MR 07.11.15 Labda Karya RESOG

8/18/2019 MR 07.11.15 Labda Karya RESOG

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GOOD

MORNINGMORNING REPORT

DUTY ON : SATURDAY, NOVEMBER 7th 2015


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Visi program studi Obstetri dan GinekologiMenjadi lembaga pendidikan spesialis obstetri dan ginekologi

yang unggul, mandiri, dan berbudaya serta mampu bersaing di

tingkat Nasional, Regional dan Global.

Misi program studi Obstetri dan Ginekologi• Melaksanakan dan mengembangkan Good ClinicalGovernance

• Meningkatkan penyelenggaraan pendidikan dokter spesialis

obstetrik dan ginekologi yang profesional, unggul, mandiri dan

berbudaya.• Meningkatkan penelitian dasar dan terapan baik di Program

Studi maupun bekerja sama dengan lembaga nasional maupun

internasional.• Meningkatkan pengabdian masyarakat dengan melibatkan

sivitas akademika, alumni, dan stakeholder.


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MORNING REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015

RESIDENTS : WSTGIR!DP"S#TT!P"!#TS$WW!PR!I"G!P"WID"SDW%MN

&'IE( : !)%

S*PERVISOR : Pro+, SW

RES*ME O( OPER!TIVE PRO&ED*RE

I, O%STETRI& II, G#NE&O)OGI&

Vaginal deli-er. : &urettage : /

Spontan deli-er. : 0 )aparatom. :

%ra12t : Ot2ers : /

VaE : (E : /

Indu1tion"!ugment :

&S : /

Ot2ers :

RES*ME O( INW!RD P!TIENTIII, IN)!%OR MS"R!TN! :

'&* : &empaka O%S :

I&&* : &empaka G#N :

I&* : Ot2ers :


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MORNING REPORT DUTY ON : SATURDAY, NOVEMBER 7th 2015

OPER!TING ROOM S&'ED*)E : MOND!#3 NOVEM%ER 4t2 05/6

N5 Name !ge Parit. Ward Diagnosis Pro1edure Operator OR

/, #EN 07 .oP5

marriedM'T

O-arian &.st 8 Primar.In+ertilit.

9I&D : N;7,03 N4,/=

)aparotomi ?(@(allopian Tubes

Paten1. Test

dr, !RT3OAG 9&=

I


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/, !RI3 04 .o W!P

N5 D!T! %!SED!SSESS

MENT

PRO%)EM

)IST

I&D P)!N O( &!RE

/, !namnesis 9I&D I : ;4,57= :Re+erred +rom midBi+e Bit2 G/P5555!"S") 2.pertension 9/


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/, !RI3 04 .o W!P

N5 D!T! %!SED!SSESS

MENT

PRO%)EM

)IST

I&D P)!N O( &!RE

0, P2.si1al Eamination 9I&D I ;4,57=W"' : 6;"/>;Present state :%P : /> bpm

VT 9G!P= 54,55 pm : &D 0 1m3 e++ 063 !M 9=

'ead palp3 SS trans-erse3 J'I *npalp small part" umb 1ord

O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY, NOVEMBER 7th 2015


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/, !RI3 04 .o W!P

N5 D!T! %!SED!SSESS

MENT

PRO%)EM

)IST

I&D P)!N O( &!RE

7,

>,

*SG 9I&D I : ;;,30"/036!lb : 7346

%*N"S& : //"53/, Risk o+

in+e1tion

O,/>,/O>0,/

Inter-ention :/,!nti SeiKure0,!nti '.pertension7,Ep, -aginal deli-er.a11elarated 0nd stage o+labor >,antibioti1Target :

/,No SeiKure0,M!P L /06 mm'g7,%orn bab. -igorousl.and mot2er in agood1ondition>,Redu1e in+e1tionInstru1tion:T:/,MgSo>F Guidelines

0,Ni+edipine 7 /5 mg9IO=7,Ep, -aginal deli-er.a11elarated 0nd stage o+labor Bit2 (E>,!moi1ilin 7655mg 9io=M : &3 VS3 ('%3 *&3impending e1lampsia Aintoi1ation MgSO>&IE



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/, !RI3 04 .o W!P

N5 D!T! %!SED !SSESSMENT PRO%)EM I&D P)!N O( &!RE

!t 55,/6 am&D : > 1m

Progress o+ labor:!t 5>,/6 amPatient urge to bear doBn

E-aluation:!bdomen :

*& 98= >6"/5 F >5>6H ('% 98= /60 bpmVT 9W!P= !t 5>,/6 am: &D 1omplete3 !M 9= 'ead palp3 O!3 J'III8

0nd stage o+ labor

7rd stage o+ labor

I! I"


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O%STETRI& EMERGEN ROOM REPORT


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0, #*)3 7> .o 'ospitaliKed : 55 Beeks da.s3 S")3Se1ondar. Primi3 /st stage o+ labor 9ROM=

E(W: 77>4 g

EDD: 5/"//"05/6

Progress O+ )abor:!t 57,>5 pmPatient urge to beardoBn

Present st :%P : /05";5 P : ;5RR : 05 Ta : 7,4

General state :E.e : anemi1 9=T2ora :

&or : S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8


*& 98= >6"/5 F >5>6H ('% 98= /60 bpmVT 9!DP= !t 57,>5 pm: &D 1omplete3 !M 9= 'ead palp3 O!3 J'III8 *npalp small part"umb 1ord

0nd stage o+labor

; pmSpontaneousl. born

bab. 3 7565g3-igorousl.



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0, #*)3 7> .o !DP

S & ! I&D P

7rd

stage o+labor I&D I

@4


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7, S!D3 7/ .o T!P

N5 D!T! %!SED!SSESS

MENTPRO%)EM

)ISTI&D P)!N O( &!RE

/, !namnesis 9I&D I : ;4,57= :Re+erred +rom %alimed 2ospital Bit2G/P55553 7;74 Beeks3 > .earsin+ertile3PROM3 &TGpatologi1"suspi1iousWater. -aginal dis12arge 98= sin1e5


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7, S!D3 7/ .o T!P

N5 D!T! %!SED!SSESS

MENTPRO%)EM


0, P2.si1al Eamination 9I&D I ;4,57=W"' : Ta : 7,<General st :E.es : anemi1 9=

T2ora : &or :S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8Obstetri1 state :!bd : (' 7 +grs bp 97/1m=3 O 4/5 *& 98= 07"/5F7576H

('% 98= />; bpm

VT 9G!P= //,55 pm : &D > 1m3 e++ 653 !M 9=

'ead palp3 )O trans-erse3 J'I *npalp small part" umb 1ord

O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY , NOVEMBER 7th 2015



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7, S!D3 7/ .o T!P

N5 D!T! %!SED!SSESS

MENTPRO%)EM


7,

>,

*SG 9I&D I : ;;,.ears3/st stage o+labor 9ROM=

E(W :7/5< g

/,In )abor 0,ROM

O;5,5O>0,/N4


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7, S!D3 7/ .o T!P

N5 D!T! %!SED !SSESSMENT PRO%)EM I&D P)!N O( &!RE

Progress o+ labor:!t 57,75 amE-alution > 2ours


*& 98= 7>"/5 F 76>5H ('% 98= /70 bpm

VT 9T!P= !t 57,55 am: &D ; 1m3 e++ .ears3/st o+ labor 9ROM=

E(W :77>g

Instru1tion:T:/,Ep, -aginal deli-er.0,!moi1illin 7 655 mg9IO=

M : manage F P W'O




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7, S!D3 7/ .o T!P

S O ! I&D P

Progress o+ labor !t 57,75 am patienturge to bear doBn3

E-aluation:!bd :

*& 98= >6"/5HF>5>6 ('% 98= />5 bpm

VT 9T!P=&D 1omplete3 !M 9='ead palp3 O!3 J'III8

*npalp small part" umb1ord

0nd stage o+labor

7rd stage o+labor

Instru1tion :Pd : T :)ead to bear doBn

!t 57,>5 am3 born bab. 3 0465 g3 -igorous3

episiotom. 98=

T :Management a1ti-e 7rdstage o+ labor

!t 57,>6 pm3 bornpla1enta 1omplete3done perineal 2e1ting



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N5 D!T! %!SED!SSESS

MENTPRO%)EM


/, !namnesis 9I&D I : ;4,57= :Re+erred +rom P'& I Denpasar TimurBit2 G/P55553 7< Beeks > da.s3bree12 pres3 S")3 PROM,Water. -aginal dis12arge 98= sin1e5/,55 am 9;"//"/6=, )abor pain 9=3 (M98=, $noBn bree12 pres sin1e s2e1ame to P'& 9"50"05/6EDD : //"//"05/6PN& : midBi+e3 OAG

Obstetri1 2istor. :

/,&urrent pregnan1.

*nmarried&ontra1eption:




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>, $!T3 /; .o G!P

N5 D!T! %!SED!SSESS

MENTPRO%)EM


0, P2.si1al Eamination 9I&D I ;4,57=W"' : 5"//Present state :%P : /05";5 RR : 05P : ;> Ta : 7,6General st :E.es : anemi1 9=T2ora : &or :S/S0 sgl3 reg3 m 9= Po : Ves 8"83 r2 "3 B2 "!bd : F Obstetri1 stateEt : Barm 8"8 8"8Obstetri1 State:!bdomen : (' 7 +inger bp 97< 1m=3 B>"6

)! 4; 1m3 *& 9= ('% />> bpmVagina : Insp -"- : amnioti1 +luid 98= +rom O*E )a1mus test 98=VT 9G!P= 5,/5 am: &D /1m3 e++ 063 !M 9= butto1k palp3 un1lear denom3J'I

unpalp umb 1ord

O%STETRI& EMERGEN ROOM REPORTDUTY ON : SATURDAY , NOVEMBER 7th 2015



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N5 D!T! %!SED!SSESS

MENTPRO%)EM


7,

>,

*SG 9I&D I : ;;,


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Thankyou

MR 07.11.15 Labda Karya RESOG

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