Download - MR 07.11.15 Labda Karya RESOG
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GOOD
MORNINGMORNING REPORT
DUTY ON : SATURDAY, NOVEMBER 7th 2015
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Visi program studi Obstetri dan GinekologiMenjadi lembaga pendidikan spesialis obstetri dan ginekologi
yang unggul, mandiri, dan berbudaya serta mampu bersaing di
tingkat Nasional, Regional dan Global.
Misi program studi Obstetri dan Ginekologi• Melaksanakan dan mengembangkan Good ClinicalGovernance
• Meningkatkan penyelenggaraan pendidikan dokter spesialis
obstetrik dan ginekologi yang profesional, unggul, mandiri dan
berbudaya.• Meningkatkan penelitian dasar dan terapan baik di Program
Studi maupun bekerja sama dengan lembaga nasional maupun
internasional.• Meningkatkan pengabdian masyarakat dengan melibatkan
sivitas akademika, alumni, dan stakeholder.
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MORNING REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
RESIDENTS : WSTGIR!DP"S#TT!P"!#TS$WW!PR!I"G!P"WID"SDW%MN
&'IE( : !)%
S*PERVISOR : Pro+, SW
RES*ME O( OPER!TIVE PRO&ED*RE
I, O%STETRI& II, G#NE&O)OGI&
Vaginal deli-er. : &urettage : /
Spontan deli-er. : 0 )aparatom. :
%ra12t : Ot2ers : /
VaE : (E : /
Indu1tion"!ugment :
&S : /
Ot2ers :
RES*ME O( INW!RD P!TIENTIII, IN)!%OR MS"R!TN! :
'&* : &empaka O%S :
I&&* : &empaka G#N :
I&* : Ot2ers :
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MORNING REPORT DUTY ON : SATURDAY, NOVEMBER 7th 2015
OPER!TING ROOM S&'ED*)E : MOND!#3 NOVEM%ER 4t2 05/6
N5 Name !ge Parit. Ward Diagnosis Pro1edure Operator OR
/, #EN 07 .oP5
marriedM'T
O-arian &.st 8 Primar.In+ertilit.
9I&D : N;7,03 N4,/=
)aparotomi ?(@(allopian Tubes
Paten1. Test
dr, !RT3OAG 9&=
I
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/, !RI3 04 .o W!P
N5 D!T! %!SED!SSESS
MENT
PRO%)EM
)IST
I&D P)!N O( &!RE
/, !namnesis 9I&D I : ;4,57= :Re+erred +rom midBi+e Bit2 G/P5555!"S") 2.pertension 9/
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/, !RI3 04 .o W!P
N5 D!T! %!SED!SSESS
MENT
PRO%)EM
)IST
I&D P)!N O( &!RE
0, P2.si1al Eamination 9I&D I ;4,57=W"' : 6;"/>;Present state :%P : /> bpm
VT 9G!P= 54,55 pm : &D 0 1m3 e++ 063 !M 9=
'ead palp3 SS trans-erse3 J'I *npalp small part" umb 1ord
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
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/, !RI3 04 .o W!P
N5 D!T! %!SED!SSESS
MENT
PRO%)EM
)IST
I&D P)!N O( &!RE
7,
>,
*SG 9I&D I : ;;,30"/036!lb : 7346
%*N"S& : //"53/, Risk o+
in+e1tion
O,/>,/O>0,/
Inter-ention :/,!nti SeiKure0,!nti '.pertension7,Ep, -aginal deli-er.a11elarated 0nd stage o+labor >,antibioti1Target :
/,No SeiKure0,M!P L /06 mm'g7,%orn bab. -igorousl.and mot2er in agood1ondition>,Redu1e in+e1tionInstru1tion:T:/,MgSo>F Guidelines
0,Ni+edipine 7 /5 mg9IO=7,Ep, -aginal deli-er.a11elarated 0nd stage o+labor Bit2 (E>,!moi1ilin 7655mg 9io=M : &3 VS3 ('%3 *&3impending e1lampsia Aintoi1ation MgSO>&IE
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
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/, !RI3 04 .o W!P
N5 D!T! %!SED !SSESSMENT PRO%)EM I&D P)!N O( &!RE
!t 55,/6 am&D : > 1m
Progress o+ labor:!t 5>,/6 amPatient urge to bear doBn
E-aluation:!bdomen :
*& 98= >6"/5 F >5>6H ('% 98= /60 bpmVT 9W!P= !t 5>,/6 am: &D 1omplete3 !M 9= 'ead palp3 O!3 J'III8
0nd stage o+ labor
7rd stage o+ labor
I! I"
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O%STETRI& EMERGEN ROOM REPORT
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O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
0, #*)3 7> .o 'ospitaliKed : 55 Beeks da.s3 S")3Se1ondar. Primi3 /st stage o+ labor 9ROM=
E(W: 77>4 g
EDD: 5/"//"05/6
Progress O+ )abor:!t 57,>5 pmPatient urge to beardoBn
Present st :%P : /05";5 P : ;5RR : 05 Ta : 7,4
General state :E.e : anemi1 9=T2ora :
&or : S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8
E-aluation:!bdomen :
*& 98= >6"/5 F >5>6H ('% 98= /60 bpmVT 9!DP= !t 57,>5 pm: &D 1omplete3 !M 9= 'ead palp3 O!3 J'III8 *npalp small part"umb 1ord
0nd stage o+labor
; pmSpontaneousl. born
bab. 3 7565g3-igorousl.
O%STETRI& EMERGEN ROOM REPORT
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0, #*)3 7> .o !DP
S & ! I&D P
7rd
stage o+labor I&D I
@4
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7, S!D3 7/ .o T!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
/, !namnesis 9I&D I : ;4,57= :Re+erred +rom %alimed 2ospital Bit2G/P55553 7;74 Beeks3 > .earsin+ertile3PROM3 &TGpatologi1"suspi1iousWater. -aginal dis12arge 98= sin1e5
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7, S!D3 7/ .o T!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
0, P2.si1al Eamination 9I&D I ;4,57=W"' : Ta : 7,<General st :E.es : anemi1 9=
T2ora : &or :S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8Obstetri1 state :!bd : (' 7 +grs bp 97/1m=3 O 4/5 *& 98= 07"/5F7576H
('% 98= />; bpm
VT 9G!P= //,55 pm : &D > 1m3 e++ 653 !M 9=
'ead palp3 )O trans-erse3 J'I *npalp small part" umb 1ord
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY , NOVEMBER 7th 2015
O%STETRI& EMERGEN ROOM REPORT
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7, S!D3 7/ .o T!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
7,
>,
*SG 9I&D I : ;;,.ears3/st stage o+labor 9ROM=
E(W :7/5< g
/,In )abor 0,ROM
O;5,5O>0,/N4
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7, S!D3 7/ .o T!P
N5 D!T! %!SED !SSESSMENT PRO%)EM I&D P)!N O( &!RE
Progress o+ labor:!t 57,75 amE-alution > 2ours
E-aluation:!bdomen :
*& 98= 7>"/5 F 76>5H ('% 98= /70 bpm
VT 9T!P= !t 57,55 am: &D ; 1m3 e++ .ears3/st o+ labor 9ROM=
E(W :77>g
Instru1tion:T:/,Ep, -aginal deli-er.0,!moi1illin 7 655 mg9IO=
M : manage F P W'O
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
O%STETRI& EMERGEN ROOM REPORT
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7, S!D3 7/ .o T!P
S O ! I&D P
Progress o+ labor !t 57,75 am patienturge to bear doBn3
E-aluation:!bd :
*& 98= >6"/5HF>5>6 ('% 98= />5 bpm
VT 9T!P=&D 1omplete3 !M 9='ead palp3 O!3 J'III8
*npalp small part" umb1ord
0nd stage o+labor
7rd stage o+labor
Instru1tion :Pd : T :)ead to bear doBn
!t 57,>5 am3 born bab. 3 0465 g3 -igorous3
episiotom. 98=
T :Management a1ti-e 7rdstage o+ labor
!t 57,>6 pm3 bornpla1enta 1omplete3done perineal 2e1ting
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
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S#!, '( yo
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S#!, '( yo
O%STETRI& EMERGEN ROOM REPORT
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>, $!T3 /; .o G!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
/, !namnesis 9I&D I : ;4,57= :Re+erred +rom P'& I Denpasar TimurBit2 G/P55553 7< Beeks > da.s3bree12 pres3 S")3 PROM,Water. -aginal dis12arge 98= sin1e5/,55 am 9;"//"/6=, )abor pain 9=3 (M98=, $noBn bree12 pres sin1e s2e1ame to P'& 9"50"05/6EDD : //"//"05/6PN& : midBi+e3 OAG
Obstetri1 2istor. :
/,&urrent pregnan1.
*nmarried&ontra1eption:
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015
O%STETRI& EMERGEN ROOM REPORT
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>, $!T3 /; .o G!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
0, P2.si1al Eamination 9I&D I ;4,57=W"' : 5"//Present state :%P : /05";5 RR : 05P : ;> Ta : 7,6General st :E.es : anemi1 9=T2ora : &or :S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8Obstetri1 State:!bdomen : (' 7 +inger bp 97< 1m=3 B>"6
)! 4; 1m3 *& 9= ('% />> bpmVagina : Insp -"- : amnioti1 +luid 98= +rom O*E )a1mus test 98=VT 9G!P= 5,/5 am: &D /1m3 e++ 063 !M 9= butto1k palp3 un1lear denom3J'I
unpalp umb 1ord
O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY , NOVEMBER 7th 2015
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>, $!T3 /; .o G!P
N5 D!T! %!SED!SSESS
MENTPRO%)EM
)ISTI&D P)!N O( &!RE
7,
>,
*SG 9I&D I : ;;,
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Thankyou