elamat pagi semuanya, saya ingin menceritakan tentang pasien ini:

Ini Bu Mila Monica, dua puluh lima tahun. Telah dirawat inap sejak tanggal tiga belas september dua
ribu dua puluh satu Dipindahkan ke RSDS dari bidan rezka dengan keluhan utama……

(bisa menambahkan history) misalnya:

Datang ke rumah sakit dengan keluhan utama ada kelebihan cairan mules - mules sejak dua waktu
indonesia barat tanggal dua belas september dua ribu dua puluh satu , pasien hamil anak
pertama,abortus (-), Keluar air - air (-), Lendir Darah (-), pilek (-), Demam (-), USG (+) tanggal tiga
bulan sembilan dua ribu dua puluh satu dengan dokter Rully spesialis Obsgyn hasil janin baik.

Diagnosa pasien tersebut adalah gravida one Zero parturition Zero abortion, term gestational age +
prolonged first stage of labor + premature rupture of membranes

Pasien ini dengan Partus satu Abortus nol setelah C-Section hari dua karena ketuban pecah dini
+fetal distres

Pasien tampak lelah/sesak napas/….. dan compos mentis Keluhan hari ini adalah…..,….,…..,….

Tanda vital: Tekanan darah: ……di atas…..milimeter air raksa, denyut jantung…..detak per menit, laju
pernapasan….. waktu ke menit, suhu…., dan saturasi o2 sembilan puluh sembilan %

Gelembung (untuk post partum)

Payudara (ASI) : simetris, warna payudara sama, keluar air susu normal atau keluar air susu tidak
lancar, harus di pegang baru bisa keluar, air susu sebelah kanan lebih baik dari sebelah kiri.

Rahim (Kontraksi): baik

Usus: dua puluh kali permenit, sudah bisa kentut, sudah bisa Buang Air Besar

Kandung kemih (urin): baik, bisa berkemih sendiri, lepas kateter tadi malam

Lochia (sekresi): rubra (Cruenta) berisi darah segar dan sisa - sisa selaput ketuban, sel desi dua,
verniks kaseosa, lanugo, dan mekonium.

Sayatan C-section: tidak ada nyeri bekas operasi, luka operasi baik

1
(jika post partum dapat ditambahkan)

- berat badan bayi……jenis kelamin laki - laki .Skor APGAR…..

- pendarahan atau komplikasi lainnya tidak ada

Perencanaan pasien tersebut adalah ….

Terapi lini pertama untuk pasien ini

- ceftriaxsone dua kal satu gram intra vena

- ketorolac tiga kali tiga puluh gram intra vena

2
Good morning everyone, I want to tell you about this patient:

This is Mrs. Mila Monica, twenty five years old. Has been hospitalized since the thirteenth of
september two thousand and twenty-one Transferred to the RSDS from midwife rezka with a chief
complaint……

(can add history) for example:

Came to the hospital with the main complaint that there was an excess of mucus fluid since the two
western Indonesian times on the twelfth of september two thousand and twenty-one, the patient
was pregnant with her first child, abortion (-), watery discharge (-), blood mucus (- ), runny nose (-),
fever (-), ultrasound (+) on the third of the ninth month, two thousand and twenty-one with Dr.
Rully, a specialist in Obstetrics and Gynecology, the results were good.

The patient's diagnosis was gravida one Zero parturition Zero abortion, term gestational age +
prolonged first stage of labor + premature rupture of membranes

This patient with first parturition Zero abortion after C-Section day two due to premature rupture of
membranes + fetal distress

The patient looks tired/short of breath/….. and compos mentis. Today's complaints are…..,….,…..,….

Vital signs: Blood pressure: ……above…..millimeters of mercury, heart rate…..beats per minute,
respiratory rate….. time to minute, temperature…., and o2 saturation ninety nine %

Bubbles (for post partum)

Breast (ASI): symmetrical, the color of the breast is the same, normal milk comes out or milk doesn't
come out smoothly, you have to hold it before it can come out, the right milk is better than the left.

Uterus (Contractions): fine

Intestines: twenty times per minute, you can fart, you can defecate

Bladder (urine): ok, can urinate on its own, removed the catheter last night

Lochia (secretion): rubra (Cruenta) containing fresh blood and remnants of the amniotic membrane,
deci two cells, vernix caseosa, lanugo, and meconium.

C-section incision: no pain from the surgery, the surgical wound is good

3
(if post partum can be added)

- baby's weight……male gender. APGAR score…..

- no bleeding or other complications

The patient plan is...

First-line therapy for this patient

- Ceftriaxsone two cal one gram intravenously

- ketorolac three times thirty grams intravenously

4
hasil laboratorium tanggal tiga belas september dua ribu dua puluh satu

wbc / white blood cell count dua puluh lima titik tujuh puluh enam (sepuluh pangkat tiga /UL)

HBG / HAEMOGLOBIN sepuluh titik satu gram/ desi liter

hct / hematokrit duapuluh sembilan titik delapan persen

plt / trombosit seratus delapan puluh tujuh (sepuluh pangkat tiga /UL)

gula darah sewaktu seratus tujuh belas mili gram per desi liter

ureum delapan belas mili gram per desi liter

creatinin nol koma enam puluh delapan mili gram per desi liter

hbsAg (negatif)

urin warna kuning

kejernihan agak keruh

leukosit (+ empat)

keton (+ dua)

darah (+ empat)

anti hiv tiga belas september dua ribu dua puluh satu (non reaktif)

rapid test antigen covid -19 tiga belas september dua ribu dua puluh satu (negatif)

edukasi :

- cara merawat luka operasi, tidak di bawa mandi terlebih dahulu

- cara menyusui yang baik

- makan makanan yang bergizi (daun katuk, pucuk pepaya, kacang - kacangan )

- minum vitamin A empat ratus intra unit sampai hari ke enam puluh setelah melahirkan

5
laboratory results on the thirteenth of september two thousand and twenty-one

wbc / white blood cell count twenty five point seventy six (ten to the power of three /UL)

HBG / HAEMOGLOBIN ten points one gram / deci liter

hct / hematocrit twenty-nine points eight percent

plt / platelets one hundred and eighty seven (ten to the third power / UL)

blood sugar when one hundred and seventeen milligrams per deci liter

eighteen milligrams of urea per deci liter

creatinine zero point sixty eight milligrams per deci liter

hbsAg (negative)

yellow urine

clarity is a bit cloudy

leukocytes (+ four)

ketones (+ two)

blood (+ four)

anti hiv thirteenth september two thousand twenty one (non reactive)

rapid test antigen covid -19 thirteenth of september two thousand and twenty one (negative)

education:

- how to treat surgical wounds, don't take a bath first

- good way to breastfeed

- eat nutritious foods (katuk leaves, papaya shoots, nuts)

- take four hundred intra-unit vitamin A until the sixtieth day after delivery