LapJag Minggu 1

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LAPORAN JAGA

Minggu 26 Juli 2015 s.d. Jum’at 31 Juli 2015

Konsulen K !

d". #. $emsi% &'.OG

d". $edd( )it"i% &'.OG

d". Juliant( Kusuma% &'.OG

Pen(a*i!

d". A+,a" No-an

'i Nu"a/ni% &.Ked

#enni &usilaati% &.Ked



AGAN$PAR4MN O&44R $AN GNKOLOG

)AKL4A& K$OK4RAN $AN LM K&#A4AN NR&4A& NGKL

RMA# &AK4 MM $ARA# $R. M. N& NGKL

2015

LAPORAN JAGA

Minggu 26 Juli 2015 s.d. Jum’at 31 Juli 2015

Konsulen VK :

dr. H. Demsi, Sp.OG

dr. Deddy Fitri, Sp.OG

dr. Julianty Kusuma, Sp.OG

O,stet"i )isiologis 3 Pasien

O,stet"i Patologis 12 Pasien

Gine+ologi 7 Pasien

On+ologi 0 Pasien

Meninggal 0 Pasien

4otal 18 Pasien

O&44R PA4OLOG&

1. 26 Juli 201508.30 9

&&4P ai $e:om'ensasi ;o"disN(. N#3<t=JKARN#&

TD : 180100 mmH!

" : 80#mnt,

$$ : %0 #m

S: &',(0)

DG&*%+0 Hamil &'&- min!!u elum inpartu den!an */ De2omp )ordis "3H+ 4V JGH *res5ep*res5ep

6 Os. TV4, His, DJJ 4VFD $7 !tt #menit mi5ro9

)e5 7a4n 7asi# 1#1

"i;edipin ta &#10 m!Konsul Jantun!

$ S) ele5ti;



2< Juli 2015

Konsul dr. 4smir,Sp.J*

6 7asi# e#tra % amp 1 # 1 "i;edipin ta &#10 m!+22 operasi

2> Juli 2015

P+l 0>.10 9

P+l 0>.15 9

7a<ir neonatus pertama <idup, =, %100!r, * >( 2m, +S -?

7a<ir neonatus 5edua <idup, =, %(00!r, * >( 2m, +S -?P+l 0>.20 9 *lasenta la<ir len!5ap

)ollo u'

31 Juli 2015

K@: ai5

TD : 1'0100 mmH!

" : 8%#mnt,

$$ : %0 #m

T: &',(0)

H: 11,% !dl

Keadaan umum pasien ai5, pasien pulan!

2. 26 Juli 2015

9

&&4P ai Kala lama ?dilua"@

N(. $N37t=JKARN#&

TD: 1>080 mmH!

"adi: 110#menit

$$: %0#menit

T: &',(0)

*roteinuria >9

H 44444

D 1>8#m

D G>*&+0 <amil aterm inpartu 5ala 44 lama di luar9 */

JTH pres5ep

6 Stailisasi 1 am

Os. TV4, His, DJJ, tandatanda inpartu

4VFD $7 Amenit

Kateter menetap

4n 6!SO> >0B sesuai proto5ol4n. )e;ota#im % #1 !r

"i;edipin & # 10 m!

)e5 la7apor Dr Julianty Kusuma, SpOG

Saran terminasi peradominam

P+l 13.50 9 7a<ir neonatus <idup , C &'00!r, * (0 2m, +S -?

FT+G+P+l 13.55 9 *lasenta la<ir len!5ap

4ntraoperati; didapat5an lu5a e#tended dan uterus

atoni,dila5u5an masase dan pemerian uterotoni5a

@terus masi< atonia

7apor Dr Julianty Kusuma, SpOG

Diputus5an untu5 dila5u5an <istere5tomi

supra2eri2al)ollo u'

2> Juli 2015

S: Kelu<an E

O: St *resent

TD: 1>080 mmH! ": 10(#mnt

$$: %0#mnt S : &',8o)

+: *>+0 post SST* ai Kala 44 lama diluar9



*: )e;adro5sil %#(00m!

+sam 6e;enamat &#(00m!

*asien ole< pulan!

3. 2< Juli 2015

00.05 9

&&4P ai 'ostte"m ,e+as &; 1B

N(. L9t=$$ ARN#&

TD: 110-0 mmH!

"adi: 8-#menit

$$: %0#menit

T: &','0)

D G%*1+0 <amil >& min!!u elum inpartu den!an e5as

S) 1# ai partus ta5 mau9 JTH pres5ep

6 Os. TV4, His, DJJ, tandatanda inpartu

4VFD $7 !tt ##mnt

)e5 D$, )6

$ terminasi peradominam ele5ti; P+l 08.00 9 7a<ir neonatus <idup, =, &100!r, * (0 2m, +S 8?

FT+G+P+l 08.05 9 *lasenta la<ir len!5ap

)ollo u'

2> Juli 2015

K@: ai5

TD : 1%080 mmH!

" : 8>#mnt,

$$ : %0 #m

T: &',&0)

Keadaan umum pasien ai5, pasien dipulan!5an

7. 2< Juli 2015 6edisinalis

N(. 4$70t=$$ ARN#&

P+l 00.50 9

TD : 1>080 mmH!

": -8# mnt

$$:%0#mnt

T: &'.(o)

H: 10.' !rdl

7eu5osit -.?00 mm&

D G(*&+1 Hamil &> min!!u elum inpartu den!an H+* e.2

susp *lasenta preia totalis JTH *res5ep

6 Os K@, perdara<an, DJJ 4n;us $7 !tt ## menit 4n 2e;ota#im %#1 !r 4n de#a 1# 1%m! % <ari9 "i;edipine >#10 m!

4n Transamin &#(00 m! )e5 la D$, )6$ @SG 5on;irmasi

)ollo u'

31 Juli 2015

Keadaan 'asien ,ai+% 'asien di'ulang+an

5. 2< Juli 2015 +st"a+si )o":e's a.i. P

N(. 20 t=$$ ARN#&

P+l 02.35 9

TD : 1?0100 mmH!

": ?0# mnt

D G1*0+0 <amil aterm inpartu 5ala 4 ;ase a5ti; den!an */

JTH pres5ep



$$:%0# mnt

T: &',(o)

H: ?.- !rdl

*roteinuria :&: ? 2m

DJJ: 1(&#m

6 Stailisasi 1& am

Os TV4, His, DJJ, <is

4VFD $7 !tt ##mnt

Kateter menetap

4n 6!SO> >0B sesuai proto5ol "i;edipine &#10 m!

)e5 la D$,)6

$ *artus pera!inam +5<iri 5ala 44 den!an tinda5an9

07.30 9

TD: 180100

: 7en!5ap

DJJ: 1&-#m

D G1*0+0 Hamil aterm inpartu 5ala % den!an */ JTH

pres5ep

6 *impin persalinan +5<iri 5ala % den!an e5stra5si

;or2eps9

07.75 9 7a<ir neonatus <idup C,perempuan : &(00!r, *: (02m,

7D 7K: &%&1 +S: 8? FT +G+

07.50 9 *lasenta la<ir len!5ap * (10 !r *T* >?2m 18# 1? 2m

Follo up

%8 Juli %01(H : (.> !dl

S: Kelu<an: O: St.present: K@: ai5 TD: 1(0?0mmH! $$: %0#m Sens: )6 ": 8?#m T: &',(I)St.Ostetri:*7: F@T % ari aa< pusat, 5ontra5si ai5, perdara<an a5ti;

9, lo5ia rura, lu5a laserasi tenan!+: *1+0 post e5stra5si For2ep* :

Oserasi TV4, perdara<an

Oat :

)e;adro#il (00 m!8 am*O

+sam me;enamat (00 m!8 am*O

$oorantia ta1% am

$ trans;usi sampai H 8 !r dl

K@ iu dan ayi ai5, pasien ole< pulan!

6. 2> Juli 2015 SST* ai e5lampsia antepartum "y S$>&t<DD+$/"HS

P+l 11.50 9 D G&*%+0 <amil aterm elum inpartu den!an e5lampsiaantepartum JTH *res5ep

TD:1(0100

mmH!

": 8(#mnt

6 Stailisasi &' am suda< di $S DKT9 4VFD $l !tt ##m

)e5 laoratorium 6!sO> >0B sesuai proto5ol



$$: %0#mnt

S : &','o)

"i;edipin &#10 m! Kateter menetap$ Terminasi peradominam7apor dr Deddy Fitri, SpOG +22 terminasi peradominam

P+l 13.15 9 7a<ir neonatus <idup perempuan %>00!, * >' 2m, +S8? FTSG+

P+l 13.20 9 *lasenta la<ir len!5ap

)ollo '

31 Juli 2015

S: Kelu<an E

O: St *resent

TD: 1>0?0 mmH! ": ?8#mnt

$$: %1#mnt S : &',-o)

+: D *&+0 post SST* ai e5lampsia H/77* sindrom*: pasien masi< diraat

<. 28 Juli 2015 SST* ai 5ala 44 lama ta5 2a5ap pera!inam "y. /$&0t<DD+$/"HS

P+l 11.30 9 D G&*%+0 <amil >% min!!u elum inpartu JTH *res5ep

TD: 1%080

mmH!

": 81#mnt

$$: 1?#mnt

S : &',?o)

6 Ost TV4, d, tanda inpartu 4VFD $l !tt ##m )e5 laor 7apor Dr Deddy Fitri, SpOG 4ndu5si persalinan

P+l 20.00 9 D G&*%+0 <amil >% min!!u inpartu 5ala 4 ;ase laten JTH*res5ep6 Os ti, <is, d 4VFD $l !tt ##m Koson!5an 5adun! 5emi<$ /aluasi sesuai parto!ra; HO modi;i5asi ;s +5ti;9 *artus pera!inam

P+l 02.00 9 D G&*%+0 <amil >% min!!u inpartu 5ala 4 ;ase a5ti; JTH*res5ep6 /aluasi sesuai parto!ra; HO modi;i5asi

$ *artus pera!inam

P+l 0>.00 9 D G&*%+0 <amil >% min!!u inpartu 5ala 44 JTH *res5ep

6 *impin persalinan

P+l 08.00 9

H 44

D G&*%+0 <amil >% min!!u inpartu 5ala 44 lama ta5 2a5ap pera!inam JTH *res5ep

6 7apor Dr Julainty Kusuma, SpOGSaran Terminasi peradominam

P+l 10.30 9 7a<ir neonatus <idup la5ila5i &-00 !, * (1 2m +S 8?FT+G+


)ollo '31 Juli 2017

S: Kelu<an E O: St *resent



TD: 1%080 mmH! ": -8#mnt

$$: 1?#mnt S : &',8o)

+: *&+0 post SST* ai 5ala 44 lama ta5 2a5ap pera!inam*: pasien masi< diraat

>. 30 Juli 2015 /5spe5tati; "y /"&%t<D6+$/"HS

P+l 1>.30 9 D G(*&+1 <amil && min!!u elum inpartu den!an */ e5as S) 1# JTH pres5ep

TD : %00110 mmH!

" : 10%#mnt

$$: 1?#mnt

S : &',8o)

6 /5spe5tati; 4VFD $l !tt ##m Kateter menetap 6!SO> >0B sesuai proto5ol "i;edipin &# 10 m! *.O De5sametason 1#1% m! 4V % <ari9

)e5 laoratorium31 Juli 2015

TD : 1'0?0 mmH!

*lt ?0.000mm&

D G(*&+1 <amil && min!!u elum inpartu den!an */JTH *res5ep *artial H/77* sindrom

6 7apor Dr Demsi, SpOGSaran : 7anut5an e5spe5tati;

)ollo u' TD: 1'0?0 mmH! ": ?8#mnt

$$: 1?#mnt S : &-,%o)

*asien masi< diraat di an!sal

8. 30 Juli 2015 /5spe5tati; "y.*O%?t<D6+$/"HS

P+l 02.00 9 D G>*&+0 <amil &' min!!u elum inpartu den!an */JTH pres5ep

TD: 1'0110 mmH! 6 /5spe5tati; 4VFD $l !tt ##m Kateter menetap 6!SO> >0B sesuai proto5ol "i;edipin &# 10 m! *.O De5sametason 1#1% m! 4V % <ari9 )e5 laoratorium

)ollo ' TD 1(0?0 mmH! " : ?0#menit$$: 1?#menitT: &',' o)

31 Juli 2015 D G>*&+0 <amil &' min!!u elum inpartu den!an */JTH pres5ep

)ollo u'

31 Juli 2015

S: 5elu<an O: TD 1(0100 mmH! " : ?0#menit

$$: 1?#menit

T: &',' o

)+: G>*&+0 <amil &' min!!u elum inpartu den!an */



JTH pres5ep*: *asien masi< diraat di an!sal

10. 31 Juli 2015 Pa"tus Pe"-aginam

N(. #25t=$MARN#&

10.559

TD : 1%0-0 mmH!

" : ?% #mnt,

$$ : %0 #m

T: &',(0)

> 2m

H: 11!rdl

@SG: 5 <amil &&

min!!u JTH pres5ep

poli<idramnion

D G%*1+0 <amil && min!!u inpartu 5ala 4 ;ase a5ti; JTH pres5eppoli<idramnion

6 Oserasi TV4, His, DJJ4VFD $7 !tt ##mnt)e;ota#ime in %#1 !r 4VDe#ametason in 1#1% m! 4V)e5 la D$, @$

$ *artus pera!inam

13.00 9 D G%*1+0 <amil && min!!u inpartu 5ala 44 JTH pres5eppoli<idramnion$ *artus pera!inam

13.30 9 7a<ir neonatus <idup perempuan 1800! * >' 2m +S8? *T+G+13.35 9 *lasenta la<ir len!5ap

)ollo ' S: Kelu<an E

O: St *resent

TD: 1%0-0 mmH! ": 8(#mnt

$$: %0#mnt S : &','o)

+: *%+0 post *artus *era!inam*: 4VFD $7 !tt ##mnt

)e;ota#ime in %#1 !r 4V

De#ametason in 1#1% m! 4V

11. 31 Juli 2015 Pa"tus Pe"-aginam

N(.$A3>t=$MARN#&

P+l 13.10 9

TD 1%080 mmH!

" ?'#m

$$ %% #m

T &8 o)

D G(*>+0 <amil aterm inpartu 5ala 4 ;ase laten JTH pres5ep Os Feris e.2 Typ<oid ;eer

6 Os TV4, His, D

4VFD $l !tt ##m )e5 laoratorium



*)T &#(00 m! )e;tria#on %#1 ! 4V ST9$ /aluasi sesuai parto!ra; HO modi;i5asi Fs +5ti;9 *artus pera!inam

P+l 15.30 9 D G(*>+0 <amil aterm inpartu 5ala 4 ;ase a5ti; JTH

pres5ep Os Feris e.2 Typ<oid ;eer 6 /aluasi sesuai parto!ra; HO modi;i5asi

$ *artus pera!inam

P+l 20.00 9 D G(*>+0 <amil aterm inpartu 5ala 44 JTH pres5ep OsFeris e.2 Typ<oid ;eer 6 *impin persalinan

P+l 20.25 9 7a<ir neonatus <idup perempuan &%00 ! * (0 2m +S8? FT+G+


)ollo ' S: Kelu<an demam

O: TD 1%0-0 mmH!

" -8#m

$$ %1 #m

T &-,? o)+: *(+0 Os Feris e.2 Typ<oid ;eer *: 4VFD $l !tt ##m *)T &#(00 m! )e;tria#on %#1 ! 4V ST9

1% 30 Juli 2015 6edisinalis "y.+"%?t<DD+$

D *1+0 post SST* 10 <ari diluar9 den!an oundde<is2en2e6 Os TV4 4VFD $l !tt ##m )e;tria#on %#1 ! 4V ST9 6etronidaLol &#(00 m! 4V Gentamisin %#80 m! 4V +sam me;enamat &#(00 m! )e5 laor

*eraatan lu5a

$ $e<e2tin!)ollo ' S: Kelu<an 9

O: TD 1%080 mmH!

" 8%#m

$$ %1 #m

T &'.8+: *1+0 post SST* 1% <ari diluar9 den!an oundde<is2en2e*: Os TV4 4VFD $l !tt ##m

)e;tria#on %#1 ! 4V ST9 6etronidaLol &#(00 m! 4V



Gentamisin %#80 m! 4V +sam me;enamat &#(00 m! )e5 laor

*eraatan lu5a

GNKOLOG $AN ONKOLOG

1. 26 Juli 2015 Ku"etase ai a,. n+om'lit

N(. 36t= $$ ARN#&

%1.1( 4

TD : 1%080 mmH!

" : 8%#mnt,$$ : %0 #m

T: &','0)

D + 4n5omplet

6 Oserasi TV4, perdara<an

4VFD $7 !tt ##mnt 4ne5si 2e;ota#ime %#1!

2< Juli 2015

P+l 08.00 9

Fetus 9

D +ortus in5omplit6 Kuretase

P+l 08.30.00 9 Dila5u5an 5uretase dan didapat5an dara< dan arin!anM&022

)ollo u'

2> Juli 2015

K@: ai5

TD : 1%080 mmH!

" : 8>#mnt,

$$ : %0 #m

T: &',&0)

H: 11,? !rdl


2. 2> Juli 2015

P+l 17.00 9

Ku"etase ai ,lig=ted o-um

N(. AA32t= $$ ARN#&TD: 110-0 mmH!

": 8% #m

$$: %0#mnt

T: &',( 0)

*T test 9

@S: GS intrauterine

Fetal pole NN

5 <amil 10 m!! JTH

intrauterine

D +ortus imminens

6 6edisinalis

edrest

Os. TV4, perdara<an

4VFD $7 !tt ##mnt

)y!est 1#1 a!inal supp

Hystolan %#1% ta

)e5 D$

$ @SG 5on;irmasi



28 Juli 2015

*5l. 0?.00 4

@SG Kon;irmasi:

5 li!<ted oum

6 $ 5uretase*5l 1%.00 4 Didapat5an dara< dan arin!an M (0 22

)ollo u'

30 Juli 2015

K@: ai5

TD : 1%080 mmH!

" : 80#mnt,

$$ : %0 #m

T: &',&0)

H: 10,(


3. 2< Juli 2015 #iste"e+tomi &u,total N(.MA70t= $$ARN#&

*5l11.>( 4

TD : 1%0-0 mmH!

" : 8%#mnt,

$$ : %0 #m

T: &',&0)

H:11

D 6yoma !eurt

6 Os TV4, perdara<an

4VFD $7 !tt ##mnt

4ne5si transamin &#1amp 4V

+sam me;enamat s&#(00m! ta

)e5 la D$

$ <istere5tomi ele5ti;9

)ollo u'

30Juli 2015

K@: ai5

TD : 1%0-0 mmH!

" : 80#mnt,

$$ : %0 #m

T: &',&0)

D *ost <istere5tomi sutotal ai myoma !eurt

Keadaan umum pasien ai5, pasien masi< diraat

7. 2> Juli 2015 Pe",ai+an Keadaan mum

Nn. $A1>t= $$ARN#&

P+l 12.00 9

TD : 1>080 mmH!

": ?8#menit

$$: %0# menit

S: &',8 )

Hasil 7a

H : (,( !rdl

$ PA e.: sus' O1

M Oserasi TV4 4VFD $7 !tt ##m +sam Trane5samat 4n 1 amp +sam 6e;enamat &#(00 m! ta

R Trans;usi sampai H 8 !rdl



)ollo u'

30 Juli 2015

K@: ai5

TD : 1&0-0 mmH! " : 80#mnt,

$$ : %0 #m

T: &',&0)

H : 8.8 !dl

Keadaan umum ai5, pasien dipulan!5an

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