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  • 05 Follow Up Fix

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    Arif Endotel
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    This document contains medical records and observations for a patient who underwent a cesarean section. It documents the patient's vital signs, symptoms, abdominal exams, and baby's condition over multiple days post-operation. Medications and treatments provided are also noted, including intravenous fluids, antibiotics, pain medications, and postpartum care instructions. The records indicate the pregnancy was at 40-41 weeks with a baby boy delivered via sungsang oblique cesarean weighing 3500 grams who received a 5/7 APGAR score.

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    This document contains medical records and observations for a patient who underwent a cesarean section. It documents the patient's vital signs, symptoms, abdominal exams, and baby's condition over multiple days post-operation. Medications and treatments provided are also noted, including intravenous fluids, antibiotics, pain medications, and postpartum care instructions. The records indicate the pregnancy was at 40-41 weeks with a baby boy delivered via sungsang oblique cesarean weighing 3500 grams who received a 5/7 APGAR score.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    9 views2 pages

    05 Follow Up Fix

    Uploaded by

    Arif Endotel
    This document contains medical records and observations for a patient who underwent a cesarean section. It documents the patient's vital signs, symptoms, abdominal exams, and baby's condition over multiple days post-operation. Medications and treatments provided are also noted, including intravenous fluids, antibiotics, pain medications, and postpartum care instructions. The records indicate the pregnancy was at 40-41 weeks with a baby boy delivered via sungsang oblique cesarean weighing 3500 grams who received a 5/7 APGAR score.

    Copyright:

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

    Lampiran

    FOLLOW UP
    Tgl
    S
    O

    11-12-2013
    05.20
    kenceng-kenceng pada
    perut (+) jarang
    KU: Cukup
    VS:
    TD: 120/80 mmHg
    N: 80x/menit
    RR: 22x/menit
    Suhu: 36,7 oC
    Abdomen :
    TFU 34 cm, Letak janin :
    punggung kanan, letak
    sungsang, U, His : (+)
    jarang, DJJ : 136x/menit
    TBJ: 3255 gram
    V/V: pembukaan (+) 1
    cm, eff 25 %, Ketuban
    (-), bokong H I (+)

    11.40
    kenceng-kenceng pada
    perut (+) jarang
    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
    TBJ: 3255 gram
    V/V: pembukaan (+) 1
    cm, eff 25 %, Ketuban
    (-), bokong H I (+)
    Hasil Lab dan USG
    terlampir
    G1 P0000 Ab000 usia G1 P0000 Ab000 usia
    kehamilan 40-41 minggu kehamilan 40-41 minggu
    T/H + letak sungsang T/H + letak sungsang
    oblique dengan PRM
    oblique dengan PRM

    Inj. Ceftriaxone
    Pro SC

    Dilakukan SC pada jam


    11:40 WIB oleh dokter
    Sp.OG,
    KU: Sadar
    VS: TD: 130/90 mmHg

    12-12-2013 (07.30)

    13-12-2013 (07.30)

    14-12-2013 (07.30)

    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 :
    780 cc/12 jam warna
    kuning kecoklatan.

    Nyeri bekas jahitan,


    Flatus (+)
    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.

    Nyeri bekas jahitan,


    Flatus (+)
    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 P1001 Ab000 Post SC hari I P1001 Ab000 Post SC hari
    a/i
    letak
    sungsang a/i
    letak
    sungsang I a/i letak sungsang
    oblique dengan PRM
    oblique dengan PRM
    oblique dengan PRM
    Ekstra RL 1 flash
    Amoxicilin 3x500 mg
    Asam mefenamat 3x500
    mg
    Methylergometrin
    22

    Aff. DC
    Amoxicilin 3x500 mg
    Asam mefenamat 3x500
    mg
    Methylergometrin

    Amoxicilin 3x500 mg
    Asam mefenamat 3x500
    mg
    Methylergometrin
    3x0,125 mg

    Lampiran
    Nadi: 78x/menit
    3x0,125 mg
    o
    t axila: 36,5 C.
    Observasi tanda
    Bayi :
    keluhan subjektif,
    Laki-laki, BBL : 3500gr,
    PB : 49 cm, ketuban
    jernih, dan APGAR skor
    5/7
    o

    -Terapi:
    Inf. RL : D5% 2:3 + OD
    10 IU 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

    3x0,125 mg
    vital, Observasi tanda
    keluhan subjektif,
    Diet TKTP

    Observasi tanda
    vital, keluhan subjektif,
    Diet TKTP
    Rawat Payudara
    Rawat luka
    BLPL
    KIE kontrol poli

    vital,

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