
Cos#$oEl : 0,3F
". Stab : 0F
". Segme$ : ?',1F
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EKG
*tr#al Ebr#las#
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+#sterektom#
REN'ANA TIN&AKAN
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uo ad #tam : ad bo$am
uo ad Gu$-t#o$am : dub#a ad bo$am
PROGNOSIS
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PASIEN (
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I&ENTITAS PASIEN
Tgl. Masuk :2 maret 2012
Jam :00.21
Reg>RM : 01024444>12004444
DPJP : dr. Rb, S.O! "ama as#e$ : "%.
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ANAMNESIS
) : ro S;
as#e$ seora$g a$#ta berus#a &? ta(u$, !1P0*0me$gaku (am#l bula$, data$g kare$a adare$-a$a s- ada ta$ggal 2 maret 2012 adaukul 0?.00. as#e$ merasa mulas $amu$ /ara$g,t#dak d#serta# ada$%a Kek, erdara(a$ dar# /ala$la(#r mauu$ keluar -a#ra$ seko$%o$g A ko$%o$gdar# /ala$ la(#r.
*: *:
R#a%at )S!: 1>&>2012, lak# A lak#, ketuba$ -uku,letak keala, T* : &200gram
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ANAMNESIS TAMBAHAN +P+T : 26 me# 2011
TTP : & maret 2012
R#a%at me$struas# : teratur, 23 (ar#, 6? (ar#
R#a%at P"; : b#da$ #$e 7349, dr. Rb, S.O!
7&49
R#a%at :
RPD : +T, DM A, asma
RP : +T, DM A, asma
R# Oeras# :
!olo$ga$ dara( : O
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RI)A*AT OBSTETRI
Perkawinan Lamakehamilan
Penolong Persalinan JK BBL Umur Keadaan
! Hamil ini
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PEMERIKSAAN %ISIK
eadaa$ umum : a#k, ;M TT= : TD: 1&0>?0 mm+g
" : 30 4>m$t
R : 20 4>m$t S : &6.5 0;
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STATS GENERALIS
eala : ko$/.a$em#s >, sklera #kter#k>
T(ora4 : -or : J S1@S2, reg, murmurA
ulmo: =S ka@k#, R( >, B( > *bdome$ : -embu$g, gra#da, ) 8
$ormal Ckstrem#tas : oedem >, akral (a$gat ,
;RT2
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STATS OBSTETRIKS
Pemer#ksaa$ luar :T) : &' -m
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!1P0*0 gra#da & A '0 m#$ggu 8
r#m# tua
&IAGNOSIS KERJA
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Obseras# TT=, DJJ, +#s
S; a># a$ak ma(al
&'00 gr, P 50 -m, *P!*R 5H: ,
TIN&AKAN
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uo ad #tam : ad bo$am
uo ad Gu$-t#o$am : ad bo$am
PROGNOSIS
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