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Morning report kasus pre op
1.
MORNING REPORT 28 MARET
2015 ------------------------------------------- ------
2.
IBS ELEKTIF
3.
1. OK VII/NY.
SUMIATI/23/TERATAI DX: G3P0A2, H 9 MINGGU DENGAN BLIGHTED OVUM PRO: KURETASE DPJP: DR. SYAFRIL S., SP.OG RPS: FLEK DARI VAGINA 3 HARI YANG LALU RPD: RIWAYAT DM (-) HT (-) ASMA (-) JANTUNG (-) ALERGI (-) OPERASI (-) TRAUMA (-) PENYAKIT LAIN (-) KU/KES: BAIK/CM A: CLEAR (+), GIPONG (-), GISU (-), GIYANG (-), MP 2 B: SPONTAN (+) RR 20X/MENIT, SD VES (+/+), RBH (-/-), RBK (-/-), WH (-/-) C: TD 110/70, HR 108X/MENIT, S1>S2, N(-) G(-) D: TIDAK NAMPAK DISABILITAS, SUHU 36,5OC BB/TB : 66/155
4.
HASIL LAB 27/3/15 HB
: 13,7 LEU: 12780 HT: 39% ERIT 5,2 JUTA TROMBO 276000 PT 10,3 APTT 33,8 KESIMPULAN : ASA I
5.
2. OK VII/NY.
JANAH/47/TERATAI DX: SUSP.CA ENDOMETRIUM PRO: KURETASE DPJP: DR. SYAFRIL S., SP.OG RPS: PERDARAHAN SUDAH 10 HARI, 5-6X GANTI PEMBALUT, NYERI DI PERUT DAN PINGGANG RPD: RIWAYAT DM (-) HT (-) ASMA (-) JANTUNG (-) ALERGI (-) OPERASI (-) TRAUMA (-) PENYAKIT LAIN (-) KU/KES: SEDANG/CM A: CLEAR (+), GIPONG (+ MOLAR BAWAH BILATERAL), GISU (-), GIYANG (-), MP 1 B: SPONTAN (+) RR 16X/MENIT, SD VES (+/+), RBH (-/-), RBK (-/- ), WH (-/-) C: TD 140/80, HR 80X/MENIT, S1>S2, N(-) G(-) D: TIDAK NAMPAK DISABILITAS, SUHU 36,5OC
6.
HASIL LAB 27/3/15 HB
: 8 LEU: 10010 HT: 23% ERIT 2,9 JUTA TROMBO 304000 UREUM 50,9 KREATININ 3,2 KESIMPULAN : ASA III
7.
3. NY.SITI ROIMAH/38/FLAMBOYAN DX:
P3A1 POST PARTUS SPONTAN PLASENTA RESTAN PRO: KURETASE RPS: TIDAK ADA KELUHAN RPD: RIWAYAT DM (-) HT (-) ASMA (-) JANTUNG (-) ALERGI (-) OPERASI (-) TRAUMA (-) PENYAKIT LAIN (-) KU/KES: BAIK/CM A: CLEAR (+), GIPONG (-), GISU (- ), GIYANG (-), MP 2 B: SPONTAN (+) RR 16X/MENIT, SD VES (+/+), RBH (-/-), RBK (-/- ), WH (-/-) C: TD 120/80, HR 80X/MENIT D: TIDAK NAMPAK DISABILITAS, SUHU 36OC
8.
HASIL LAB 26/3/15 HB
7 LEU 12800 HT 20 ERIT 2,6 JUTA TROMBO 234000 ASA II
9.
OK IGD ELEKTIF
10.
4. NY. EVA
TRI H/34 TH/FLAMBOYAN DIAGNOSIS : G2P1A0 H31 MG DG PEB PRO : SC + MOW RPS : tidak ada keluhan RPD : HT (diluar kehamilan) (-) HT (selama kehamilan) (+) DM (-) ALERGI (-) ASMA (-) TRAUMA (-) JANTUNG/PARU (-) RIW OP (+) SC DG RA 4,5 YLL A : CLEAR (+) GIYANG (-) GIPONG (-) GISU (-) TRISMUS (+) MP 2 B: SPONTAN (+) RR 20X/M REG. SD VES (+/+) RBK (-) RBH (-) WH (-) C: TD 200/120 MMHG. N 80X/M S1>S2 M(-) G(-) GCS 15/ BB 106,5 KG/ TB 169 CM
11.
UREUM 16,5 CR` 0,61 GDS
71 LAB (26/3/2015) HB 13,6 LEU 14570 ↑ HT 38 ERIT 4,8 JT TROMB 337.000 PT 8,9 APTT 31,5 KESIMPULAN : ACC ASA II
12.
5. NY. TRI
HARTANTI/38 TH/FLAMBOYAN DIAGNOSIS : G3P2A0 H41 MG RIW.SC 2X PRO : SC + MOW RPS : tidak ada keluhan RPD : HT (diluar kehamilan) (-) HT (selama kehamilan) (-) DM (-) ALERGI (-) ASMA (-) TRAUMA (-) JANTUNG/PARU (-) RIW OP (+) SC 2003 DAN 2007 RA A : CLEAR (+) GIYANG (-) GIPONG (-) GISU (-) MP 1 B: SPONTAN (+) RR 20X/M REG. SD VES (+/+) RBK (-) RBH (-) WH (-) C: TD 130/70 MMHG. N 60X/M S1>S2 M(- ) G(-) GCS 15/ BB 73 KG/ TB 154 CM
13.
LAB (27/3/2015) HB 8
↓ LEU 7810 HT 25 ↓ ERIT 3,4 JT ↓ TROMB 378.000 PT 9,4 APTT 31,9 GDS 86 KESIMPULAN : ACC ASA II
14.
6. NY. SUYANTI/36
TH/FLAMBOYAN DIAGNOSIS : G3P2A0 H39 MG PP MARGINALIS KISTA GINJAL PRO : SCTP + MOW RPS : KENCENG2, PINGGANG SAKIT RPD : HT (+ SEJAK 2 TAHUN YLL) DM (-) ALERGI (-) ASMA (-) TRAUMA (-) JANTUNG/PARU (-) RIW OP (-) A : CLEAR (+) GIYANG (-) GIPONG (+ PREMOLAR SUPERIOR INFERIOR DEXTRA) GISU (-) MP 2 B: SPONTAN (+) RR 20X/M REG. SD VES (+/+) RBK (-) RBH (-) WH (-) C: TD 130/70 MMHG. N 64X/M S1>S2 M(- ) G(-) GCS 15/ BB 58 KG/ TB 151 CM / SUHU 36
15.
LAB (27/3/2015) HB 11,4 LEU
7950 HT 33 ERIT 3,7 JT TROMB 206.000 PT 9 APTT 32,1 UREUM 23,3 KREATININ 0,8 GDS 86 KESIMPULAN : ACC ASA II
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