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  • Tgl. Keadaan Klinis Tindakan Pengobatan: Progress Note

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    Akhmad Isna
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    This patient is a 36-year-old woman, G4P3A0, at 34 weeks gestation with a history of antepartum bleeding due to complete placenta previa. She was treated conservatively with bed rest, hydration, and medications to prevent preterm labor. After heavy bleeding, she underwent an emergency cesarean section, delivering a live female infant. A bilateral tubal ligation was also performed. Post-operatively, she was stable and recovering well with close monitoring of vital signs and output.

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    This patient is a 36-year-old woman, G4P3A0, at 34 weeks gestation with a history of antepartum bleeding due to complete placenta previa. She was treated conservatively with bed rest, hydration, and medications to prevent preterm labor. After heavy bleeding, she underwent an emergency cesarean section, delivering a live female infant. A bilateral tubal ligation was also performed. Post-operatively, she was stable and recovering well with close monitoring of vital signs and output.

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    21 views6 pages

    Tgl. Keadaan Klinis Tindakan Pengobatan: Progress Note

    Uploaded by

    Akhmad Isna
    This patient is a 36-year-old woman, G4P3A0, at 34 weeks gestation with a history of antepartum bleeding due to complete placenta previa. She was treated conservatively with bed rest, hydration, and medications to prevent preterm labor. After heavy bleeding, she underwent an emergency cesarean section, delivering a live female infant. A bilateral tubal ligation was also performed. Post-operatively, she was stable and recovering well with close monitoring of vital signs and output.

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    of 6

    PROGRESS NOTE Tgl. 06-09-2011 Pukul 22.

    30 Keadaan Klinis Status internus: KU: baik, compos mentis TD: 110/80 mmHg Nadi: 84x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: TFU : 30 cm TBJ : 2945 gr His : + jarang DJJ : 12-12-13 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) Tindakan Pengobatan USG : 06-09-2011 Tampak janin 1 intrauterine presentasi kepala punggung kanan FM(+) FHM(+) FHR:146x/menit Biometri janin: BPD: 9,06 cm AC: 31,3 cm FL: 7,2 cm AVG: 36w3d EFW: (S) 2782 g (H) 2825 Plasenta implantasi di fundus, meluas ke korpus lateral kiri sampai SBR, menutup OUI gr II kalsifikasi (-) Likuor amnii jernih (+) ICA = 8,83 cm Tidak tampak kelainan kongenital mayor Manning score 8 (tanpa KTG) S/. Konservatif Bed rest Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1 tablet Nifedipin 30 mgr dilanjutkan 3 x 10 mgr Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito S/. Konservatif Bed rest Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1 tablet Nifedipin dilanjutkan 3 x 10 mgr

    07-09-2011 Pukul 05.00

    Status internus: KU: baik, compos mentis TD: 100/60 mmHg Nadi: 80x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur

    Ekstremitas: edema sup -/inf -/Status obstetri: PPV : His : + jarang DJJ : 12-12-12 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) 07-09-2011 Pukul 06.00 Status internus: KU: baik, compos mentis TD: 100/60 mmHg Nadi: 80x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: PPV : His : + jarang DJJ : 12-12-12 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) 07-09-2011 Pukul 18.00 Status internus: KU: baik, compos mentis TD: 100/80 mmHg Nadi: 80x/menit RR: 20x/menit

    Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito

    S/. Konservatif Bed rest Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1 tablet Nifedipin dilanjutkan 3 x 10 mgr Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito

    S/. Konservatif Bed rest Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1

    Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: PPV : His : + jarang DJJ : 12-12-12 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) Status internus: KU: baik, compos mentis TD: 100/80 mmHg Nadi: 80x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: PPV : + His : + jarang DJJ : 12-12-12 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) Status internus: KU: baik, compos mentis TD: 100/60 mmHg

    tablet Nifedipin dilanjutkan 3 x 10 mgr Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito

    08-09-2011 Pukul 05.00

    S/. Konservatif Bed rest Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1 tablet Nifedipin 3 x 10 mgr Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito

    08-09-2011 Pukul 06.00

    S/. Konservatif Bed rest

    Nadi: 80x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: PPV : + His : + jarang DJJ : 12-12-12 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun Anemia ringan (Hb = 9,7 gr%) Keluhan : keluar darah banyak dari jalan lahir Status internus: KU: baik, compos mentis TD: 120/80 mmHg Nadi: 88x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: membuncit, membujur Ekstremitas: edema sup -/inf -/Status obstetri: PPV : + mengalir His : + DJJ : 12-12-11 D/. G4P3A0 36 tahun hamil 34 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi 11 tahun

    Infus RL 20 tpm Vitamin Bc / C / SF 2 x 1 tablet Nifedipin dilanjutkan 3 x 10 mgr Injeksi dexametason 2 x 6 mgr (2 hari) Pengawasan keadaan umum, tanda vital, PPV, DJJ Jika sewaktu-waktu berdarah, akhiri kehamilan dengan SC cito

    08-09-2011 Pukul 06.45

    S/. Akhiri persalinan dengan SC cito Ijin tindakan Pengawasan keadaan umum, tanda vital, PPV, DJJ, His Konsul anestesi Konsul perinatologi Usaha darah Informed consent MOW

    08-09-2011 Pukul 9.30

    Anemia ringan (Hb = 9,7 gr%) P4A0 36 tahun Pasca SCTP + MOW G4P3A0 36 tahun hamil 35 minggu. Janin 1 hidup intrauterine presentasi kepala punggung kanan Partus prematurus imminens Plasenta previa totalis berdarah Riwayat perdarahan antepartum et causa plasenta previa totalis Usia tua Primi sekundi Lahir bayi perempuan BB 3100 gr, Apgar Score 9 10 10 Injeksi oksitosin 10 IU Plasenta dilahirkan kotiledon lengkap, infark (-), hematom (-) Eksplorasi: perdarahan (-), kontraksi uterus baik, kedua adnexa dbn Dilakukan sterilisasi secara pomeroy pada kedua tuba KU Ibu post-op: baik, komposmentis TD: 110/60 mmHg Nadi: 82x/menit RR: 20x/menit Suhu: 37oC Lama operasi 45 menit Diuresis = 200 cc Perdarahan = 400 cc

    S/. Infus RL / D5 / NaCl 18 tpm (2 botol pertama RL + 10 IU oksitosin) Inj. cefazolin 2 x 1 gr IV (24 jam pertama) Inj. kalnex 3 x 500 mgr IV (24 jam pertama) Inj. ketorolac 3 x 30 mgr IV (24 jam pertama) Boleh minum bila tidak muntah Tidur bantal tinggi 24 jam pertama Mobilisasi bertahap DC balance cairan Pengawasan keadaan umum, tanda vital, PPV, TFU, ASI, BAB, BAK Cek darah rutin post-op

    08-09-2011 Pukul 12.00

    Keluhan (-) KU: baik, compos mentis TD: 110/70 mmHg Nadi: 88x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: TFU 2 jari di bawah pusar, kontraksi kuat Ekstremitas: edema sup -/inf -/PPV : (+) lochea ASI : (+) BAK : (+) DC BAB : (-)

    S/. Infus RL / D5 / RL / D5 / NaCl 0,9% 20 tpm (2 botol pertama + 10 IU oksitosin) Inj. cefazolin 2 x 1 gr IV Inj. kalnex 3 x 500 mgr Inj. ketorolac 3 x 30 mgr Diet cair I Tidur bantal tinggi 24 jam pertama Mobilisasi bertahap DC balance cairan Pengawasan keadaan umum, tanda vital, PPV, TFU, ASI, BAB, BAK

    P4A0 36 tahun Pasca SCTP + MOW e.c. plasenta previa totalis berdarah 08-09-2011 Pukul 12.30 Keluhan (-) KU: baik, compos mentis TD: 110/70 mmHg Nadi: 88x/menit RR: 20x/menit Suhu: 37oC Mata: konjungtiva palpebra anemis -/Thorax: cor/pulmo dbn Abdomen: TFU 2 jari di bawah pusar, kontraksi kuat Ekstremitas: edema sup -/inf -/PPV : (+) lochea ASI : (-) BAK : (+) DC BAB : (-) D/. P4A0 36 tahun Pasca SCTP + MOW e.c. plasenta previa totalis berdarah S/. Infus RL / D5 / RL / D5 / NaCl 0,9% 20 tpm (2 botol pertama + 10 IU oksitosin) Inj. cefazolin 2 x 1 gr IV / 24 jam Inj. kalnex 3 x 500 mgr Inj. ketorolac 3 x 30 mgr Diet cair I Tidur bantal tinggi 24 jam pertama Mobilisasi bertahap DC balance cairan Pengawasan keadaan umum, tanda vital, PPV, TFU, ASI, BAB, BAK

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