morning report (vk)
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contoh morning report vk obgyn ciawiTRANSCRIPT
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Morning Report (VK)
27 April 2015
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Identitas Pasien
• Nama : Ny. M• Nama Suami : Tn. S• Umur : 18 tahun• Umur Suami : 24 thn• Pendidikan : SMP/SD• Tanggal/Jam Masuk : 27/04/2015 : 15.53• No. RM :5054xx• Alamat :Kp. Babakan Sukaraja
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Anamnesa
• RPS : Pasien dirujuk dari Puskesmas Sukaraja dg Oligohidramnion. Keluar air-air (-), mules-mules sejak pk 21.00 (26/4). Mules dirasakan makin kuat dan sering. Keluar lendir campur darah(+), gumpalan darah (+), pusing (-), mual muntah (-), pingsan (-). Hamil anak pertama, HPHT 7/8/14, Riw ANC ke posyandu 7x, pernah di USG ketuban kurang.
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• RPD : – Riw keguguran (-)– Riw KB (-)– Riw Asma (-)– DM(-)– HT(-)– Alergi obat/makanan(-)
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Pemeriksaan Fisik
• Ku/kes: TSS/ CM• TD : 120/70 mmHg• S : 36,5• HR : 80 X/m• RR : 21 x/ m• St. Generalis
– Mata : CA-/- ; SI -/-– Thorax : C/P dbn– Abdomen : buncit, lembut, NT (-),BU(+) N– Genital :V/V tak, darah (-)– Extremitas : akral hangat, edema -/-
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St. Obstetri
• L1 : bokong, TFU 29 cm• L2 : puki, DJJ : 157 X/m• L3 : kepala• L4 : sudah masuk PAP
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Pemeriksaan Dalam
• v/v TAK• Ostium terbuka d 3cm• Portio tebal lunak, ketuban (+)• ST : lendir (+), darah (+)
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Pemeriksaan Penunjang
• CTG• Lab darah :– Hb 7,8– Ht 27– Leukosit 9900– Trombosit 376000– Ct 11’10”– Bt 3’20”– Gds 71– HbsAg non reaktif – HIV 1-2 rapid non reaktif
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Diagnosis
• G1P0A0 gr 38 mg inpartu kala 1 fase laten + oligohidramnion
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Terapi
• Resusitasi Intrauterine• 2 jam konsul ulang/ ctg ulang
• Setelah CTG ulang :– Observasi ketat DJJ,HIS dan kemajuan persalinan
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Diagnosis Akhir
• Pasien masih dirawat di VK
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Terima kasih