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LAPORAN JAGA17-18 Desember 2014
7/23/2019 LAPAG 17-18 Des 14
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2
MRS : 7Obstetri : 11
Ginekologi : 9TINDAKAN OBSTETRI DAN GINEKOLOGIObstetri
Fisiologis : 2Patologis : 2
Rencana SC : 1Ginekologi
Kuretase : -Kuretase PA : -Biopsi PA : -
Manual Plasenta : -Sis K!r Berslin : "I#$ : -Bngsl #e!%k : 19&oliklinik : -Meninggl : 1
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
No nama diagnosa Keadaan terakhir
1. Ny. Ajizah/ 18h/A!a" hi#$%& 0
MRS 17-12-2014/12.00 '()A
G1P0A0 *8-*+ mi!,,$ J)( Pres"e% "aa (ase a"i )J *200,
3oo $% era"hir 518/12/20146P". 0.00
& "e$ha! 5-6
O& ) &G9 4-:- A(9D 5-6)D & 110/70 N & 80;/m! RR& 20;/m!)& *099/P & #b!)O &)3 & 2 jari baah %$sa
"o!ra"si $er$s 56 bai" </< $"s$s 5-6
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
No nama diagnosa Keadaan terakhir
2. Ny. Rahmi!i/ *0h/A!a" hi#$%& 1
MRS 17-12-2014/11.4: '()A
G2P1A0 Preerm J)( Pres"e% =aa( ase a"i P> i%eriroi# >#em Par$ )J 1:00,
3oo $% era"hir 518/12/20146P". 0.00
S) Perdarahan (-) Nyeri kepala(-) Sesak
(+)↓, nyeri ulu hati (-)) !"#1$%/%7 N#&7 RR# 2't#$7
!*# 2 ari diaah u.ilius 0/0 #luksus# (-) ntraksi# (+)aik
M # /1% a.
# /1% a.
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
No ama diagnosa Keadaan terakhir
*. Ny. N$r Azizah/17 h
MRS 17-12-2014/14.00 '()A
$s%. )$mor $er$s ##$mor soi# o<ari$m As?ies
3oo $% era"hir 518/12/20146P". 0.00
S) Perdarahan (-) Nyeri perut (-)
) !"#113/73 N#%'RR# 22 t#$4,7 0/0 #luksus# (-)
No nama diagnosa Keadaan terakhir
4. Ny. @is!aai/42h
MRS 18-12-2014/00.1: '()A
$s%. 9a O<ari$m 3oo $% era"hir 518/12/20146P". 0.00
S) Perdarahan (-) Nyeri perut (-)) !"#153/133 N#%'
RR# 23 t#$4,7
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
No ama diagnosa Keadaan terakhir
:. Ny. ii Ra$#ah/2: h
MRS 17-12-2014/04.10 '()A
G1P0A0 **/*4 mi!,,$G// Les$ %res"a"i/"e% (!%ar$=aa ( 3ase A"i )J100 ,ram
3oo $% era"hir 518/12/20146P". 0.00
S) Perdarahan (+)
) !"#123/%3 N#%4RR# 23 t#$5,%
No nama diagnosa Keadaan terakhir
. Ny. @ar#ia!a/ 44h
MRS 18-12-2014/04.*0 '()A
G1*P12A0 *2 mi!,,$ J)( %resi! =PD AP e.? PP)
3oo $% era"hir 518/12/20146P". 0.00
S) Perdarahan (+) Nyeri perut (+)) !"#123/&3 N#%'
RR# 23 t#$4,7 !*# $1 . "# 1$% 6/.
7/23/2019 LAPAG 17-18 Des 14
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No nama diagnosa Keadaan terakhir
7. Ny. aizah/ *8h/A!a" hi#$%& 1
MRS 18-12-2014/0:.00 '()A
G*P1A1 40/41 @i!,,$ a" i!%ar$ =PD J)( %res"e% )J200 ,r
3oo $% era"hir 518/12/20146P". 0.00
S) enan-kenan (+)
) !"# 113/&3 RR# 22 6/. N# &2 6/. !# $587 !*# 2& . "# 1'% 6/. 0!# 9 1./ 25:/ preskep/ ss .ell/;<
7/23/2019 LAPAG 17-18 Des 14
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Partus Fisiologis
(1)
12/17/15
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1. Ny. Ajizah/ 18 h/A!a" hi#$%& 0
MRS 17-12-2014/12.00 '()A
G1P0A0 *8-*+ mi!,,$ J)( Pres"e% "aa ( ase a"i )J *200,
* # kenan-kenan
RPS# Pasien kiri.an dari puskes.as denan =1P3>3 $& .inu + inpartu kala <
?ase akti? denan e.eli8 Pasien kenan-kenan seak pai hari8 eluar air-air
(-), lendir darah (-)
RP" # ;t (-), "M(-), >s.a (-)
RP # ;t (-), "M(-), >s.a (-)
R/ Perkainan # 16/2 th
R/haid# .enarhe #1' tahun
la.a# 7 hari
siklus# 27 hari
R/ ntrasepsi # Pil @ erhenti 1,5 tahun yan lalu
R/ stetri # ha.il iniR/ >N# @idan 76 nr.al
;P;! # 1&-3$-231'
!P #2'-12-231'
7/23/2019 LAPAG 17-18 Des 14
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) &
G9 4-:- A(9D 5-6
)D & 120/80 N & 80;/m! RR& 20;/m! )& *09
)O &
)3 &*2 ?m DJJ& 11-12-12
is & 56 Lea" & %rese!asi "e%aa
) & B :?m/:0C/"e 56/"e%aa/= "i #e%a!/(
Dia,!osa &G1P0A0 *8-*+ mi!,,$ J)( %res"e% i!%ar$ "aa ( ase a"i
)J *200 ,.
Pa!!i!,&
Obs. 9P
><a$asi 2 jam %ro s% =
G
7/23/2019 LAPAG 17-18 Des 14
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Hasil Pemeriksaan Laboraturium15 Desember 2014
Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<
;e.lin 13,% /dl
Beuksit &,5 Riu/ul
Aritrsit ',$3 uta/ul
;e.atkrit $2,' 0l:
!r.sit 231 Riu/ul
R"C-0 1' :
M0, M;, M;
M0 %1,' lM; 24,% P
M; $',$ :
7/23/2019 LAPAG 17-18 Des 14
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14.00
6 =e!?a!,-"e!?a!, 56
O6 )D 110/70 N82 RR18 )*E2
)O& is
DJJ 11-12-1*
) & B 7 ?m/ "e56/7:C/=/ ((
A6 G1P0A0 *+ mi!,,$ J)( =aa ( ase a"i )J *200,
P6 Am!ioomi
7/23/2019 LAPAG 17-18 Des 14
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14.20
6 (b$ i!,i! me!,eja!
O6 )D 110/80 N8 RR18 )*E2
)O& is
DJJ 11-12-12
) & B e!,"a%/ "e5-6/100C/= #e%/ (((
A6 G1P0A0 *+ mi!,,$ J)( (!%ar$ "aa (( )J *200,
P6 (b$ #i%im%i! me!,eja!
14.*0
Lahir bayi s% = %erem%$a!/2+00,/4+?m/A 7-8-+
@A= ((( %ase!a ahir e!,"a%
7/23/2019 LAPAG 17-18 Des 14
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B>PR>N P>R!*S "AN=>N AP<S<!M<
18 Pe.ukaan lenkap, kepala erada didepan DulDa8 "ilakukan episit.i .edilateral8 !anan kanan .enekan perineu., tanan kiri .enahan de?leksi k
epala8
28 epala dilahirkan spntan, teradi putaran paksi luar, tanan .e.ean kep
ala iparietal, dilakukan penarikan ke arah psterir sa.pai ahu depan er
ada di aah si.?isis8 "ilakukan penarikan ke arah anterir elakan sa.pai ahu elakan8 e.udian dilakukan penarikan seaar lantai erturut-turut,
lahir adan, kn dan kedua kaki8
$8 Bahir spntan ayi pere.puan,@@ 2&33r, P@ '& ., >S 7-%-&, >nus (+), kel
ainan knenital (-)
'8 "ilakukan kle. 2 psisi pada tali pusat8 !ali pusat diptn dilakukan penyu
ntikan ksitsin 13 <* (<M) pada rei ?e.ur lateral58 "ilahirkan plasenta lenkap denan insersi lateralis, in?eksi (-) he.at. (-)
48 serDasi perdarahan 153
78 "ilakukan penahitan luka episit.i
7/23/2019 LAPAG 17-18 Des 14
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=o!#isi era"hir & 18-12-2014 P". 0.00
& "e$ha! 5-6
O& ) &
G9 4-:- A(9D 5-6
)D & 110/70 N & 80;/m! RR& 20;/m! )& *09
9/P & #b!
)O &
)3 & 2 ja baah %$sa
"o!ra"si $er$s 56 bai"
</< $"s$s 5-6
7/23/2019 LAPAG 17-18 Des 14
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Partus Patologis Pervaginam
(1)
7/23/2019 LAPAG 17-18 Des 14
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2. Ny. Rahmi!i/ *0 h/A!a" hi#$%& 1
MRS 17-12-2014/11.4: '()A
G2P1A0 Preerm J)( Pres"e% =aa ( ase a"i P> i%eriroi# >#em Par$ )
J 1:00,
* # kenan kenan
RPS# Pasien .erupakan ruukan dari RS*" Pelaihari8 Pasien .eneluhkan kenan-kenan se
ak pukul 3&833 C<!> (2 a. SMRS)8 eluar lendir darah (+), keluar air-air (-)8 Pasien ua .ene
luhkan sesak8
RP" # ;t (+), "M(-), >s.a (+), ;ipertirid (+)
RP # ;t (-), "M(-), >s.a (-)R/ Perkainan # 16/ 11 tahun
R/haid# .enarhe # 1' tahun
la.a # 7 hari
siklus # !idak teratur
R/ ntrasepsi # Pil @
5 tahun y lalu stp
;P;! #
!P #
R/ stetri # 18 233'/laki-laki/Spt8@/$333r/@PS/ater./hidup
28 ;a.il ini8
12/17/15
Bupa .erasa ha.il % ulan
7/23/2019 LAPAG 17-18 Des 14
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S!*# =S '-5-4 ><" -/-/-/+
!" # 143/113 N # 1136/.nt RR# 24-2%6/.nt !# $4,53
# S1S2 tunal P # Rh +/+ Ch -/-
S! !* # 24 . "# 12-12-1$
, ;is # (+) letak # .e.uur kep
0! # 9 % . /75:/ketuan (+) kep/ss .ell/;<</*P" E N
"iansa #G2P1A0 Preerm J)( Pres"e% =aa ( ase a"i P> i
%eriroi# >#em Par$ )J 1:00,
Plannin#
ek la lenkap, ?aal tirid
A=,!hraks tNi?edipin $613 .
urse.ide 2 a.p iD
serDasi ;P@
ADaluasi 2 a. pr perepat kala <<
12/17/15
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<
;e.lin 128$ /dl
Beuksit 118' Riu/ul
Aritrsit 583$ uta/ul
;e.atkrit $78& 0l:!r.sit 1'% Riu/ul
R"C-0 1782 :
M0, M;, M;
M0 7585 l
M; 2'8' P
M; $28' :
12/17/15
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<
;asil P! 128$ /dl
<NR 118' Riu/ul
ntrl Nr.al P! 583$ uta/ul
;asil >P!! $78& 0l:ntrl Nr.al >P!! 1'% Riu/ul
=ula "arah Seaktu 1782 :
B"; 5'7 l
S=! 2% P
S=P! 4 :
hlesterl !tal 11% M/dl
>lu.in $8$ /dl
12/17/15
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<
*reu. 22 /dl
reatinin 38% Riu/ul
>sa. *rat &8% uta/ul
Natriu. 1'18% 0l:aliu. $8' Riu/ul
hlrida 11284 :
12/17/15
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12/17/15
Pukul 12825
S) <u inin .enedan (+)
) S!* #!"# 143/&3 N# 115 6/. RR# 2' 6/. !# $4,5S!# ;is (+) adekuat
"# 1'2 6/.
0! 9 lenkap/ket (-)/kep/uuk ki dpn/ ;<<<
>) G2P1A0 Preerm J)( Pres"e% =aa (( P>
i%eriroi# >#em Par$ )J 1:00 m,
P) <A F <n?r.ed nsent perepat kala << denan 0A
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
Pukul 128$3
Bahir ayi Spt kep pere.puan /1433r/ '%./ >S 7-%-&
@S # $2-$' .
7/23/2019 LAPAG 17-18 Des 14
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B>PR>N P>R!*S denan episit.i
18 Pe.ukaan lenkap, kepala didepan DulDa, iu dipi.pin .enedan
saat his8 !anan kanan .e.ean perineu., tanan kiri .enahan
de?leksi kepala8 epala dilahirkan seara spntan8 epala dipean
seara iparietal, dilakukan penarikan kearah psterir untuk .elahirkan ahu depan hina diaah si.?isis, ke.udian dilakukan pena
rikan kearah anterir untuk .elahirkan ahu elakan8 e.udian dil
akukan penarikan seaar lantai8 @erturut turut lahir adan, kn, d
an kedua kaki8
28 Bahir ayi pere.puan, @@# 1433 r, P@# '%. >S# 7-%-&anus (+) kelainan knenital (-)
$8 "ilakukan kle. 2 psisi pada tali pusat, tali pusat diptn dilakuka
n penyuntikan ksistsisn 13 <* (i.)pada rei ?e.ur lateral
'8 "ilahirkan plasenta lenkap denan inserti lateralis, kalsi?ikasi (-), h
e.at. (-), in?ark(-)58 serDasi perdarahan 133
48 "ilakukan penahitan luka episit.i
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;asil knsul ardi per telp
urse.ide 2 a.p iD
1'8$3 nsul dr Ryanr Sp8= #
>dDise urse.ide $ dd 1 a.pul <0
7/23/2019 LAPAG 17-18 Des 14
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1'8$3 ll up
S # pusin (-), .ual (-), .untah (-) sesak (+)
# S!* # =S '-5-4
!" # 153/&3 N # 13'6/.nt RR# 2' ! # $7,'
P # Des (+/+), Rh (+/+) Ch (-/-) >d # Supel
S! # !* 2 ari aah pusat
0/u # lu6us(-), lur (-)
knt uterus # (+) aik
># P2>3 PP Spt kep + PA@ + hipertirid + ede.a paru
P# "6 tunu hasil, aal tirid, @=> (alat rusak)!G # 2 % lp. .asker
<n?8 R"5 533 .l/2' a.
"rip ksitsin 2 a.pl dl. R"5
<n8 e?tria6ne 261 <0
>sa. Ma?ena.at 26533.
Ni?edipine $613.
Retriksi airan
<n8 SM ditunda
<n8 Basi6 $61 a.pl <0
M6 # el/0s/ l6/ nt8 *terus/ tanda i.pendin ekla.psia/ tanda krisis
tirid !unu knsul ipd
7/23/2019 LAPAG 17-18 Des 14
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on"isi terak#ir (1$%12%2014 &kl 06'00)
S) Perdarahan (-) Nyeri kepala(-) Sesak
(+)↓, nyeri ulu hati (-)
) !"#1$%/%7 N#&7 RR# 2' t#$7
!*# 2 ari diaah u.ilius
0/0 #luksus# (-)
ntraksi# (+)aik
M # /1% a. #/1% a.
7/23/2019 LAPAG 17-18 Des 14
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Patologis Perab"ominan
(2)
12/17/15
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1. Ny. Arbayah/ 2 h/A!a" hi#$%& 1
@R 1-12-2014/17.00'()A
G*P2A0 28/2+ @i!,,$ J)( Pres"e% AP e? ?$ri,a Pase!a
Pre<ia )J 100 ,ram
= & "e$ar #arah
RP& Pasie! #aa!, se!#iri. Pasie! me!,e$h"a! "e$ar #arah #ari"ema$a!. Darah ber$%a #arah se,ar besera ?aira! a,a" "er$h seb
a!ya" 200?? m$ai jam 1.00 51 jam @R 1/12/146. 2 b$a! y %asie! #iraa #i R i! #e!,a! "e$ha! %er#araha!.
RPD & 5-6E D@5-6E Asma 5-6
RP= & 5-6E D@5-6E Asma 5-6
R/ Per"ai!a! & 1;/ 10 ah$!
R/ ai# & @ & 11)
L & 7
& *0
R/ =o!rase%si & -
R/ Obseri & 1. Aerm/% "/P/P/*200,/20072.Preerm/R/ 2014/me!i!,,a
;P;! # 1$/5/231' !P # 23 2 2315 * # $1/$2.inu
7/23/2019 LAPAG 17-18 Des 14
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;P;! # 1$/5/231' !P # 23-2-2315 * # $1/$2.inu
S!* =S '-5-4 n8>ne.is(-/-)
!" # 123/%3 N # %46/.nt RR# 1&6/.nt !# $4,13
S! !* # 2' . "# 12-12-12
!@ #1433 ra. ;is# (-)
0! # 9 tidak dilakukan karena ta.pak perdarahan .ene
rin
"iansa #=$P2>3 2%/2& Minu + !;<* + Preskep + ;>P e uri
a Plasenta PreDia + !@ 1433 ra.
7/23/2019 LAPAG 17-18 Des 14
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Plannin#NS!
@edrest
Pr peraatan knserDati? #
<n8 "e6a.ethasn 265 . selan 12 a. sela.a 262' a. untuk pe.atanan paru
Pr *S= M untuk eDaluasi letak plasenta
@ila ?luksus akti? pr it S
12/17/15
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Hasil Lab 16%12%2014
Pemeri"saa! asi a$a!
; 1387 /dl
Beuksit 1387 Riu/ul
he.atkrit $18& 0l:
tr.sit $1' Riu/ul
M0 77 l
M; 2587 P
M; $$85 :
7/23/2019 LAPAG 17-18 Des 14
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a. 1%815
Bapr dr8<an "har.a Putra,Sp8= ()
>dDie #
<n8 e?tria6ne 261r
!klitik ni?edipine 26$3 . ulan sela.a % a. dilan
utkan denan ni?edipine $623 . sela.a 262' a.
Bain lain lanutkan
12/17/15
17 Desember 2014
7/23/2019 LAPAG 17-18 Des 14
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0.00
S) eluhan (-)
) !" # 123/%3..; RR # 236/.
N # 7%6/. ! # $585H/P # dn
S!= # D/D # ?l6 (I)
22.00 5R,. 9em%a"a6
S) Perdarahan perDaina. (+) Nyeri perut aah (+)
) !" # 133/73 ..; RR # 22 6/.
N # 123 6/. ! # $4,' H
?l6 (+) akti? Dlu.e # 533 " # 1'3 6/.
>) =$P2>3 2%/2& Minu + !;<* + Preskep + ;>P e uria Plasenta PreDia ttalis + ?luksus akti? + !@ 1433 ra.
P) Pindah ke 0 @ersalin
22.*0 5 = ersai! 6
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5 6
S) Perdarahan perDaina. (+)
) S!* # >(+) <" (-)
!" # &3/73 ..; RR # 23 6/.
N # 113 6/. ! # $4,5 HS! # " # &-%-% 6/.
0/0 # ?l6 (+) akti? Dlu.e # 1333
>) =$P2>3 2%/2& Minu + !;<* + Preskep + ;>P e uria Plasenta PreDia
+ ?luksus akti? + ?etal distress +!@ 1433 ra.
P) S it
sedia darah C@ 2 a
Pkl 8 2$8$3Bahir ayi P/1$33r/>S 3
@ayi .eninal dunia8
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LAPORAN 9 518-12-20146
18 <A, <n?r.ed nsent, ateter dan in?us terpasan, >@ pr?ilaksis8
28 Pasien terlentan dala. penaruh anestesi S>@
$8 "esin?eksi pada lapanan perasi denan pDidn idin 13: dan diperse.pit denan duk steril8
'8 <nsisi kulit ad.en .idline I 13 ., diperdala. lapis de.i lapis sa.pai
aDu. ad.en teruka8
58 Pada eksplrasi dite.ukan # - *terus raDida ater.
- >P "/S dn
48 "iputuskan dilakukan# BSS
- <nsisi S@R I 2 . diperlear8
- Selaput ketuan dipeahkan ernih
- 2$8$3 ita ayi dilahirkan8 @ayi pere.puan, tidak .enanis, @@#1$33
r, >S 3
anus (+) kelainan knenital (-)- Plasenta dilahirkan denan tarikan rinan8
- S@R diahit sudut F diahit 2 lapis8
- aDu. ad.en diui denan PJ I 533
- Bapanan perasi ditutup lapis de.i lapis
- eDaluasi perdarahan sekitar 233
- p selesai12/17/15
Follo u& Post *
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Follo u& Post *
), 18-12-2014 %$"$ 01.*0
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<n8 e?tria6ne 2 6 1
<n8 >lina.in $ 61
<n8 etrla $ 6 1
<n8 Ranitidin 2 6 1
ek "B pst p
l b
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 1$%12%2014 (&ost o&)
Pemeri"saa! asi a$a!
; 48% /dl
Beuksit 1%84 Riu/ul
he.atkrit 218$ 0l:
tr.sit 24& Riu/ul
M0 77 l
M; 2'87 P
M; $18& :
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N # %2 6/.! # $5,%H
S! # !*E2pst
kntraksi uterus (+) aik
0/0 # ?l6 (-)
>) P$>3 pst S ai ;>P e uria PP
P) P) Se.entara Puasa
<n?8 RB#"5 2#2 /2' a.
"rip 6ytsin 2 a.p dala. 533 RB s/d 12 a. pst p<n8 e?tria6ne 2 6 1
<n8 >lina.in $ 61
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<n8 Ranitidin 2 6 1
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7/23/2019 LAPAG 17-18 Des 14
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1. Ny. ii Ra$#ah/ 2: h/A!a" hi#$%& 0
@R 1-12-2014/04.1: '()A
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= & =e!?a!,-"e!?a!,
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R/ Per"ai!a! & 1;/ 1ah$!
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& 28
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S!* =S '-5-4 n8>ne.is(-/-)
!" # 123/%3 N # %46/.nt RR# 1&6/.nt !# $4,13
S! !* # $' . "# 12-12-1$ 1$-12-12
!@ #1433 ra./1433 ra. ;is# (+)
Betak # Sunsan presentasi kaki/presentasi kepala
0! # 9 5/et (-)/53:/kaki
"iansa #
G1P0A0 **/*4 @i!,,$ G// Les$ Pres"a"i/"e% (!%ar$ =aa ( 3ase A"i )J 100 ra./1433 ra.
Plannin #
>tas perti.anan#
18 =e.eli
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$8 <npartu kala < ase akti?
'8 it S atas <*"
58 nsul dr8 Sp8=
7/23/2019 LAPAG 17-18 Des 14
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1. Ny. @ar#ia!a/ 44 h/A!a" hi#$%& 12
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MRS 18-12-2014/ 04.*0 '()A
G1*P12A0 *2 mi!,,$ J)( %resi! =PD AP e.? PP)
* # Perdarahan
RPS# Pasien .erupakan ruukan dari idan denan uria plasenta preDia8 Perdarahan per Daina. seak dini hari pukul 32815 C<!>8 Pasien ua .eneluhkan keluar air-air seak puk
ul 2$8$38 Pasien .erasa ha.il & ulan8
RP" # ;t (-), "M(-), >s.a (-)
RP # ;t (-), "M(-), >s.a (-)
R/ Perkainan # 16/2% th
R/haid# .enarhe #1$ tahun la.a# 7 hari
siklus# 27 hari
R/ ntrasepsi # -
R/ stetr i # 18 1&%4/ ater./ SPt-@/ P/ $533 r/ hidup
28 1&%%/ ater./ SPt-@/ B/ '533 r/ hidup
$8 1&&3/ ater./ SPt-@/ B/ '333 r/ hidup
'8 1&&2/ ater./ SPt-@/ P/ $533 r/ hidup
58 1&&'/ ater./ SPt-@/ B/ $$33 r/ hidup
48 1&&4/ ater./ SPt-@/ B/ $333 r/ hidup
78 1&&%/ ater./ SPt-@/ P/ '333 r/ hidup
%8 2333/ ater./ SPt-@/ B/ $333 r/ hidup
&8 2332/ ater./ SPt-@/ P/ $333 r/ hidup
138 233'/ ater./ SPt-@/ P/ $533 r/ hidup
118 2334/ ater./ SPt-@/ B/ $333 r/ hidup128 233%/ ater./ SPt-@/ P/ 5333 r/ hidup
;P;! # Bupa
7/23/2019 LAPAG 17-18 Des 14
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;P;! # Bupa
!P # sde
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P6 Pro 9io 9 @O' =(> =e$ar,a
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!inekologi
(2)
12/17/15
1. Ny N$r Azizah/ 17 ah$!
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1. Ny N$r Azizah/ 17 ah$!
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=esa#ara! & 9@ G9 4-:- A(9D 5-6
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Ab# & $!#$asi 56
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!AS"# #AB 1$%12%2&1'Pemeri"saa!
asi
a$a!
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tr.sit $'2 Riu/ul
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P! 13,' "etik
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@iliruin "irek 3,35 M/dl
@iliruin <ndirek 3,2& M/dl
>lu.in $,& /dl
G(NJAL
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reatinin 3,& M/dl
>sa. *rat 14,5 M/dl
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Dia,!osa & $s%. @yoma $eri ## $mor soi# o<ari$m
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on"isi terak#ir (1$%12%2014 &kl 06'00)
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7
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$s%. 9a O<ari$m
*# @enlan diperut aah
S# Pasien .erupakan ruukan dari RS @atuliin denan pasien .eneluhkan
enlan di perut aah seak $ tahun yan lalu8 @enlan se.akin la.a se.ak
in esar8 Pasien ua .eneluhkan nyeri pada enlan terseut saat sedan
.enstruasi8 Pasien ua .eneluhkan darah .enstruasi dapat disertai u.pa
lan-u.palan8 Pasien .e.iliki riayat .la hidatidsa 1$ tahun yan lalu8
RP" # ;t (+), "M(-), >s.a (+), Mla ;idatidsa (+)
RP # ;t (+), "M(-), >s.a (+)
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R/ ntrasepsi # Pil @
R/ stetri # 18 1&&3/preter./P/dkter/hidup
R/ ;aid # .enarhe K 1$ tahun
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R/ ;aid # .enarhe 1$ tahun
la.a K 7-13 hari
siklus K 2% hari
haid terakhir K <u lupa
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Hasil Lab 1$%12%2014
Pemeri"saa! asi a$a!
b 10 ,/#
Le$"osi 7.8 Rib$/$
hemao"ri *0.: oC
rombosi 414 Rib$/$
@9 81. 3
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.! ( ,.D +anbu )
Massa se.islid di in?erir Desia urinaria yan
.eluas sa.pai ke ad.en tenah8
"" # Persisten tr?lastik neplasia
Massa Dariu.
12/17/15
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ndisi !erakhir
1%-12-231' pukul 34833
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N# %% 6/.
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S<S> 0
($ pasien)
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1. Ny. aizah/ *8 h/A!a" hi#$%& 1
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RP= & 5-6E D@5-6E Asma 5-6
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2. Abor$s
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S!* =S ' 5 4 n8>ne.is( / )
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Sikap #serDasi tanda-tanda inpartu8
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 1$%12%2014
Pemeri"saa! asi a$a!
b 12.+ ,/#
Le$"osi 8 Rib$/$
hemao"ri *8 oC
rombosi 241 Rib$/$
@9 87 3
@92+.:
P,@99 **.+ C
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on"isi +erak#ir
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Pukul 348$3
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>) G*P1A1 40/41 @i!,,$ a" i!%ar$ =PD J)( %re
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2 Ny Rahmi!i/ *0 h/A!a" hi#$%& 1
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2. Ny. Rahmi!i/ *0 h/A!a" hi#$%& 1
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J 1:00,
* # kenan kenan
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ak pukul 3&833 C<!> (2 a. SMRS)8 eluar lendir darah (+), keluar air-air (-)8 Pasien ua .ene
luhkan sesak8
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R/haid# .enarhe # 1' tahun
la.a # 7 hari
siklus # !idak teratur
R/ ntrasepsi # Pil @ 5 tahun y lalu stp
;P;! #
!P #
R/ stetri # 18 233'/laki-laki/Spt8@/$333r/@PS/ater./hidup
28 ;a.il ini8
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# S1S2 tunal P # Rh +/+ Ch -/-
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%eriroi# >#em Par$ )J 1:00,
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ek la lenkap, ?aal tirid
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urse.ide 2 a.p iD
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Hasil Lab 16/12/14
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
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;e.lin 128$ /dl
Beuksit 118' Riu/ul
Aritrsit 583$ uta/ul
;e.atkrit $78& 0l:
!r.sit 1'% Riu/ul
R"C-0 1782 :
M0, M;, M;
M0 7585 l
M; 2'8' P
M; $28' :
12/17/15
Hasil Lab 16/12/14
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<;asil P! 128$ /dl
<NR 118' Riu/ul
ntrl Nr.al P! 583$ uta/ul
;asil >P!! $78& 0l:
ntrl Nr.al >P!! 1'% Riu/ul
=ula "arah Seaktu 1782 :
B"; 5'7 l
S=! 2% P
S=P! 4 :
hlesterl !tal 11% M/dl
>lu.in $8$ /dl
12/17/15
Hasil Lab 16/12/14
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 16/12/14Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<*reu. 22 /dl
reatinin 38% Riu/ul
>sa. *rat &8% uta/ul
Natriu. 1'18% 0l:
aliu. $8' Riu/ul
hlrida 11284 :
12/17/15
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7/23/2019 LAPAG 17-18 Des 14
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S! !* # 2' . "# 12-12-12
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0! # 9 tidak dilakukan karena ta.pak perdarahan .ene
rin
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Plannin#
NS!
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Pr peraatan knserDati? #
<n8 "e6a.ethasn 265 . selan 12 a. sela.a 262' a. untuk pe.atanan paru
Pr *S= M untuk eDaluasi letak plasenta
@ila ?luksus akti? pr it S
12/17/15
Hasil Lab 16%12%2014
7/23/2019 LAPAG 17-18 Des 14
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Hasil Lab 16 12 2014
Pemeri"saa! asi a$a!
; 1387 /dl
Beuksit 1387 Riu/ul
he.atkrit $18& 0l:
tr.sit $1' Riu/ul
M0 77 l
M; 2587 P
M; $$85 :
7/23/2019 LAPAG 17-18 Des 14
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12/17/15
on"isi +erak#ir
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), 18-12-2014 %$"$ 0.00
S) Perdarahan (+) Nyeri (+)
) S!* # >(+) <" (-)
=S# '-5-4!" # 113/%3 ..; RR # 1% 6/.
N # %2 6/.! # $5,%H
S! # !*E2pst
kntraksi uterus (+) aik
0/0 # ?l6 (-)
>) P$>3 pst S ai ;>P e uria PP
P) P) Se.entara Puasa
<n?8 RB#"5 2#2 /2' a.
"rip 6ytsin 2 a.p dala. 533 RB s/d 12 a. pst p
<n8 e?tria6ne 2 6 1
<n8 >lina.in $ 61
<n8 etrla $ 6 1
<n8 Ranitidin 2 6 1
ek "B pst p
M8 */!0/l6
Pst trans?usi C@ 2 kl?
7/23/2019 LAPAG 17-18 Des 14
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P>S<AN MAN<N==>B
(1 pasien)
12/17/15
1. Ny. Norham#a!ah/ 47 ah$! @R 1-12-2014/ 12.*0 '()A
7/23/2019 LAPAG 17-18 Des 14
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= & Per$ membesar
RP & Pasie! mer$%a"a! r$j$"a! #ari %oi "a!#$!,a! #e!,a! #ia,!osa 9a o<ari$m. Pasie! me!,a"$ %er$!ya membesar seja" 1 b$a!
ya!, a$ #a! #iraa #i R $!o". Pasie! j$,a me!,e$h !yeri #i
ba,ia! %er$E ba#a! emas #a! i#a" !as$ ma"a!.
RPD & ) 5-6 D@ 5-6 Asma 5-6 Aer,i 5-6 (= 5-6
RP= & ) 5-6 D@ 5-6 Asma 5-6 Aer,i 5-6
R/ ai# & @e!ar?he & 1* ah$!
Lama & : hari
7/23/2019 LAPAG 17-18 Des 14
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i"$s & i#a" era$r
R/ Per"ai!a! & 1;
R/ =o!rase%si & -
R/ Obseri &
1. + b$a!/R/%-=/a"i-a"i/1++*/i#$%
2. + b$a!/R/%-=/%erem%$a!/2008/hi#$%
O6 =& Lemah
=esa#ara!& =om%os @e!is
G9 & 4-:-
)D & 140/+0mm, RR & 24;/m
N & 80;/m ) & *E0F9
a$s Ge!erais
=e%aa/Leher& =o!j. A!emis 5/6 s"era i"eri" 5/6
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% j 5 6 5 6
)hora; & i#a" simerisE s$ara %ar$ #a#a "a!a! emah
Rh5-/-6E ' 5-/-6
Ab#ome! & ( & am%a" ?emb$!,
A& 56 N
P& )im%a!i
P& Nyeri e"a! 56
>"sermias & A"ra ha!,a
>#em
Parese
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- -
- -
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Status Obstetri:
VT :
7/23/2019 LAPAG 17-18 Des 14
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VT :
V/V : Fluxus (-)/ flour (-)
P : sde
CU
AP D/S :
CD : tak A :Ca ovariu !ost o! " as#ites " $idro%efrosis Dextra " efusi !leura
!) Perbaika% &U
'O-VP *o%t+e% t$orax
Follo .&
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Follo .&1 Desember 2014
2*.00 iaS) Sesak (+) le.ah (+)
) !" # 133/73..;RR # 2'6/.
N # 1236/. ! # $5,%H
nuntiDa ane.is (+/+) >kral dinin (+/+)
>) 9a o<ari$m %os o% as?ies 5ri,h hi#ro!erosis De;ra6 e$si %e$ra
P) Pr peraikan * R/ @N-<0P
2 $-5 lp.
Hasil Pemeriksaan Laboraturium1 D b 2014
7/23/2019 LAPAG 17-18 Des 14
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1 Desember 2014Pemeri"saa! asi Niai R$j$"a!
;AM>!B=<;e.lin &82 /dl
Beuksit 1$8$ Riu/ul
Aritrsit $83% uta/ul
;e.atkrit 2&81 0l:
!r.sit 22& Riu/ul
R"C-0 1&84 :
M0, M;, M;
M0 &'87 l
M; 2&8% P
M; 2%81 :
Hasil Pemeriksaan Laboraturium
1 D b 2014
7/23/2019 LAPAG 17-18 Des 14
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1 Desember 2014Pemeri"saa! asi Niai R$j$"a!
<M<>=*B> ">R>;
=luksa "arahSeaktu
%1 M/dl
;>!<
S=! 42 u/l
S=P! %2 u/l
G(NJAL
*reu. 154 M/dB
reatinin $8$ M/dB
17 "ese.er 231' pkl8 11833
S) sesak (+) le.ah
7/23/2019 LAPAG 17-18 Des 14
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S) sesak (+) le.ah
)!" # %3/53..; RR # 2%6/.
N # 1156/. ! # $7,&,4H
!hK Desikular (-/+)
>) a Dariu. pst p + asites (riht hidrne?rsis "e6tra) + e?usi pleura
p) dr Ry Sp8=
>dDie# ksienasi sunkup + paru it
1$833 dr8 risna/dr8 Paul Sp8P
>dDie# a eDakuasi pleura ika !"L 133 (sistle)
*ntuk naikkan sistle ladin NS ?lash / 15 .enit, drip Dasn (nrepine?rin 1 a.p) dala. 133 NS .ikrdrip 7tp.
1'833
Bapr tutup aa dr8 Ry Sp8=
>dDie# setuu tindakan residen paru +lapr hasil la
15833Bapr uka aa dr8 Ry Sp8= (lapr hasil la)
>dDie# terapi lanutkan
17 "ese.er 231' pkl8 11833
S) sesak (+) le.ah
7/23/2019 LAPAG 17-18 Des 14
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S) sesak (+) le.ah
)!" # %3/53..; RR # 2%6/.
N # 1156/. ! # $7,&,4H
!hK Desikular (-/+)
>) a Dariu. pst p + asites (riht hidrne?rsis "e6tra) + e?usi pleura
p) dr Ry Sp8=
>dDie# ksienasi sunkup + paru it
1$833 dr8 risna/dr8 Paul Sp8P
>dDie# a eDakuasi pleura ika !"L 133 (sistle)
*ntuk naikkan sistle ladin NS ?lash / 15 .enit, drip Dasn (nrepine?rin 1 a.p) dala. 133 NS .ikrdrip 7tp.
1'833
Bapr tutup aa dr8 Ry Sp8=
>dDie# setuu tindakan residen paru +lapr hasil la
15833Bapr uka aa dr8 Ry Sp8= (lapr hasil la)
>dDie# terapi lanutkan
158$3
!"K%3/43 NK113 le.ah
7/23/2019 LAPAG 17-18 Des 14
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14833
!"K%3/43 NK133 le.ah
14815
!"K53/23 NK nadi tidak teraa
14825
!"K -
NK tidak teraa
>kral dinin, .ata .idriasis talS dinyatakan .eninal dihadapan keluara, "M, dan peraat
12/17/15
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+K Berslin Jefry Albari TribowoM. NasrullahDevita Wijayanti
Yulia MargarethRizki Agalia !orayya
R,ng Nis Miranti Rahi A"rillia#n$ah Dwitari %hairunnisa !a"utri
#$aa Asi$o Rohana ! Alvita &ani Yulita
&oliklinik Rasdita Nurhidayati Indah Sarweny Muhammad Akbar AnifaEvi Febrina HazahBagas i!!iant"