2 NOVEMBER 2009
Name
: Mrs. X/BatuKliang
Age
: 16 years old
Wakt
u
Subject
23.3
0
(31/
11/0
9)
admite
d
: Oct, 31 th 2009
: 13.30pm
Object
General status :
General condition: good
Conciousness: CM
BP: 120/70
RR: 16x/mnt
Pulse :104 x/mnt
T: 38,8C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : breech
L2 : L3 : head
L4 : desend 4/5
UFH: ~ cm
AC:98 cm
EFW : 3234 g
UC : 4x10-40
Fetal Heart Rate : 136 bpm
VT : full, eff 100 %, AM (+),
descend HIV, palpable small organ
Assesment
Planning
G2P1A0 40W/S/L/IU
with abortus
provokatus infeksious
Wakt
u
Subject
Object
Assesment
Planning
Lab. result:
HBsAg (-)
HB = 13,8
WB =20.200
TRB = 371.000
Hct = 28.0
13.4
5
14.0
0
20.0
0
Wakt
u
08.0
0
Subject
Object
BP: 120/70 mmHg
PR; 88 bpm
RR: tmp
Temp : 37,2C
Assesment
Planning
Inj ceftriaxon 2 gr/day