TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
Panik 8 oktober_2015_fm ruangan
1. Duty Team :
1. dr. Rizky Fachriza Harahap
2. dr. Mashdarul Ma’arif
3. dr. Handri RV
Department of Obstetric and Gynecology
Faculty of Medicine University of Sumatera Utara
Adam Malik General Hospital
2015
Fetomaternal Ward Report
Thursday, October 8th 2015
3. 1. Mrs. M, 32 years old, P4A0
Dx: Post C – Section dt Hep-B +Prev C-Section 1x + Post
Pommeroy Sterilization + PD 2
Plan : Oral Therapy
Check Anti HbsAg, HbsAb
Consult to Gastroentero Hepatology
Supervisor : dr.Iman Helmi Effendi, M.Ked (OG), SpOG.K
Resident : dr. Rizky
Length of stay : 5 days
4. Follow up Monday, 6th October 2015 8 am
Chief Complaint: -
Present state
Level of Cons : Alert Anemic : (-)/(-)
BP : 110/80 mmHg Icteric : (-)/(-)
HR : 82 times/minute Cyanosis : (-)
RR : 20 times/minute Dyspnea : (-)
Temperature : 36,5 0C Oedem : (-)
Generalized state
Head : Eye : Conjuctive Palpebra Inferior anemic -/-, icteric -/-
Nose : Within normal limit
Ear : Within normal limit
Mouth : Within normal limit
Neck : JVP R-2 cmH2O, enlargement of lymph node(-)
5. Thorax :
Breathing sound : Vesicular
Heart : Cor S1S2 (N)
Localized State :
Abdomen : asymmetrical enlargement
Fundal height : 3 finger below bpx
Tension : Left
Lowest art : Head
Movement : (+)
His : (-)
Fetal Heart rate : 148 x/I
6. Diagnosis : Hep B + Prev CS 1x + MG + IUP (38-40) wga + Head Presentation + Live
fetus
Therapy :
- IVFD RL 20 gtt/i
- Inj Cefazolin 2 gr prophylaxis skin test
- Foley Catheter
Plan :
- C-section on October 6th 2015 in Emergency OT
- Consult to Anesthesiology
- Consult to Perinatology
7. Follow up Wednesday, October 7th 2015 8 am
Chief Complaint: Pain
Present state
Level of Cons : Alert Anemic : (-)/(-)
BP : 110/70mmHg Icteric : (-)/(-)
HR : 92 times/minute Cyanosis : (-)
RR : 20 times/minute Dyspnea : (-)
Temperature : 36,7 0C Oedem : (-)
Generalized state
Head : Eye : Conjuctive Palpebra Inferior anemic -/-, icteric -/-
Nose : Within normal limit
Ear : Within normal limit
Mouth : Within normal limit
Neck : JVP R-2 cmH2O, enlargement of lymph node(-)