Documente Academic
Documente Profesional
Documente Cultură
26 Desember 2017
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Pembimbing
M. Ilham Aldika., dr., Sp.OG (K)
PPDS:
Junior B: dr. Darmi
Patol A: dr. Dimas
Chief: dr. Atika
DM:
Kamal Musthofa
Tu Gus
Bayuwega
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PASIEN BARU
3
1. Ny.Su/ 40 tahun/
In Hospital 26 Desember 2017 jam 15.00
Adress: Wonokusumo, Surabaya
Obstetric History:
1. First born aterm BW 3000gr / Midwife / now 22 years old
2. Second born aterm/ Midwife/ now 20 years old
3. This pregnancy
Marriage: 1x; 23 tahun
Contraception: Injection Contraception 3 months, stop 2
months before known she was pregnant
Physical Examination (Delivery room, 26 Desember 2017 pk 15.00):
Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 190/107 HR : 87 RR: 20 T :36.2
Cor : normal S1/S2
Pulmo : Vesicular +
+
+
+
+ +
Ronchii - -
- -
- -
Wheezing - -
- -
- -
I
Status Obstetri
TFU : 27 cm
Letak : Breech Position
Fetal heart rate :-
His :-
VT : 1 cm / 25% / Amnion membrane
(+) / breech pos. / H I / PS 2
7
Laboratory UL
HB : 13,3 Protein urine +3
Leukosit : 4,39 Eritrosit +5
Trombosit : 287 Lekosit 6-8
SGOT: 21
SGPT: 10
BUN: 8,7
SK: 0,51
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Diagnosis :
GIIIP 2002 32/33 minggu + breech pos.+ IUFD + PEB + secondary old
pregnancy (40 y.o) + EFW 1600 gr
Tatalaksana :
- Inf RD5 500cc/24 hours
- Inj MgS04 20% 4gr IV continue with MgSO4 40% 1gr/ hour SP
- Nifedipin 3 x 10 mg if BP≥ 160/110
- Metildopa 3 x 500mg
- Pro termination pervaginam with Cervix ripenin: Misoprostol
25mcg per vaginam / 6 hours until PS≥ 5
- If PS≥ 5 pro OD 12 hours
- If Inpartu pro Spt Bracht
- Max drink 1000cc/ 24 hours
- Fluid Balance I = O + 500
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26 Desember 2017 pk 15.00
S: ibu ingin mengejan
O: Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 110/70 HR : 88 RR: 20 T :36.7
Status Obstetri
HIS (+) DJJ: 12-12-12
VT: Ø lengkap/ketuban(-)/kepala/ UUK depan/H III +
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19 Desember 2017 pk 16.00
S: ibu tampak kelelahan
O: Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 110/70 HR : 88 RR: 20 T :36.7
Status Obstetri
HIS (+) DJJ: 12-12-12
VT: Ø lengkap/ketuban(-)/kepala/ UUK depan/H III +
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• OBSERVATION (26th Dec 2017)
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• OBSERVATION (27th Dec 2017)
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• OBSERVATION (27th Dec 2017)
Time BP HR/mn Respira Temperature Fundus Height HIS (in 10 VT
t tory minutes)
rate
04.45 157/89 103 24 36,5’C 27 cm -
05.15 153/79 89 20 36,5’C 27 cm - Ø 1 cm /
25% /
Amnion
membran
e (+) /
breech
pos. / H
I / PS 2
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• Kondisi Terakhir Pukul 06.00 di Ruang Rawat Inap
- S : Nyeri (+)
- O : GCS : 456
TD : 100/60 N : 80 RR : 16
TFU : 3 jari dibawah Pusat
V/V : perdarahan (-)
Kontraksi uterus : (+)
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THANK YOU
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