mr 26 august

Upload: retna-gumilang

Post on 24-Feb-2018

215 views

Category:

Documents


0 download

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>