Download - morning report obsgyn
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JAGA MALAM3 Mei 2015
DM Jaga : Cikal, Frizal, Emika, Sukma
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• Pasien VK :Pasien baru : 1Pasien lama : -
• Persalinan fisiologis : -• Persalinan patologis : -
• Jumlah sisa pasien VK : 1
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Pasien Baru VK
1. Ny. Dini / 25 thn MRS tgl 4/5/15 pkl 02.10
KU: keluar darah melalui vagina
KT : Lemas, nyeri di vaginaRPS : Pasien datang atas rujukan dari BP Anugrah dengan
keluhan keluar darah melalui vagina setelah 3 jam melahirkan secara spontan. Pasien juga mengaku badan terasa lemas dan nyeri di sekitar vagina. Sesak (-), demam (-), mual (-), muntah (-).
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• Riw HaidHPHT : 25/09/2014 TP : 1/06/2015Menarche : 12 thn
• Riw Pernikahan: Menikah 1x tahun 2014• Riw KB: -• Riw ANC: Pasien kontrol di bidan 8x• Riw persalinan: -
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• RPD: HT(-), DM(-), asma(-), PJK(-),alergi obat (-).
• RPK : DM (-), asma(-), PJK(-), gemeli(-)
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KU : BaikKesadaran/ GCS : CM / 4-5-6TB: 156 cmBB: 64kg , BB sebelum = 52 kgT : 90/60 mmHg RR : 20 x/mntN: 100x/mnt, reg T : 36,2°C Axiller
St. GeneralKepala: A(+)/I(-)/C(-)/D(-)Leher: Pembesaran KGB (-), pembesaran tiroid (-)
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Thorax:
Pulmo: Vesikuler/vesikuler; Rh -/- ; Wh -/-
Cor : S1/S2 tunggal reg; Murmur (-) ; Gallop (-)
Abdomen:
Cembung simetris, Linea nigra (+) striae lividum (-)
Extremitas:
AH +/+ ; Edema -/-
+/+ -/-
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St. ObstetriAbdomen:Cembung, linea nigra (+), luka bekas operasi (-)
TFU : setinggi pusatKontraksi uterus (+)V/V :
Flx (+)/flr (-)jahitan di dinding lateral vagina (+), rembesan (+)Vulva (S) Hematom (+)
Portio posisi anterior, intak,laserasi (-)SAR intakSBR intakEvakuasi clot 300 cc
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Lab tanggal 4/5/2015 pk 00.15• WBC : 27.000• RBC : 3,40 x 10⁶• HB : 10 g/dl• Hct : 28,9 %• PLT : 249.000• Gluc : 134,2• Na : 3,61• Cl : 105,8
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Assessment:
P0101 Hemmorage Post Partum + Hematom Vulva + Ruptur Perineum
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Planning:
• O2 masker• Inf HESS RL:D5 1:1/24 jam• Rehecting laserasi dinding lateral vagina• Inj Metegrin 1 amp• Drip Oxytocin 2 amp/12 jam• Amox 3x500 mg• Ceftriaxone Profilaksis 2x1g• Monitoring keluhan/VS
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FOLLOW UP05:00S : Nyeri di sekitar vaginaO : KU: CMA/I/C/D (+)/(-)/(-)/(-)TD = 100/70 mmHg, t = 36,5o C,
N= 95 x/menit, RR = 20 x/menitKepala: dbnLeher: dbnThorax: dbnEkst.: dbn
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Status obs:•TFU pusat•Kontraksi uterus (+)•V/V :
Flx (+)/flr (-)jahitan di dinding lateral vagina (+), rembesan (-)Vulva (S) Hematom (+)
•VT:Portio intakSAR intakSBR intak
•Perdarahan 50cc
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• A : P0101 Post Hecting Perineum + Hematom Vulva
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Planning:
• Aff infus• Amox 3x500 mg• As mef 3x500 mg• SF 1X1• Monitoring keluhan/VS
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TERIMA KASIH