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  • 05 Follow Up

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    Arif Endotel
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    This document contains medical records for a patient over a 14 day period following a cesarean section delivery. It includes daily records of vital signs, symptoms, abdominal exams, and postpartum care. The patient had an uneventful C-section at 40-41 weeks gestation delivering a female infant weighing 2700g with Apgar scores of 5/7. Post-op care included IV fluids, antibiotics, pain medications, and monitoring of contractions, bleeding, and urinary output.

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    TYREWYYYR

    Original Title

    05 FOLLOW UP

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    This document contains medical records for a patient over a 14 day period following a cesarean section delivery. It includes daily records of vital signs, symptoms, abdominal exams, and postpartum care. The patient had an uneventful C-section at 40-41 weeks gestation delivering a female infant weighing 2700g with Apgar scores of 5/7. Post-op care included IV fluids, antibiotics, pain medications, and monitoring of contractions, bleeding, and urinary output.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    2 views2 pages

    05 Follow Up

    Uploaded by

    Arif Endotel
    This document contains medical records for a patient over a 14 day period following a cesarean section delivery. It includes daily records of vital signs, symptoms, abdominal exams, and postpartum care. The patient had an uneventful C-section at 40-41 weeks gestation delivering a female infant weighing 2700g with Apgar scores of 5/7. Post-op care included IV fluids, antibiotics, pain medications, and monitoring of contractions, bleeding, and urinary output.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 2

    Lampiran

    FOLLOW UP
    Tgl
    11-12-2013
    S kenceng-kenceng pada perut
    (+) jarang
    O KU: Cukup
    VS:
    TD: 110/80 mmHg
    N: 88x/menit
    RR: 18x/menit
    Suhu: 36,2 oC
    Abdomen :
    TFU 34 cm, Letak janin :
    punggung
    kanan,
    letak
    sungsang, U, His : (+) jarang,
    DJJ : 136x/menit
    V/V: pembukaan (+) 1 cm, eff
    25 %, Ketuban (-), bokong H I
    (+)
    Hasil Lab dan USG terlampir
    A G1 P0000 usia kehamilan 40-41
    minggu T/H + PRM + Letsu
    P Obs. Inpartu
    Pro USG
    Inf. D5% drip synto 5IU mulai
    8 tpm, naik 4 tetes tiap 15
    menit sampai his adekuat
    (maksimal 40 tpm)

    12-12-2013
    Nyeri bekas jahitan, Flatus (+)

    13-12-2013
    Nyeri bekas jahitan, Flatus (+)

    14-12-2013
    Nyeri bekas jahitan, Flatus (+)

    KU: Cukup
    VS:
    TD: 110/70 mmHg
    N: 88x/ menit
    RR: 20x/ menit
    Suhu: 36oC
    ASI +/+
    Abdomen :
    Abdomen : TFU 1 jari dibawah
    pusat, kontraksi uterus baik,
    Lokhea Rubra + sedikit.
    Produksi urin output : 400cc/13
    jam warna kuning kecoklatan.

    KU: Baik.
    VS :
    TD: 120/80 mmHg
    Nadi: 88x/menit
    RR: 18x/menit
    Suhu: 35,6oC
    ASI +/+
    Abdomen : TFU 1 jari dibawah
    pusat, kontraksi uterus baik,
    Lokhea Rubra + sedikit.

    KU Baik.
    VS :
    TD: 110/70 mmHg
    Nadi: 88x/menit
    RR: 20x/menit
    Suhu: 37,7oC
    ASI +/+
    Abdomen: TFU 1 jari dibawah
    pusat, kontraksi uterus baik,
    Lokhea Rubra + sedikit.

    P1001 Ab000 Post SC hari I a/i


    PRM + Letsu
    -Pro SC cito
    -Telah dilakukan SC dengan
    SAB pada jam 10:30 WIB oleh
    dokter Sp.OG, kembali ke
    ruangan jam 12:00 WIB dengan
    KU: Sadar
    VS: TD: 120/80 mmHg
    Nadi: 74x/menit
    toaxila: 36,5oC.
    Bayi :

    P1001 Ab000 Post SC hari II a/i


    PRM + Letsu
    Amoxicilin 3x500 mg
    Asam mefenamat 3x500 mg
    Methylergometrin 3x0,125
    mg
    Observasi tanda vital, keluhan
    subjektif,
    Diet TKTP

    P1001 Ab000 Post SC hari III a/i


    PRM + Letsu
    Amoxicilin 3x500 mg
    Asam mefenamat 3x500 mg
    Methylergometrin 3x0,125
    mg
    Observasi tanda vital, keluhan
    subjektif,
    Diet TKTP
    Rawat Payudara

    22

    Lampiran
    , BBL : 2700gr,
    PB : 50 cm, ketuban jernih, dan
    APGAR skor 5/7
    -Terapi:
    Inf. RL : D5% 2:3 + OD 10IU
    s/d 12 jam post operasi
    Inj. Ceftriaxone 2x1
    Inj. Alinamin F 3x1
    Inj. Ketorolac 3x1
    Inj. Vit C x1
    Observasi tanda vital, keluhan
    subjektif,
    kontraksi
    uterus,
    fluxus, dan produksi urin.

    23

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