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    Laporan Jaga 23 September 2019

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    Strawhat Games
    1. A 26-year-old woman, G3P2A0 at 13-14 weeks of gestation, presented with vaginal bleeding since 1:30 pm. On examination, the cervix was closed and no retained products of conception were seen. A diagnosis of threatened abortion was made. She was given ceftriaxone and tranexamic acid injections and scheduled for ultrasound the next day. 2. A 33-year-old woman, G2P1A0 at 38-39 weeks of gestation, presented with lower abdominal pain and contractions. Examination found an IUFD. She was given IV fluids and scheduled for consult and observation. 3. A 42-year-

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    Laporan Jaga 23 September 2019

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    1. A 26-year-old woman, G3P2A0 at 13-14 weeks of gestation, presented with vaginal bleeding since 1:30 pm. On examination, the cervix was closed and no retained products of conception were seen. A diagnosis of threatened abortion was made. She was given ceftriaxone and tranexamic acid injections and scheduled for ultrasound the next day. 2. A 33-year-old woman, G2P1A0 at 38-39 weeks of gestation, presented with lower abdominal pain and contractions. Examination found an IUFD. She was given IV fluids and scheduled for consult and observation. 3. A 42-year-

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    1. A 26-year-old woman, G3P2A0 at 13-14 weeks of gestation, presented with vaginal bleeding since 1:30 pm. On examination, the cervix was closed and no retained products of conception were seen. A diagnosis of threatened abortion was made. She was given ceftriaxone and tranexamic acid injections and scheduled for ultrasound the next day. 2. A 33-year-old woman, G2P1A0 at 38-39 weeks of gestation, presented with lower abdominal pain and contractions. Examination found an IUFD. She was given IV fluids and scheduled for consult and observation. 3. A 42-year-

    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    9 views12 pages

    Laporan Jaga 23 September 2019

    Uploaded by

    Strawhat Games
    1. A 26-year-old woman, G3P2A0 at 13-14 weeks of gestation, presented with vaginal bleeding since 1:30 pm. On examination, the cervix was closed and no retained products of conception were seen. A diagnosis of threatened abortion was made. She was given ceftriaxone and tranexamic acid injections and scheduled for ultrasound the next day. 2. A 33-year-old woman, G2P1A0 at 38-39 weeks of gestation, presented with lower abdominal pain and contractions. Examination found an IUFD. She was given IV fluids and scheduled for consult and observation. 3. A 42-year-

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    LAPORAN KOASS JAGA UMUM

    DEPT OBGYN RSUD RADEN


    MATTAHER JAMBI
    23-09-2019 (14.00-07.00)

    KOAS :
    FAHMI, RISKI AYU, HANIFA, MENTARI
    •REKAPITULASI PASIEN BANGSAL

    VK BAN GD GD PINA MAY ICU ICCU HCU


    GSA KL 1 KL 2 NG ANG
    L
    OBS 2 - - - - - - - -
    GIN - 2 - - - - - - -
    I. Kamar Bersalin VII. Rencana Tindakan Operasi
    A. Partus Fisiologis :-
    a. Obstetri mayor :-
    B. Partus Patologis :-
    C. Tindakan Obstetri :- b. Ginekologi mayor :-
    D. Tindakan Ginekologi :- c. Obstetri sedang dan minor :-
    d. Ginekologi sedang dan minor :-
    II. Kamar Operasi Mayor
    A. KOM Obstetri :-
    B. KOM Ginekologi :-

    III. Kamar operasi sedang dan minor


    A. Obstetri :-
    B. Ginekologi :-

    IV. Pasien baru


    A. Obstetri :2
    B. Ginekologi :2

    V. Pasien bermasalah
    A. Obstetri :-
    B. Ginekologi : -

    VI. Pasien sisa kamar bersalin : -


    PASIEN BARU
    1. Ny.U/24 tahun/G1P0A0 hamil 40-41 minggu/MRS 23-09-2019 17.45 wib /dr. Essy Octavia, Sp.OG/
    Koass hanifa-fahmi

    S : pasien datang dengan keluhan keluar air-air sejak >12 jam SMRS. Disertai nyeri perut yang menjalar (+).
    Lendir darah (+)
    HPHT: 12-12-2018 TP 19=9-2019
    O: TD = 110/70 mmHg, HR=80x/i, RR= 20 x/i, T= 36,2 C

    PF : Generalisata: dbn
    TFU: 32 cm TBJ: 3255 gram
    DJJ: 145x/menit
    His: 1 x 10’/ 10”
    Leopold: JTH IU preskep

    Laboratorium:
    VT:
    • WBC: 12,93 x 10*9/L
    Portio: medial, kaku
    • RBC: 4,81 x 10*12/L
    Eff: 40%
    • HGB: 13,4 g/dL
    Pembukaan: 2 cm
    • PLT: 299.000
    Ketuban: -
    • HCT: 43,1%
    Penurunan: Hodge I
    • GDS: 102 mg/dL
    A: G1P0A0 hamil 40-41minggu inpartu kala 1 fase laten+ JTH
    IU preskep+ KPD

    P:
    - IVFD RL 20 tpm
    - Inj. Ceftriaxone 2x1 gr
    - Observasi kemajuan persalinan
    1. Ny.S/33 tahun/G2P1A0 hamil 38-39 minggu/MRS 23-09-2019 22.40 wib /dr. Zul Andriahta, Sp.OG/
    Koass mentari-riski ayu

    S : pasien datang dengan keluhan nyeri dan kram pada perut bagian bawah, keluar air-air (+), lendir darah (-)
    HPHT: 25-12-2018 TP : 1- 10- 2019
    O: TD = 110/80 mmHg, HR=88x/i, RR= 22 x/i, T= 36,5C

    PF : Generalisata: dbn
    TFU: 28 cm TBJ: 2.480 gram
    DJJ: 140x/menit
    His: -
    Leopold: JTH IU preskep

    VT:
    Laboratorium:
    Portio: medial, kaku
    • WBC: 9000 x 10*9/L
    Eff: 0%
    • RBC: 4,02 x 10*12/L
    Pembukaan:-
    • HGB: 11,1 g/dL
    Ketuban: +
    • PLT: 267.000
    Penurunan: Hodge I
    • HCT: 33,6%
    • TSH: 1,34
    • FT4N: 18,71
    A: G2P1A0 hamil 38-39 minggu JTH IU preskep+
    oligohidroamnion+ hypertiroid terkontrol+ KPD 1 hari

    P:
    - IVFD RL 20 tpm
    - Cek T3,T4, TSH
    - Konsul penyakit dalam
    - observasi
    1. Ny.S/26 tahun/G3P2A0 hamil 13-14 minggu/MRS 23-09-2019 18.15 wib /dr. Panggayuh, Sp.OG/
    Koass hanifa-fahmi

    S : Pasien mengaku keluar darah sejak jam 13.30 wib, darah keluar seperti darah haid, berwarna merah segar,
    tidak bergumpal, mules (+)
    HPHT: 17-6-2019 TP : 24-3-2020
    O: TD = 100/70 mmHg, HR=80x/i, RR= 20 x/i, T= 36,5C

    PF : Generalisata: dbn
    TFU: tidak teraba
    DJJ: -
    His: -
    Leopold: -

    Inspekulo: portio licin, OUE tampak Laboratorium:


    tertutup, tidak terdapat sisa • WBC: 7,77x 10*9/L
    jaringan • RBC: 4,42 x 10*12/L
    • HGB: 11,6 g/dL
    • PLT: 240.000
    • HCT: 36,3%
    • GDS : 76
    A: G3P2A0 hamil 13-14 minggu dengan AB imminens
    P:
    - Inj. Ceftriaxone 2x1 gr
    - Inj. As tranexamat 1 gr
    - R/ USG besok
    1. Ny.S/42 tahun/P6A0 H3/MRS 23-09-2019 121.20wib /dr.Zul Andriahta, Sp.OG/ Koass mentari-riski
    ayu

    S : pasien datang dengan keluhan menstruasi lama yaitu 17 hari


    O: TD = 110/60 mmHg, HR=88x/i, RR= 22 x/i, T= 36,5C

    PF : konjungtiva : anemis (+/+)

    Laboratorium: A: perdarahan pervaginam (PUA)


    • WBC: 9,38 x 10*9/L dengan anemia berat
    • RBC: 2,57 x 10*12/L
    • HGB: 3,8 g/dL
    • MCV: 60,9 P: inj. Ceftriaxone 2x1
    • MCH: 14,8 as. Tranexamat 3x500 mg
    • MCHC: 242 R/ transfusi 2 kolf/hari
    • PLT: 390.000
    • HCT: 15,7%
    • GDS : 118

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