Download - Jaga Malam 26 - 27 September 2013
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JAGA Malam26 27 September 2013
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Pasien VK :Pasien baru : 1Pasien Lama : 2
Persalinan fsil!is : 2Persalinan patl!is : 1Pasien Gine"l!is : 0
Jumla# sisa pasien VK : 2
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$ama: $% $ita &'( 31 t#nM)S 26*+*13 p" 0,'20 &-.
K/: Keluar air pera!inam
K:
)PS :Pasien atan! iantar .PS $%' -smari en!an"elu#an "eluar air pera!inam se4a" p" 02'30526*+*2013 &arna 4erni#' Kenen!"enen! 5'Keluar lenir ara# 5 Gera" 4anin 58 bai"
Persalinan patl!is 91
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RPD : DM (-);HT(-) ; Alergi (-) ; Asma (-) RPK : DM (-); HT(-); Alergi (-); Asma (-); Gemeli (-) Riw Alergi obat : (-) Riw Pemakaian Obat en!akit Kronik : (-) Riw Haid
" HPHT: #$-#%-%#$&" TP: #'-$$-%#$&" mr ke*amilan &&-&+ mingg" Menarr,*e : ' t*" ikls *ai. : %' *ari/ teratr" 0ama Hai. : 1 *ari
" Dismenorr*ea : (-) Riw Persalinan$2 ereman3 4bln3 st53 RA03%16#g37t* %2 *amil ini
Riw Pernika*an" ami 83 selama ta*n
Riw K5 : Pil/ sto % t* !ang lal Riw A9 :- + .i RA0$2 $+373%#$&--< $6 mingg%2 '313%#$& --< %%-%& mingg&2 6343%#$& --< &$ mingg+2 $1343%#$&--
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K/ : bai" .: 1,1 m ..: 3(,*,3 "! Kesaaran* G;S : ;M * ,6
" : 120*+0 mm*mnt" $: +0>*mnt( re! -emp 5a>illar: 36(2; (emp 5ret:
36(7;
St' General
Kepala : A5*-5*;5*?5;lasma !raiarum 5
Le#er :Pembesaran KG. 5 struma !raiarum 5 #ra>: Pulm : Vesi"uler*esi"uler@ )# *@ *
;r : S1S2 tun!!al re!@ Murmur 5@ Gallp 5 Abmen: embun! ( simetris: supel 58: termitas:
A< 8*8 @ ema * @ ;) B 2t"
8*8 8*8
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St Obst :" - : C/ : 3 4ari baDa# p>
teraba 2 ba!ian besar 4anin berbentu" bulat( "eras( batas4elas( melentin! "esan: "epala
" -- :teraba ba!ian 4anin "eras meman4an! sebela# "anan an"iri ibu"esan : .a%i - : Pun!!un! "anan
Kesan : .a%i -- : Pun!!un! "iri
" --- : teraba ba!ian besar 4anin( bulat( luna" ( berbatas tia"te!as( tia" melentin!( tia" terf>ir "esan: b"n! belummasu" PAP
" -V: "ner!en
C/ : 30 m
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$$3#63$6
/SG
t!l ,*+*2013" /SG 2+30 min!!u
" Plasenta rpus !rae -- "et u"up
t!l 1*6*2013" .P? : (1= 1= m!!u
"
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Assessment :
G-- P 1001 33*3 m!!u G
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$$3#63$6
1+'00
S: "enen! "enen! serin! Gera" 4anin 58 bai"
: S/: ;M * ,6 : 120*70 mm*mnt$: ==>*mnt( re! emp're"tal : 36(;S: * 10( urasi ,0
V : 3 m * 7,F*"et5*b"n!*sarum mell*
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$$3#63$6
CllD up t!l 260+2013 p"1+'3,
S: ibu in!in men!e4an ( b"n! membu"a ula
: S/: ;M * ,6 : 110*70 mm*mnt
$: +2>*mnt( re!S:
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$$3#63$6
CllD up t!l 260+2013 p"20'30
Pasien i me4a KS: "enen! "enen! serin!: S/: ;M * ,6
: 11=*71 mm*mnt
$: =1>*mnt( re!S:
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CllD up t!l 2, 0+ 2013pu"ul 20'0
ela# la#ir ba%i perempuan *2000!r*2 m* AS 7 =
$$3#63$6
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$$3#63$6
Pasien VK 9 1
$ama: $%' A4en! Saftri( 3 t#n
M)S 2,*+*13 p" 0+'30 Dib
K/: "eluar Ne"Ne"
K:
)PS :
Pasien atan! seniri en!an "elu#an "eluar Ne" ari"emaluan se4a" 1 min!!u %an! lalu' Ne" berDarna"lat( aDaln%a #an%a "eluar sei"itsei"it( an se4a"
tai malam pu"ul 22'00 perara#an pera!inamsema"in ban%a"( ara# 5( "eluar airan pera!inam5( "enen!"enen! 5( .A. bn( .AK bn
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$$3#63$6
)P? : ?M 5@
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$$3#63$6
)iDa%at Sin!"at
Pasien riDa%at M)S i VK .ersalin t!l =17 Juli 2013! G-V P2012 23*2 m!
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$$3#63$6
Saran r' Crans( SpG5K:
Pr primer S; /'K' 3= m! 51,102013
K- S; s* #istere"tmi
Knsul )ail!i untu" persiapan pemasan!an"ateter V' Hemralis untu" emblisasi
O Sua# i"nsul"an ia pli"linis 510062013: -nterensi rail!i sesuai Da"tu
terminasi ari b!%n
Knsul Anestesi untu" persiapan p
Knsul /rl!i untu" "emun!"inan "nsul
urante p bila iapat"an "elainan i bian!url!i
Siap GS< &. min' 2 ba!
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$$3#63$6
K/ : bai" .: 1,= m ..: =*,= "! Kesaaran* G;S : ;M * ,6
" : 110*70 mm*mnt" $: =>*mnt( re! -emp : 36(6;
St' General Kepala : A5*-5*;5*?5
;lasma !raiarum 5
Le#er :Pembesaran KG. 5 struma !raiarum 5 #ra> : Pulm : Vesi"uler*esi"uler@ )# *@ *
;r : S1S2 tun!!al re!@ Murmur 5@ Gallp 5 Abmen: embun! ( simetris: supel 58: termitas: A< 8*8 @ ema * @ ;) B 2t"
8*8 *
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$$3#63$6
St Obst :" - : C/ : 3 4ari ibaDa# pr> >%p( tia" teraba
ba!ianba!ian 4anin i ba!ian tertin!!i perutibu 5"sn!
" -- : teraba ba!ian 4anin besar( bulat( bataste!as( melentin! iba!ian "anan ibu
"esan : b"n!" --- : tia" teraba ba!ian 4anin" -V: 5
C/ : 2+ m
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$$3#63$6
/SG 7*6*2013 .P? CL 20*21
min!!u .J 37, ! plaenta inin!
psterir meluas "e
baDa# s* S.)anterir !!ambaran a"reta5susp'per"reta*--*;u"up
/SG 3*7*2013 .P? CL 2*2,
min!!u .J 6,0 ! plaenta preia
a"reta
"et u"up
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$$3#63$6
/SG 1=*+*2013 5/K 3*3, m!
Leta" lintan! "epala "anan*?JJ58 .P? = mm
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$$3#63$6
Assessment :G-V P2012 3,*36 m!! us
Visite r' Crans( SpG5K- Se!era "nsul -P?( )ail!i- Pr /SG CM
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$$3#63$6
lab 2,+2013
#b 11(, leu"sit ,=00 trbsit 20
#t 3( ppt 12(2 apt 30(7 t*pt 1*33
alb (0 bun*reat +(*1(0 na*"*l 10(,*(62*111(+
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$$3#63$6
CllD up t!l 260+2013 p"06'00
S: Perara#an pera!inam 5 Gera" 4anin 58bai"
: S/: ;M * ,6 : 110*70 mm*mnt
$: =>*mnt( re! emp're"tal : 36(;S: us 5;M:100 *22 4am ;K: 1,0 *22 4am
pr /SG CM #ari ini Knsul -P? an )ail!i pr persiapan
pemasan!an "ateter V' Hemralis untu"emblisasi
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$$3#63$6
CllD up t!l 260+2013 p"10'1,
)enana : Seia &. 5i tan!an 2 ba! an GS< 2 ba! Knselin! pasien Q "eluar!a bersama
r')nn%( Sp)a 5untu" "enala interensirail!i Knsul -P?( Anestesi( Ana" )enana s' an M& 27*+*13 p" 0+'00(
bila perara#an #ebat pr A< 58 rese"siparsial buli
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$ama: $%' ?r' Citriana ( 30 t#nM)S 26*+*13 p" 13'1= Dib
K/: Gera" Janin menurun
K: "enen!"enen!)PS :
Pasien atan! "e "amar bersalin r' Sp' Gen!an "elu#an !era" 4anin menurun se4a"
min!!u lalu' /SG "e r' .ui Sp' G en!an#asil : lilitan tali pusat seban%a" 2>( anisaran"an untu" M)S' Kenen! "enen!2> lm 10 menit R 2,30 eti"( se4a" t
malam' Kenen! "enen! irasa"an setela#ran san utin susu' lenir ara#
Pasien VK 9 2
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)P? : ?M 5@ pli #amil )SAL r' )amelan 6> /SG )SAL = >
K/ : bai"
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K/ : bai"
.: 1,6 m
..: ,*70 "!
Kesaaran* G;S : ;M * ,6
" : 110*70 mm*mnt
" $: = >*mnt( re! -emp : 37(;
St' General
Kepala : A5*-5*;5*?5
;lasma !raiarum 5 Le#er :Pembesaran KG. 5 struma !raiarum 5
#ra>: Pulm : Vesi"uler*esi"uler@ )# *@ *
;r : S1S2 tun!!al re!@ Murmur 5@ Gallp 5
Abmen: embun! ( simetris: supel 58: termitas:
A< 8*8 @ ema * @ ;) B 2t"
8*8 *
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St Obst :" - : C/ : 3 JA)- p> ( teraba ba!ian besar ba%i luna"( tia"
melentin!( bts t" te!as( "esan: ."n!
" -- : teraba ba!ian 4anin "eras meman4an! sebela# "ananibu
"esan : Pun!!un! "anan
" --- : teraba ba!ian besar 4anin( bulat("eras( bts te!as(melentin!( ta" f>' Kesan: "epala belum masu" PAP
" -V: "ner!en
C/ : 31 m
alam 0 menit urasi 2, eti"
?JJ : 121112 5?ppler I 136 V : E 1 m*eHH 2,F*"ep*ss melintan!*
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USG 26/09/13
.P?: +,
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Assessment :
G--P1001 01 m!! 2 4am tia" inpartu( pr K)S "ntrl pli#amil sesuai 4aDal
- bila inpartu pr spt .
- Mnitrin! "ell * VS * ?JJ *