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  • Bangsal Obs 1agustus

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    Metharisa Sujana
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    The document summarizes the medical records of two patients in the maternity ward on August 1, 2019. Patient 1 is a 31-year-old woman admitted with symptoms of hypovolemic shock after a ruptured uterus during her second pregnancy. She received multiple blood transfusions and underwent hysterectomy surgery. Patient 2 is a 36-year-old woman admitted for an emergency C-section due to fetal distress and IUGR in her post-term second pregnancy complicated by oligohydramnios. Both patients are being treated with medications, IV fluids, and monitored for recovery.

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    The document summarizes the medical records of two patients in the maternity ward on August 1, 2019. Patient 1 is a 31-year-old woman admitted with symptoms of hypovolemic shock after a ruptured uterus during her second pregnancy. She received multiple blood transfusions and underwent hysterectomy surgery. Patient 2 is a 36-year-old woman admitted for an emergency C-section due to fetal distress and IUGR in her post-term second pregnancy complicated by oligohydramnios. Both patients are being treated with medications, IV fluids, and monitored for recovery.

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    1 views1 page

    Bangsal Obs 1agustus

    Uploaded by

    Metharisa Sujana
    The document summarizes the medical records of two patients in the maternity ward on August 1, 2019. Patient 1 is a 31-year-old woman admitted with symptoms of hypovolemic shock after a ruptured uterus during her second pregnancy. She received multiple blood transfusions and underwent hysterectomy surgery. Patient 2 is a 36-year-old woman admitted for an emergency C-section due to fetal distress and IUGR in her post-term second pregnancy complicated by oligohydramnios. Both patients are being treated with medications, IV fluids, and monitored for recovery.

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    © All Rights Reserved
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    of 1

    BANGSAL OBS 1 AGUSTUS 2019

    PEMERIKSA
    BED NAMA DPH DIAGNOSIS AWAL DIAGNOSIS SAAT INI LAB TERAPI
    AN FISIK
    2B Ny. Novia Wahyu 3 KU:BaikCM Syok hipovolemik ec Post histeroraphy ai 31/7/19 Asam mefenamat 3x500mg
    P2A0 31 tahun TD 110/70 susp.ruptur uteri ruptur uteri, syok Hb 9.7 Ht 31 AL 16.4 AT 98 Ae Vit.C 2x50mg
    (01364762) HR 82x fetal distrees pada hipovolemik teratasi, IUFD 3.47 Cripsa 3x1
    I : perempuan IUFD 7 RR 20x sekundigravida pada sekundipara hamil 30/7/19 Amoxicillin 3x500mg
    bulan (2017) T 36.6 hamil imatur imatur + anemia (9.7) + Hb 8.8 Ht 25 AL 13.1 AT 81 Ae Diet putih telur
    II : laki –laki BBL anemia (6.9) + Trombositopenia (98) + 2.86 Alb 3.2 Medikasi Luka
    600gram, meninggal Total riw.laparotomi ai Riw.histerorafi ai ruptur Usul BLPPL
    Transfusi : ruptur uteri 2 tahun uteri 2 tahun yang lalu + 29/7/19 (2:35PM)
    Rujukan Hermina 4PRC yang lalu + riw.reseksi adenomiosis Hb 9.6 Ht 27 AL 14.8 AT 74 Ae
    dengan solutio 3WB riw.laparoskopi 3 perlaparoskopi 3 tahun 3.15
    plasenta fetal distress 4FFP tahun yll yll DPH III GDS 105 Alb 2.1 Na 134 K 4.2 Cl
    riw.SC + syok 1 plasbumin BC Durante Operasi 104
    hipovolemik 4TC Input : 4180cc 29/7/19 (11.00 AM)
    Kristaloid Hb 6.9 Ht 20 AL 20,9 AT 275 Ae
    Output : 4810cc 2.22 PT 13.4 APTT 31.5 INR
    Urine 150 cc 1.040 GDS 172 SGOT 9 SGPT 3
    Darah 4000 cc Protein total 7 Alb 2.7 Cr 0.8 Ur
    IWL 50 cc 20 Na 134 K 3.0 Cl 102
    Maintenance 660 AGD Ph 7.390 BE -6.1 PCO2
    30.0 PO2 278
    BC -200cc HT 27 HCO3 18.3 Total CO2
    UO : 75 cc/jam 19.3 O2 saturasi 100
    2500cc Arteri 3.00
    Koloid : 500cc
    Darah 2PRC : 460 cc
    2WB 720cc

    2G Ny. Yuniati Safitri 2 KU baik CM IUGR pada Post SCTP emergency + 30/7/2019 asam mefenamat 500mg/8jam
    P2A0 36th T 121/67 sekundigravida insersi IUD ai fetal distress Hb 11,7,Hct 33,AL 6,2,AT Vit C 80mg/12jam
    I Perempuan 11 tahun N 78 hamil postterm + IUGR pada sekundipara 240,AE 3,44,PT11,1,APTT Mobilisasi bertahap
    2400gr Spt Klinik Rr 18 BDP+ 27,5,INR 0,82,GDA 70,HBSAG Aff infus DC
    hamil postterm dengan
    II Perempuan 2650gr T 36,1 oligohidramnion NR,rotein Kualitatif negatif Awasi KU/VS/tanda perdarahan
    AS 4-7-8 oligohidramnion DPH 2

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