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LAPORAN JAGA

Sabtu 26 Desember 2015 – Jum’at 1 Januari 2016

Konsulen K !

Dr" #au$i% Rama&'an (asibuan) S*"OG

Dr" Dian Di$la Riani) S*"OG

Pen+a,i!

Dr" Set+o #e-u' .alu+o

Jessi/a Gaenti) S"Ke&

Niar Dul%arnain R) S"Ke&

7/25/2019 lapjak_2


AG3AN4DPAR#N OS##R3 DAN G3NKOLOG3

7AK8L#AS KDOK#RAN DAN 3L8 KS(A#AN 8N3RS3#AS NGK8L8

R8A( SAK3# 88 DARA( DR" " 98N8S NGK8L8

2016

7/25/2019 lapjak_2


LAPORAN JAGA

Sabtu 26 Desember 2015 s"&" Jum’at 1 Januari 2016

Konsulen VK :

Dr. Taufiq Ramadhan Hasibuan, Sp.OG

Dr. Dian Difla Riani, Sp.OG

Obstetri 7isiolo-is 0 Pasien

Obstetri Patolo-is Pasien

Gineolo-i 2 Pasien

Onolo-i 0 Pasien

enin--al 1 Pasien

#otal Pasien

OS##R3 PA#OLOG3S

1" 2: Desember 2015

Puul 0;"15 .3

Konser<ati$

N+" (RL4=0 t'44ND>4JS?4#7

TD: 110!0 mmH"

#: $! %meni&

RR: '(%meni&

T: )*,+0

- : Tifu& 1' pusa& /

proessus %iphoideus '$

m2, meman3an", pu4a,

pres4ep, His 1%105106,

D77 1)!%m

-D :por&io luna4, pos&erior,

eff '+8, 9 4unup, 4epala,

H1, 4e&uban 2, penun3u4

belum dapa& dinilai

H;: <,' "d

D G)-'=0 Hamil '! min""u den"an -->, 7TH pres4ep

? Konser@a&if

Obser@asi His, TV>, D77

e4 DR

>VAD R %% "&&meni&

#ifedipin &ab (%10 m" p.o2

De%ame&hason 1%1' m" i.@2

efo&a%im '%1 " i.@2

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HT: '$ 8

eu4o : 1'.000 mm)

Trombo :)*'.000 selmm)

7ollo@ 8*

2 Desember 2015

Puul 0:"00 .3

His : B

S: B

O:KC: ;ai4, Kes: ?

TD: 110!0 mmH" #: !( %m

-: '0 %m

S: )*,+ o

=: G)-'=0 Hamil )! min""u 7TH pres4ep

-: B

Keadaan umum pasien bai4, pasien boleh pulan"

2" 2 Desember 2015

Puul 1B"=0 .3

SS#P a"i an 'i&ramnion

N+" SR3426t'4 JS?4ND>4G8(4#7

TD: 100!0 mmH"

#: !! %meni&

-: '( %meni&

S: )*,+0

TAC: )' m

His: B2

D77 : 1)$ %meni&

VT : -or&io luna4, pos&erior,9 4unup,

eff '+8, 4e&uban B2,

4epala, H>, penun3u4 belum

dapa& dinilai

Hb: 10,+ "rd

H&: )1 8

eu4osi&: 10.*00 mm)

Trombosi&: '(+.000mm)

D G'-1=0 Hamil )$ min""u belum inpar&u den"an K-D

+ hari an hidramnion 7TH -res4ep

? Obser@asi TV>, KC, D77

>VAD R "&& %%m

e4 DR, Crossmacth

>n3. efo&a%im '%1 "

Ka&e&er mene&ap

CSG:B Tampa4 7TH presen&asi 4epala

B ;iome&ri 3anin

;-D: <0 mm sesuai )$ min""u

B -lasen&a implemen&asi di orpus an&erior

B Ke&uban : =A> 0,1 1,1 1,<

0,$ 0

R Terminasi perabdominam

Puul 15"00 @ib apor dr. Taufi4 Ramadhan, Sp.OG Se&u3u &erminasi

perabdominam

Puul 15"=0 .3 ahir neona&us hidup, E , ;; '$00 "r, -; (< m, KD

)))' m, =S !< AT=G=Puul 15"=5 .3 -lasen&a lahir len"4ap

7ollo@ 8* S : Keluhan : B

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1 Januari 2016

Puul 0:"00 .3

Hb: 11 "rd

O: KC: Sedan"

Sens: ?

TD: 110!0 mmH"

#: $+ %meni&

RR: '' %meni&

T: )*0

=: -'=) pos& STT- a.i an hidramnion, ahir neona&us

hidup, E , ;; '$00 "r, -; (< m, =S !<

- : efadro%il &able& '%+00 m"

=sam ?efenama& &able& )%+00 m"


=" 2 Desember 2015

Puul 15"=0 .3

Kuretase a"i sisa *lasenta

N+" 9N34=1t'n4 JS?4ND>4G8( #7

TD: 1)0$0 mmH"

#: !0 %m

-: 1!%m

S: )*,+o

Hb: $.$ "rd

H&: ')8

eu4osi&: '$.000 mm)

Trombosi&: (('.000 mm)

D -)=0 pos& par&us spon&an $ 3am diluar2 den"an H--

dini e. sisa plasen&a anemia bera&

? Obser@asi TV> dan perdarahan

>VAD R "&& %%m

efo&a%im '%1 "

e4 DR, Crossmacth

R Kure&ase

Puul 16"00 .3 Dila4u4an 4ure&ase

Didapa&4an darah dan 3arin"an F 1+0 7ollo@ 8*

=1 Desember 2015

Puul 0:"00 .3

Hb : +,( "rd

S : Keluhan : B

O: KC: sedan", Sens: ?

TD: 110$0 mmH"

#: $+ %meni&

-: '0 %meni&

S: )*,(0

=: -os& Kure&ase a.i Sisa -lasen&a

- : >VAD R "&& %%m efadro%il '%+00 m"

=sam mefenama& )%+00 m"

Transfusi sd Hb ! m"dl

-asien pulan" a&as permin&aan sendiri

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B" =0 Desember 2015

Puul 16"00 .3

SS#P a"i Oli-o'i&ramnion

N+" NLN4=1t'4JS?4ND>4G8(4 #7

TD: 1'0<0 mmH"

#: !! %m

-: '' %m

S: )*,'0

Hb: 10,! "dl

H&: )'8

eu4osi&: 10.*00mm)

Trombosi&: '*+.000mm)

TAC )' m

D77 1)! %m

His B2

VT: -or&io luna4, pos&erior,

9 1 m, 4e&uban B2,

-resen&asi 4epala, penun3u4

belum dapa& dinilai

D G)-'=0 Hamil )+ min""u belum inpar&u den"an K-D

' hari an" lalu 7TH pres4ep

? Obser@asi TV>, D77, H>S >VAD R "&& %%m

e4 DR

>n3. efo&a%im ' % 1 "

>n3. De%ame&ason 1%1' m"

#ifedipin (%10 m"

R Terminasi perabdominam

1 Januari 2016

Puul 10"00 .3

ahir neona&us hidup, I, ;; "r, -; m, =S AT=G=

Puul 10"05 .3 -lasen&a lahir len"4ap

5" =0 Desember 2015

16"15 @ib

SS#P a"i (AP e"/ Plasenta *re<ia mar-inalis

N+" RNK425t'4 JS?4ND>4G8(4 #7TD: 1'0!0 mmH"

#: !0 %meni&

-: '' %meni&

S:)*,'J

D77: 1+! %meni&

TAC: '( m

Hb: 11,( "rd

H&: )' 8

>nspe4ulo:

-or&io li@idae, OC &erbu4a,

&ampa4 3arin"an plasen&a

dimuara OC>, fluor B2,

flu%us 2 darah &ida4 a4&if

D G'-1=0 hamil )) min""u belum inpar&u den"an H=-

e. plasen&a pre@ia mar"inalis den"an perdarahan

berulan" 7TH pres4ep

? Obser@asi TV>, His, perdarahan

>VAD R "&& LLmeni&

e4 DR, Crossmatch

>n3. efo&a%ime '%1 "r


#ifedipin (%10 m"

R Terminasi -erabdominam

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=1 Desember 2015

Puul 11"15 .3

ahir neona&us hidup, I, ;; 1$00 "r, -; (0 m, KD

)1'! =S $! AT=G=

Puul 11"20 .3 -lasen&a lahir len"4ap7ollo@ 8*

1 Januari 2015

Puul 06"00 .3

S: Keluhan : B

O: s&. presen&

KC: Sedan", Kes: ? TD: 110!0 mmH"

#: $$ %m

-: '' %m

S: )*,' 0

=: -'=0 Hamil )) min""u belum inpar&u den"an den"an

H=- e. plasen&a pre@ia mar"inalis den"an perdarahan

berulan" 7TH pres4ep

-: Obser@asi TV>, D77, &anda inpar&u

>VAD R "&& %%m

>n3. efo&a%im ' % 1 "


#ifedipin (%10 m"Puul 0;"=0 .3 -asien pulan" a&as permin&aan sendiri

6" =0 Desember 2015

Pl 20"B= .3

R4 s*etati$

N+" L3L4=;t'n4 ND>4JS?4G8(4#7

TD : '101+0 mmH"

# : 110%mn&,

RR : '0 %m

T: )$,'0

Hb: 1(,$ "rdl

H&: ('8

eu: !.!00 mm)

Tromb: 1*1.000 selmm)

SGOT: '! ul

SG-T: '$ ul

-ro&ein urin :

DH : <+ >C

D G)-'=0 hamil )' min""u belum inpar&u den"an -;

7TH -res4ep

? 4spe4&a&if

B S&abilisasi )B* 3am

B Obs. TV>, D77

B e4 DR, CR, KD, pro&ein urine

B >VAD R "&& %% meni&

B >n3. ?"SO( (08 ( "r bo4a >?, ( "r bo4i >?

selan3u&na ( "r bo4a a&au bo4i >? se&iap * 3am

B #ifedipine )%10 m" &ab p.o2

B De%ame&hason 1% 1' m" i.@2

B Ka&e&er mene&ap, a&a& >O

7ollo@ u*

2 Januari 2015

Pl 0:"00 .3

S : Keluhan B

O: KC: bai4

TD : 1(0<0 mmH"

# : !'%mn&

RR :'0%mn&

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T: )*,!0

=: D G)-'=0 hamil )' min""u belum inpar&u den"an

-; 7TH -res4ep

-: >VAD R "&& %% meni&

#ifedipine )%10 m" &ab p.o2

-asien masih diraMa&

:" =1 Desember 2015

Puul 05"B= .3

S*ontan ra/'t

N+" DL421 t'4ND>4JS?4G8(4#7

TD: 1'0$0 mmH"

# : !0%meni&

- : '' %meni&

S : )$o

H;: <,+ "d

HT '$ 8

eu4o : 1(.(00 mm)

Tromb : )0<.000 selmm)

- : Tifu& ) 3bp% )0 m2,

meman3an", bo4on", His

)%105(06, D77 1(!%m

-D : por&io luna4, an&erior,

eff 1008, 9 ! m, 4e&uban

2, sa4rum 4anan depan

D G1-0=0 Hamil )$ min""u den"an 4ala > fase a4&if,

7TH -resbo

? Obser@asi D77, His, TV>

>VAD R "&& %%m

e4 DR

@aluasi 4ema3uan persalinan den"an par&o"raf NHO

modifi4asi

R -ar&us per@a"inam

Puul 0:"50 .3

9 len"4ap

D77 : 1(+ %meni&

D G1-0=0 Hamil )$ min""u den"an 4ala >>, 7TH -resbo

? -impin persalinan

Puul 0;"10 .3 ahir neona&us hidup I, ;; '<00 "ram, -; (! m, =s

!< AT=G=Puul 0;"20 .3 -lasen&a lahir len"4apPuul 16"00 .3 -asien pulan" a&as permin&aan sendiri

;" =1 Desember 2015

Puul 0"00 .3

Kematian maternal

N+" AS41t'4 JS?4ND>4G8(4 DR

KC: Tampa4 sesa4 D G'-0=1 Hamil )) min""u inpar&u 4ala > fase a4&if

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Sens: ?

TD: 1'0!0 mmH"

#: <+ %meni&

-: )' %meni&

T: )*,)0

VT: -or&io luna4, medial,

eff !08, 9 ( m, 4e&uban

2, 4epala, penun3u4 CCK

7TH pres4ep den"an 4elainan 3an&un" 4on"eni&al

#H= >V

? Obs. TV>, H>S, D77

>VAD R "&& %meni& miro

O' + meni& sun"4up

e4 lab DR, Crossmacth

Konsul Sp.7p

R -ar&us per@a"inam a4selerasi persalinan den"an

drip o4si&osin

=4selerasi 4ala >> den"an forep e4s&ra4siKonsul spesialis 3an&un" dr. usuf ndan" Sp.7p

K Sindrome eisenmen"er

hoardio"rafi den"an CSG abdomen: VSD 9 1,' %1,* m

Saran: -erepa& persalinan

Hindari neri dan men"edan seMa4&u melahir4an

>n3. lasi4 ' amp

hoardio"rafi ulan"Puul 10"B0 .3 =pnea

TD: &a4 &eraba

#adi: &a4 &erabaPuul 10"B5 .3

TD &ida4 &eru4ur #adi &ida4 &eraba

Dila4u4an R7- +% si4lus &ida4 berespon

Hen&i napas 2Hen&i 3an&un" 2

-upil midriasis 2Puul 10"55 .3 Os dina&a4an menin""al dunia oleh do4&er, di hadapan

4eluar"a dan bidan.Puul 11"00 .3 Dila4u4an @aum permin&aan 4eluar"a2 lahir

neona&us menin""al, I, ;; 1+00 "r

Puul 11"05 .3 -lasen&a lahir len"4ap

G3NKOLOG3

1" 2; Desember 2015

Puul 02"00 .3

Kuretase a"i abortus inom*lit

N+" DS421 t'4JS?4ND>4G8(4#7

TD: 110$0

#: !0 %meni&

D =bor&us >n4ompli&

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-: '0%meni&

T: )*,* 0

H;: 10,< "rd

HT: )0 8

eu4o: <.100 mm)

Trombo: '1<.000 selmm)

-TT Tes& 2

? Obs TV>, -erdarahan

>VAD R %% "&&meni&

efo&a%ime '%1" p.@2

e4 DR, ?

R Kure&ase

2 Desember 2015

Puul 10"00 .3

Dila4u4an 4ure&ase dan didapa&4an darah dan 3arin"an

F1+07ollo@ u*

=0 Desember 2015

Puul 06"00 .3

Hb: 10,* "dl

S : Keluhan : B

O: KC: bai4

Sens: ?

TD: 110$0 mmH"

#: !! %meni&

-: '0 %meni&

T: )*,! 0

=: -os& 4ure&ase ai. abor&us in4ompli&

-: efadro%il &ab ' % +0 m" p.o2

=sam ?efenama& &ab ) % +00 m" p.o2


2" =0 Desember 2015Puul 10"00 .3

e&isinalisNn"DNA421t'4 JS?4ND>4G8(4 #7

TD: 1'0!0

#: !0 %meni&

RR: '0 %meni&

T: )*,+0

-- &es& 2

D G1-0=0 Hamil ! min""u den"an abor&us iminens

? Obs TV>, -erdarahan

>VAD R %% "&&meni&

"es& 1%(00 m"

e4 -- &es&

Puul 12"00 -asien pulan" a&as permin&aan sendiri

lapjak_2

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