Beruflich Dokumente
Kultur Dokumente
USG Staff 11/1019: Janin ganda preskep-presbo, kesan monochorion diamnion. Air
ketuban cukup. Plasenta di corpus anterior. Janin I preskep DJJ +, BPD 6.53 AC 21.56
TBJ 931. Janin II presbo DJJ +, BPD 7.15 AC 23.88 TBJ 1262 gram
11/10/19: LE -, LE - bact 11.9 . Prot +/-. Swab vagina: tidak ditemukan bakteri
KU baik sadar TD 139/96 N 87 R 20T 36.5 His (-) . CM 1600 CK 1150 BC +450 UO:
2 24.5
0.5
Lab 15/10/19: AL 19.5 AE 4.2 Hb 12.9 AT 311 PPT/APTT 12.5/41 Alb 3.11 SGOT 24
SGPT 16 BUN 16 creat 1.39 AU 7.1 LDH 698 Na 137 K 4.1 Cl 110 URINE Prot +3
Lab 14/10/19: AL 9.35 AE 4.2 Hb 9.3 Hmt 29.3 MCV 69.6 MCH 22,1 MCHC 31.7 AT
246. PPT/APTT 15.6/29.9 Alb 3.34 SGOT 40 SGPT 55 BUN 6.2 creat 0.63 HbsAg NR
Na 137 K 3.57 Cl 102 URINE: nit -. LE -. Bact 3.3 Prot +-
CTG 10/10/19. 23.00: FHR baseline 155 variability >5 akselerasi +, decelerasi -. FM +.
KAT 1
LAB 9/10/2019 (16.04) : AL 9,87, Ae 4,76, Hb 12,4, Hmt 38,8, AT 279, LDH 325, Na
142, K 4,3, Cl 110, PPT 14,4/14,7, APTT 32,3/30,5, INR 1,05, ALb 3,06, SGOT 20,
SGPT 9, BUN 8,10, Cr 0,89, GDS 88, HbsAg NR, URIN : LE -, Bact 11,1, epithel 2,5,
Protein -
NST FHR baseline 135 kpm, variabilitas>5, akselerasi +, deselerasi -, gerak +, kategori
I
USG janin tunggal memanjang preskep, djj + gerak + ak cukup (AFI 10,21 cm),
plasenta di corpus lateral kanan, BPD 8,29~39w3d HC 30,20~33w4d,AC 26,48~30w4d
FL 6,06~31w3d TBJ 1836 gr
BPS : FM 2, FB 2, FT 2, AFI 2, NST 2 = 10/10
Lab 14/10/19: AL 10.46 AE 4.27 Hb 12.1 Hmt 35.3 AT 376 PPT/APTT 14.3/33.6 Alb
3.58 SGOT 14 SGPT 10 BUN 9.8 creat 0.82 GDS 83 HbsAg 83 LDH 312 Na 140 K
3.85 Cl 108 URINE: nitrit -. LE +3. bact 706.6
USG 14/10.19: janin tunggal, memanjang, preskep. DJJ +, gerak +, AK cukup plasenta
di fundus anterior . TBJ 1614gram BPS 10/10
CTG 14/10/19. 23.00: FHR baseline 150 variability >5 akselerasi +, decelerasi -. FM +.
KAT 1
KU baik sadar TD 148/82 N 90 R 18 T 36.6 CM 300 CK 850, BC -350 UO 1.6 His (-),
1 36.2
DJJ 136 kpm
15/10/19: AGD: pH 7.4 pCO2 28.3 pO2 98 Lac 1.12 HCO3 18 BE -7 (asidosis
metabolik terkompensasi). Al 10.5 AE 3.74 Hb 9.2 Hmt 28.9 MCV 77.4 MCH 24.6
MCHC 31.8 AT 246 PPT 15 APTT 28.8 LDH 282 Na 137 K 3.24 Cl 111 . URINE: Nit -
LE +2 bac 51 Keton +2 Prot +1
USG 15/10/19 : janin tunggal, memangjang, preskep. DJJ +, gerak +. Plasenta di
fkorpus posterior tidak meluas ke OUI. AK cukup. TBJ 3733gram
2 31.2 KU baik sadar TD 126/74 N 63 R 20 T 36.0 His (-), DJJ 150 kpm
Lab AL 9.8 AE 4 Hb 8.2 Hmt 26.4 MCV 65 MCH 20 MCHC 31.1 AT 339. PPT 16.3
APTT 25.1 Alb 3.33 SGOT 15 SGPT 10 BUN 9.8 creat 0.44 GDS 79 Na 140 K 3.8 Cl
109
USG 15/10/19: janin tunggal, memanjang, preskep. DJJ +, gerak +, AK cukup. Plasenta
di corpus anterior. Lakuna + tidak meluas ke OUI. Retroplasental zone +. TBJ 3644
gram
CTG 15/10/19 FHR baseline 160 variability >5 akselerasi +, decelerasi -. FM +. KAT 1
KU baik sadar TD 120/80 N 03 R 20 T 36.6 tfu 2jbp. Lochia rubra. Cm 900 CK1026
0 26.9
BC -126 UO 0.76
Post op: 16/10/19: AL 12.96 AE 4.16 Hb 11.8 AT 178
lab 11/10/19: AL 6.99 AE 4.35 Hb 12.4 Hmt 37.5 AT 200. PPT/APTT 13.9/28.5 Alb 3.72
OT/PT 22/12 BUN 4.5 crwat 0.62 GDS 83. HbsAg NR Na 141 K 4.66 CL 111 INR 1.01
Anti ds DNA 7 ANA IF dalam konfirmasi
Lab 13/10/19: AL 8.63 AE 3.87 hb 11.9 Hmt 33.1 AT 93. Alb 2.67 --> 3.23 . SGOT 52
SGPT 54 LDH 533. URINE LE +3. Bact 10780 yeast like 55.21. PROTN +3.
Lab 12/10/19: Creat urine 55.52 Prot total 366 ratio prot/creat 6592
11/10/19: USG staff: janin tunggal, memanjang, preskep. DJJ +, gerak +, AK cukup,
plasenta di corpus anterior. BPD 7.78 AC 23.46 TBJ 1358 gram
10/10/19: AL 9.8 AE 4.25 Hb 13.1 AT 103. BUN 16.9 Crea 0.97 LDH 1141 Urine: Nitrit
+2 Leu 21 Bact 6215 Prot +3
LAB 6/10/2019 (14.23) : AL 13,71, Ae 4,28, Hb 13,2, Hmt 36,3, MCV 84,8, MCH 30,8,
MCHC 36,4, AT 208, Alb 3,4, SGOT 34, SGPT 34, BUN 47,2, Cr 1,77, GDS 115, LDH
931, Na 134, K 4,38, Cl 102, URIN :Protein +3
EKG 6/10/2019 : sinus rhytm 122 kpm, RAD. Kesan sinus takikadi
NST FHR baseline 140kpm, Akselerasi +, Deselerasi, Variabilitas >5, Gerak (+) kesan
reaktif
3/10/19 AL 10,73 AE 4,53 Hb 14,1 Hmt 39,7 AT 94 PPT 12,8/14,8 APTT 35,8/32,7 Alb
2,79 SGOT 59 SGPT 101 BUN 17,4 Cr 0,85 LDH 515 Na 138 K 4,17 Cl 105 GDS 115
INR 0,92 URIN LE +- Bact 91,5 prot +3
USG 2/10/19 Janin tunggal memanjang preskep DJJ(+) gerak (+) AK cukup plasenta
di fundus meluas ke corpus anterior.TBJ 1318 g
0 29.9 KU baik sadar TD 131/83 N 100 R 18 T 36.1 CM 2150 CK 2390 BC-240 UO 1.08
CTG 12/10/19. FHR baseline 140 variability >5 akselerasi +, decelerasi +. FM +. KAT 1
13/10/19: AL 13.92 AE 3.92 Hb 10.6 Hmt 31 MCV 79.1 MCH 27 MCHC 34.2 AT 239
GDS 112 PTT/APTT 15.8/21.1 Alb 3.7 SGOT/SGPT 14/9 BUN 4.8 creat 0.47 Na 141 K
3.5 Cl 109 INR 1.17
CTG 13/10/19. FHR baseline 150 variability >5 akselerasi +, decelerasi -. FM +. KAT 1
USG 13/10/19: USG: Janin tunggal, memanjang, presbo DJJ (+), gerak (+), plasenta di
korpus anterior, AK cukup TBJ 2547
Lab 13/10/19: AL 11.69 AE 4.6 Hb 13.1 AT 194 PPT/APTT 13.6/39.5 Alb 3.37 OT/PT
34/60 BUN 10.1 creat 0.74 Na 133 K 3.97 Cl 100 URINE: Prot +1
USG 12/10.19: janin tunggal, memanjang, preskep. DJJ +, gerak +, AK cukup plasenta
di fundus . BPD 9.03 AC 32.28 TBJ 2802 gram
CTG 12/10/19 FHR 130 kpm, variabilitas>5, akselerasi +, deselerasi - gerak + his
2x/10'/110mvU kategori I
0 33.2 KU baik sadar TD 120/76 N 68 RR 20 T 36,1. CM 2530 CK 2200 BC +330 UO 0.6
Lab 12/10/19: AL13.24 AE 4.91 Hb 13.9 Hmt 38.5 AT 298 Alb 2.49 SGOT 29 SGPT 28
BUN 16.8 Creat 0.87 LDH 188 Na 140 K 4.36 Cl 106 GDS 100 URINE: nitrit -, LE -,
bact 760 . PROT +3
CTG 12/10/19. FHR baseline 140 variability >5 akselerasi +, decelerasi +. FM +. KAT 1
CTG 12/10/19. FHR baseline 145 variability <5 akselerasi -, decelerasi +. FM +. KAT 2
Lab 15/10/19: Al 13.56 AE 4.3 Hb 11.7 Hmt 34.6 AT 185 PPT/APTT 15.6/32.9 Alb 3.15
OT/PT 18/19 BUN 5.6 creat 0.5 Na 136 K 3.75 Cl 101 GDS 82
USG 15/10/19: USG: Janin tunggal, memanjang, preskep, DJJ (+), gerak (+), plasenta
di korpus posterior, AK cukupTBJ: 2729gram
CTG 15/10/19. 23.00: FHR baseline 140 variability >5 akselerasi +, decelerasi -. FM +.
KAT 1
Lab 14/10/19: BUN 6.9 creat 0.45 HbsAg NR LDH 202 URINE: nit -. LE -. BCT 132 .
PROT +1 AL 12.3 HB 11.5 HMT 35.3
USG 14/10/19: Janin tunggal, memanjang, preskep DJJ +. AK cukup plasenta di
corpus posterior. EFW 3293
CTG 14/10/19.: FHR baseline 140 variability >5 akselerasi +, decelerasi -. FM +. KAT 1
Lab 16/10/19: JAM 03.36 pH 7.154 pCO2 29.3 pO2 149 HCO3 10.3 BE -19 lact 0.56
LAB 15/10/19: JAM 09.40 AGD pH 7.23 pCO2 15.9 pO2 123.3 HCO3 6.7 a/A.0.4 . Alb
2.57 BUN 107.4 Creat 10.48 Na 138 K 4.96 Cl 96 Na 136 K 4.96 Cl 96. JAM 22.19: pH
7.24 pCO2 20.5 pO2 172 HCO3 8.8 BE -19 lact 0.83
LAB 14/10/19: JAM 10.36 AL 29.39 AE 3.25 Hb 9.3 AT 331 PPT/APTT 19.6/41.3 Bil tot
0.84 bil dir 0.56 Alb 2.56. BUN 91.9 creat 9.39. Na 138 K 4.32 Cl 99 procal 20.66 INR
1.49 AGD: pH 7.25 . pCO2 27.2 pO2 146 lact 2.34 BE -14 HCO3 12.3
13/10/19: AGD 08.54 pH 7.34 HCO3 15.2 pCO2 28 pO2 136 Eeb -8.7 a/A 0.4 . JAM
9.04 AL 29 AE 3.22 Hb 9.3 Hmt 26.8 AT 179 Na 142 K 3.99 Cl 100. JAM 16.59 GDS
124 . JAM 20.40 GDS 126
11/10/19: 19.17 AGD: pH 7.46 pCO2 26.8 pO2 231 lac 1.47BE -4. 11/10.19: AGD pH
7.46 pCO2 26.8 pO2 231 lact 1.47 (alkalosis respiratorik) . 19.22 : AL 17.21 AE 4.36 Hb
12.7 Hmt 35.5 AT 126 Alb 4.06 BUN 48.8 creat 4.39 GDS 34 Na 141 K 3.2 Cl 95 cal
2.69 11/10/19: AGD 9.37 pH 7.41 pCO2. 28 pO2 184 Lac 1.83 BE -7 HCO3 17.8
(asidosis metabolik terkompensasi). LAB 9.53 AL 15.25 AE 2.99 Hb 8.6 Hmt 24.6 AT
91 alb 2.64 BUN 98. creat 8.6 Na 142 K 4.24 Cl 97 Cal 1.78 GDS 83 INR 1.38
PPT/APTT 35.6/31.4.
Lab 10/10/19
AL 12.9 AE 2.89 Hb 8.3 Hmt 23.7 AT 62 Lab pkl 11.48 Hb 8.4 AL 11.8 AT 53 Hmt 24.4
Ppt 18/14.4 Aptt 34.7/30.2 Fibrinogen 266 D-Dimer 453 AGD pH 7.43
PCO2 22.2 PO2 131 HCO3 14.8 BE -7.9 Bil 2.37 Alb 2.9 SGOT 63 SGPT 204 Na 141
K 4.21 Cl 98 Ca 1.74 Procal 16.35 Gds 112 Inr 1.36 Bun 79.5 Cr 7.66 Lab 10/10/19
(04.00) pH 7.22 PC02 50.8 PO2 240 Hc03 20.9 BE -7 Lact 1.73
10/10/19: RO THORAX ::
- Pneumonia lobaris dextra
- Pleural reaction pulmo dextra
- Oedema pulmonum
- Cardiomegaly, LVH
- Terpasang HD cath dengan insersi melalui vena jugularis eksterna dextra dan ujung
distalnya mengarah ke caudal di linea paravertebralis dextra setinggi corpus V.Th 6-7
Lab 10/10/19 (02.16) Hb 5,6, AL 11,02, AT 44, Hmt 17, PPT 21,3/14,7, APTT 40,8/30,5,
INR 1,64, Alb 2,58, OT 57, BUN 72,4, Cre 7,18, Na 142, K 4,33, Cl 99, Ca 1,71,
(02.13), PH 7,33, PCO2 36,1, HCO3 19,1, PO2 47,2, SO2 80,5, TCO2 20,2, BE -5,6
(02.09) PH 7,262, PCO2 46,2, HCO3 20,9, PO2 230, Lac 1,65, SO2 100, TCO2 22, BE
-6
LAB 9/10/2019 (21.15) : AL 11,04, Ae 2,47, Hb 6,9, Hmt 20,7, MCV 83,9,MCH 27,9,
MCHC 33,3, AT 51, PPT 21,7/14,7, APTT 41,9/30,5, SGOT 68, SGPT 311, BUN 75,1,
Cr 7,02, GDS 106, Na 144, K 3,72, CL 1,9, Ca 1,9, INR 1,67, AGD : pH 7,25, PCO2
42,8, PO2 178, HCO3 19,2, BE -8, Lac 1,94, GDS 139, LAB 9/10/2019 (09.31) : AL
11,7, Ae 2,94, Hb 8,1, Hmt 23,7, MCV 80,6, MCH 27,6, MCHC 34,2, AT 52, PPT 20,2/
14,7, APTT 35,6/30,5, INR 1,55, Fibrinogen 320, D-Dimer 461, Bil total 2,27, Bil direct
2,15, bil indirect 0,12, Alb 2,12,SGOT 173, SGPT 858, BUN 71, Cr 7,48, GDS 121, Na
141, K 3,84, Cl 102, Mg 2,24, Ca 2,03, Procalsitonin 19,91, AGD pH 7,4, PCO2 27,2,
PO2 141, HCO3 17,6, BE -7, Lac 2,56
8/10/19: HASIL CULTUR URINE: BACTERIA TIDAK DI TEMUKAN
Lab 8/10/19 j09.38 AL 12.93 AE 3.19 Hb 8.9 Hmt 25 AT 59 PPT 20.7 APTT 36.2 Alb
2.65 BUN 88.1 Cr 0.03 Na 148 K 3.82 Cl 89 Mg 1.85 Cal 1.9 GDS 134 Ph 7.4 Pco2
28.2 p02 84 Lac 3.37 SO2 96 BE -7 j13.54 AL 13.63 AE 4.5 Hb 12.1 Hmt 36.1 AT 66
BUN 48.4 Cr 5.3 Na 138 K 3.18 Cl 98 Mg 2.5 Cal 2.46 j19.23 AL 9.97 AE 2.82 Hb 7.8
Hmt 22 AT 66 Alb 2.19 BUN 60.5 Cr 6.97 Na 140 K 3.6 Cl 100 GDS 158
Dibandingkan dengan foto thorax sebelumnta tanggal 07/10/2019 jam 13.46 secara
radiologis gambaran oedema pulmonum berkurang
lab 7/10 (10,19) ph) 7,301 pco2 38,2 pO2 83 HCO3 18,9 (09.49) al 11,45 ae 3,65 hb
10,1 hmt 29,2 at 41 ppt 24,3 aptt 47,8/29,4 bilirubin total 2,96 alb 2,91 sgot 1523 sgpt
2148 bun 74 cr 7,31 gds 82 na 144 k 4,05 cl 102 mg 1,69 ca 1,83 NT pro BNP 25942
procal 27,81 inr 1,91 (08,22) al 10,99 ae 2,89 hb 8 hmt 23 at 53
LAB 6/10/2019 (14.26) : GDS 74, (13.47) : 20, (11.15) : AL 13,11, Ae 3,72, Hb 10,4,
Hmt 30,3, MCV 81,5, MCH 28, MCHC 34,3, AT 50, PPT 26,2/14,4, APTT 38,1/30,3,
INR 2,08, Fibrinogen 253, D-DImer 1154, ALb 3,47, BUN 66,8, Cr 6,19, GDS 38, Na
140, K 4,10, Cl 104, Ca 1,95 , AGD : PH 7,30, PCO2 37,6, PO2 111, HCO3 18,9, BE -7,
Lac 5,34
LAB 5/10/2019 (21.00) : AL 6,27, Ae 2,84, Hb 7,8, Hmt 23, MCV 81, MCH 27,5, MCHC
33,9, AT 39, PPT 29,2/14,4, APTT39,6/30,3, INR 2,35, BUN 57, Cr 5,43, GDS 78, Na
144, K 3,63, Cl 100, AGD (14.00) : pH 7,37, PCO2 37,4, PO2 234, HCO3 22, BE -3, ,
Lac 3,01 LAB
5/10/2019 (08.00) : Al 8,12, Ae 2,7, Hb 7,4, Hmt 21,5, MCV 79,6, MCH 27,4, MCHC
34,4, AT 40, PPT 31,6/13,8, APTT 36/30,9, INR 2,57, ALb 3,32, BUN 47,40, Cr 4,63,
GDS 60, Na 145, K 3,56, Cl 98, Ca 1,85 , AGD : pH 7,36, PCO2 40,3, PO2 107, HCO3
22,8, PH 7,39, Lac 2,53,
Lab 3/10/2019 (20.35) : AL 11,7, Ae 1,21, Hb 3,4, Hmt 10,3, MCV 85,1, MCH 28,1,
MCHC 33,0, AT 56, PPT 56,4/14,2, APTT 88,4/30,8, Alb 1,31, BUN 12,0, Cr 1,87, Na
147, K 4,26, CL 95, Mg 1,6, Ca 1,82, INR 4,97, AGD (19.20) : pH 7,036, PCO2 46,2,
PO2 23, HCO3 12,4, Lac 12,38
Lab 3/10/2019 (17.22) : AL 14,6, Ae 2,49, Hb 7, Hmt 21,3, MCV 85,5, MCH 28,1,
MCHC 32,9, AT 29, GDS 100, AGD 3/10/2019 (16.59) : pH 7,17, PCO2 30,1, PO2
238, HCO3 11,1, lac 10,98
Lab 3/10/2019 (15.23) : Al 26,65, Ae 3,30, Hb 9,5, Hmt 28,9, MCV 87,6, MCH 28,8,
MCHC 32,9, AT 54, PPT 60,4/14,2, APTT 119,2/30,8, Fibrinogen <6, D-Dimer >20000,
Bil total 1,13, Bil direct 0,90, Alb 1,58, SGOT 401, SGPT 293, BUN 11, Cr 1,63, HbSAg
NR, Na 139, K 5,17, CL 107, Mg 1,7, Ca 1,83, GDS 101, INR 6,69, AGD (15.13) : PH
7,08, PCO2 29,2, PCO2 225, HCO3 8,8, BE -21, Lac 13,67
019
MFM B
dr. DEN (dr. NAW)
dr. SME (dr. KHA)
Diagnosis/ assesment
TS UROLOGI
Post SC emergency ai. Prolong latent phase
riwayat SC 7 tahun yang lalu. Ibu pre eclampsia
P2A0. Riwayat asma tidak dalam serangan H3
Post partum spontan bracht ai prespo, preterm,
PEB, IUGR, ologohidramnion, hipoalbuminemia
teratasi , ibu obese grade I. Infertil primer 7
tahun. Riwayat induksi misoprostol 25mcg/6jam
tablet IV seri I. H1
Post partum spontan P4A0 , Ibu riwayat PDA
post closure. 1 tahun yang lalu WHO CR I CF I.
H1
Planning TBJ/BBL AS
MFM/ DN A
MFM/DN A
MFM/DN A
MFM/ DN A
MFM/DN A
A
B
MFM/DN A
MFM/DN A
OBS/DN A
MFM/DN B
OBS/NUR A
MFM/DN A
MFM/DN A
MFM/DN A
MFM/ RK B