MR Obgyn Adit Jess
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MORNING REPORT01 JUNI 2015
DOKTER MUDA JAGAAdit - jessica
PPDS JAGAdr.CEP/GOL/TIL/DOF/TAW
SUPERVISORdr. Eka Nasrur Sp.OG
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IGD :
Kamar BersalinPartus Fisiologis : Partus Patologis• Pervaginam : • Perabdominam : 4
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1
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IDENTITAS
• Register : 267563• Ny. N/ 24 th/ IRT• Tn. K/ wiraswasta• Menikah 1x/2 tahun• Alamat : lekok – bangil - Pasuruan• MRS : 30-7-15
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SUBYEKTIF
• Pasien rujukan dari PKM lekok. merasa hamil 9 bulan, kencang – kencang sejak tadi pagi, lendir +, darah -, pusing +, mata buram +, muntah -.
• Riw minum jamu beras kencur +, pijat 2x +.
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Subyektif • Riwayat persalinan yang lalu :
1. Keguguran usia kehamilan 3 bulan2. Hamil ini
• HPHT : 29- 10-14 (39-40 mgg)
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Obyektif KU : Baik, CMTD : 160/100mmHg, N: 106x/m, RR: 20x/mTax : 36,50 CK/L : An-/-, Ict-/-Th : C/ S1S2 tunggal, murmur-
P/ Rh≡│≡, Wh ≡│≡Ext: bawah oedem +/+
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Obyekyif
• Abd:• Tfu: 32cm
• Letak anak: membujur presentasi kepala
• BJA:145x/m• HIS: 10.3.30• TBJ: 3255gram
VT : • Ø 6cm, • eff 100%, • Hodge 2, • Ketuban +, jernih• Presentasi kepala,
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• NST
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Assesment
• G2P0000Ab100 part 39-40 minggu T/H• + kala 1 fase aktif• + AOD ec CPD • + PEB• + Impending eklamsi
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Planning • Diagnosa:
– Cek lab lengkap
• Terapi :• Terminasi dengan SC + IUD• Injeksi SM full dose lamjunt maintenance sampai dengan 24jam post OP• Persiapan OP :• Inj ampicilin 1 amp• Inj ranitidin 1 amp iv• Inj metildopa 1 amp• PO :• Nifedipin 3x10mg, metildopa 3x50mg
• P.monitoring: VS,keluhan, HIS, DJJ
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wbc 20.6
hgb 10.1
plt 270
Protein -
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Outcome
OUTCOMEKamis , 31 Juli 2015
Pk. 16.52Laki-laki
3500 gramAS 7-8