mr 26 august
TRANSCRIPT
-
7/24/2019 Mr 26 August
1/11
MORNING REPORT DMFRIDAY , 18TH DECEMBER 2015
by :
Andri H. Utami
Erwin K.
Retna Gumilang
Yuliza Rahmayanti
LABORATORIUM / SMF OBSTETRIC GYNECOLOGYFACULTY OF MEDICINE, BRAWIJAYA UNIVERSITY
DR.SAIFUL ANWAR HOSPITAL MALANG
-
7/24/2019 Mr 26 August
2/11
IDENTITAS PASIEN No Register R. Inap : 1536536
No Register R. Jalan : 11267581 Nama : Mrs. J
Umur : 30 yo
e!er"aan : mar!eting perusa#aan
$uami : Mr.%
Umur : 32 yo
e!er"aan : mar!eting &iro "asa umro#
Meni!a# : 2 ' 1 t#
%na! : (ari perni!a#an pertama
%na! 1 ) 13 t# * 2 ) 8 t#*+ari perni!a#an !e(ua
%na! 1 ) #amil saat ini %lamat : Jaga III mina#asa utara
+atang pa(a : +esem&er, 15t# 2015 pu!ul 20.55 am
-
7/24/2019 Mr 26 August
3/11
SUBJECTIVEasien (iru"u! ole# &i(an (engan -30202%000 / !etu&an pea# (ini, usia !e#amilan
&elum u!up 336 4!s $
Keluhan utama : kenceng-kenceng
15-12-2015
%t 13.00 4i&
asien mengelu# kenceng-kencengpasien tetap (iruma#
%t 18.00
asien merasa!an !eluar cairan darah dan lendir
%t 1.00 4i&
pasien merasa!an gera!an (an !eneng!eneng sema!in sering pasien pergi !e &i(an
(iperi!sa 9 ; m, !etu&an pea# spontan usia !e#amilan &elum u!up
%t 20.30 4i&
asien ti&a (i R$$% (engan pem&u!aan leng!ap 10 m
(iperi!sa 9 ; 10m, eIII
Ri4ayat !eputi#an /2 minggu yang lalu, &elum &eru&a#
Ri4ayat !oitus
Ri4ayat anyanganyangen
-
7/24/2019 Mr 26 August
4/11
Riwayat darah tinggi
DM
Riwayat kehamilan ebelumnya :
! kali melahirkan n"rmal# uia kehamilan $rematur % !& minggu '
Riwayat (renatal :
A)*: K"ntr"l ke $ukema !+K"ntr"l ke bidan ,+ %terakhir k"ntr"l ,-,!!/,0'
H(H1 ,2/-!/,0
1akiran kelahiran : !//,!/,3
K"ntrae$i elama hamil
Kegagalan K4
Riwayat $eralinan ekarang :
,0,!!/,0 5am ,2.// wib hi dimulai
,&.// wib keluar darah dan lendir
-
7/24/2019 Mr 26 August
5/11
OBJECTIVES?U : ai!, @M
: 160m : 73 !g
: 12080 N : 88'm RR: 20 'm
%' : 36,5A@ ret : 36,5A@
? : an , it #o : $1$2 single, murmur
p r# B B 4# B B
%&( : CU : 25 m, leta! &u"ur U
+JJ : 132 &pm (oppler
>is / !uat, 3 !ali10 menit, tiap #is 5 (eti!
J : 2170 gram CU11'155
-
7/24/2019 Mr 26 August
6/11
OBJECTIVES
9 :
D 10 m, eo(ge III, selaput !etu&an
"erni#, presentasi !epala, (enominator u&unu&un
!eil "am 12, pelEi measurement : (alam &atasnormal
-
7/24/2019 Mr 26 August
7/11
LABORATORIUM> : 12,50 g(l
eu!osit : 13.350 u
@@ : 00,180,11,87,7
U : rotein /2
eu!osit /1
+ara# /3
-
7/24/2019 Mr 26 August
8/11
ASSESSMENT
G3P0202Ab000 parturien 34-36 wk !"#$ Partu prematurume
$ Kala %%
-
7/24/2019 Mr 26 August
9/11
PLANNING
(D+ : 6(1+ : 7bu di$im$in untuk menge5an 7bu $r"ek$ektati8e $er8agina
(M": 9ber8ai 8ital ign# keluhan# hi# D#
kemungkinan $endarahan
(ed : K7Ein;"rmed
-
7/24/2019 Mr 26 August
10/11
OUTCOME B!" #$"%#$" #&"'
D()(*+(' 15&2015 - 21.20 WIB
220 '/ *
(#"33 $43(3"# %6
A-' )4'( 7/
-
7/24/2019 Mr 26 August
11/11
1ER7MA KA=7H>