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Laporan Kasus KJDR
Laporan Kasus KJDR
Name Age Address Admitted to Hospital : : : : Mrs. D 21 years old Pemenang, KLU Oct 23th 2012
SUBJECTIVE Patient pregnant 6 month came to obstetric Policlinic confessed hadnt feel fetal movement since 1 weeks ago (17/10/12). 2 Days ago patient have go to TBA to examine her gestation. No history of TBA massage. Abdominal pain (-), history rupture of membrane (-), bloody slim (-). History of HT, DM, asthma (-) LMP : 18/04/12 EDD : 25/01/13 History of ANC : 3x at Polindes Last ANC : 11/10/2012 Resut : Normal Histori of USG : Never History of family planning : (-) Next family planning : Injection 3 month Obstetrical History : 1. This
OBJECTIVE General Status : GC : well Cons : CM E4V5M6 BP : 110/70 mmHg PR : 88 bpm RR : 20 bpm T : 36,Oc Local Status : Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single regular, murmur (-), gallop (-). Pulmo : vesicular (+/+), wheezing (-), rhonki (-). Abdomen : scar (-), striae gravidarum (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+) Obstetrical Status : L1 : breech L2 : back on left side L3 : head L4 : 5/5 UFH : 20 cm UC : (-) FHR : (-) VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.
PLANNING - Observation mother well being. - DM consult to SPV suggest termination with oxytocin drip. SPV acc
TIME
SUBJECTIVE
OBJECTIVE Lab Examination : Hb : 11,2 g/dl HCT : 36,6% RBC : 4,06 M/uL WBC : 9,20 K/uL PLT : 178 K/uL HbsAg : (-)
ASSESMENT
PLANNING
12.00.
General Status : GC : well Cons : CM E4V5M6 BP : 120/70 mmHg PR : 100 bpm RR : 20 bpm T : 36,3oC UC: (-) UC: (-) UC: (-) UC: (-) UC: (-) UC: (-)
UC: (-) UC: (-) UC: (-) UC: (-) UC: (-) UC: 1x10 ~10 UC: 2x10 ~15 General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 92 bpm RR : 20 bpm T : 36,5oC UC: 2x10 ~15 UC : 2x10 ~15 UC : 2x10 ~15
19.00 19.30
40 dpm 40 dpm
20.00
UC : 2x10 ~20
40 dpm
20.30
40 dpm
21.00
General Status : GC : well Cons : CM E4V5M6 BP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,7oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.
SUBJECTIVE
OBJECTIVE General Status : GC : well Cons : CM E4V5M6 BP : 120/70 mmHg PR : 100 bpm RR : 20 bpm T : 36,3oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 92 bpm RR : 20 bpm T : 36,5oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal &
ASSESMENT
PLANNING - SPV visite to VK teratai advice Insertion misoprostol 100 mcg/6 hours
16.00
22.00
General Status : GC : well Cons : CM E4V5M6 BP : 120/80 mmHg PR : 96 bpm RR : 20 bpm T : 36,7oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. General Status : GC : well Cons : CM E4V5M6 BP : 110/70 mmHg PR : 80 bpm RR : 20 bpm T : 36,3oC UC: :2x10 ~20 VT : 1cm, eff. 25 %, Amnion (+) clear, head palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord.
04.00