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presentasi kasus kala ii lama
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7/21/2019 Presus Kala II Lama
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Arum Purbondari
20100310085
PRESENTASI KASUSKALA II LAMA
7/21/2019 Presus Kala II Lama
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ANAMNESIS
IDENTITAS PASIEN
Nama : Ny. I
Umur : 2 T!nA"ama# : Ramb$an%& MK'
P$($r)aan : IRT
A%ama : I*"am
Ma*u( RS : 25 +(#ob$r 201. ,am 0-.30 I/ .
Keluhan Utama
Pa*i$n ru)u(an dari bidan d$n%an 1P0A0 !ami" 3 min%%u d$n%an (a"a II "ama ma*u( m$"a"uiI' ada #an%%a" 25 +(#ob$r 201 )am 0-.30 ib. K$n4an%($n4an% 67 *$)a( )am 02.00& ($"uar
"$ndir dara! 67& air ($#uban ($"uar *$)a( )am 03.00& %$ra( )anin 67& u*in% 6& andan%an(abur 6& mua" 6& mun#a! 6& ibu in%in m$n%$)an *$)a( )am 03.00.
,am 03.00 di"a(u(an $m$ri(*aan da"am o"$! bidan& $mbu(aan *uda! "$n%(a. Ibu diimin
m$n%$)an.
9P9T 23 ,anuari 201& 9PL 30 +(#ob$r 201
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Riwayat Obstetri
1P0A0 & ana( I: !ami" ini
Riwayat Pernikahan1& "ama m$ni(a! ; 1 #!
Riwayat Haid
Umur m$nar4!$ 13 #a!un& *i("u* !aid #$ra#ur&
"amanya 5 !ariRiwayat AN
Ru#in ($ bidan
Riwayat K!
/$"um $rna! m$n%%una(an K/
Riwayat Penyakit Dahulu
9T 6& Riaya# ($)an% 6& 'M 6& a"$r%i 6& a*ma6
Riwayat Penyakit Keluar"a
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RESUME ANAMNESIS
Primi%ra<ida !ami" a#$rm d$n%an (a"a II "ama
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PEMERIKSAAN#ISIK
PEMERIKSAANO!STETRI
= K$adaan Umum : >u(u& >M
= ?i#a" Si%n :
= T' : 130@80 mm!%
= 9R : 88 @m
= RR : 22 @m
= # : 3-&5o >
= P$m$ri(*aan K$a"a
= Pa"$bra : Ed$ma 6@
= Kon)un4#i<a : An$mi* 6@
= S("$ra: I(#$ri( 6@
= P$m$ri(*aan $(*#r$mi#a*Su$rior : Ed$ma 6@
Inorior : Ed$ma 6@
= L$oo"d 1 : TBU 30 4m& ba%ian #$ra#a*#$raba "una(& ($*an bo(on%.
= L$oo"d 2 : )anin #un%%a"& m$man)an%&
#$raba m$man)an% di *$b$"a! (iri($*an PUKI.
= L$oo"d 3 : #$raba ($ra*& ($*an($a"a.
= L$oo"d : di<$r%$n 6($a"a *uda!ma*u( an%%u".
= ',,: 1-1@m
= 9IS: @10C@30CC
= ?T: <@u #$nan%& dindin% <a%ina "i4in&or#io #ii*& $mbu(aan 104m& air
($#uban 67. KK 67 STL' 67& ($a"a92& uu( )am 0.00
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PEMERIKSAANPENUN$AN%
#&ll&w U'()*+,*(,+-
./am +010,2= AL : 20&D3. 10
3
L6m$nin%(a#
= AE: &22. 105 L6norma"
= 9b: 10&0 %@dL6norma"
= AT : 21. 103@ PL6norma"
= o"dar : += 9/*A% : n$%a#i
= N$u#roF" : 8&8 G
H S : T$"a! diiminm$n%$)an *$"ama 0m$ni#& bayi b$"um "a!ir
H +: KU: 4u(u& >M9IS:3@10C@30CC #:
3D&-o> ',,:185@m?T: <@u #$nan%&
dindin% <a%ina "i4in&$mbu(aan 10 4m& KK6& ($a"a 92.
H A: rimi%ra<ida !ami"a#$rm (a"a II "ama& *yara#<a(um #a( #$r$nu!i
H P: S> $m$r%$n*i
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DIA%NOSIS
Primi%ra<ida !ami" a#$rm d$n%an (a"a II "ama$# 4au*a 'i*roor*i K$a"a Pan%%u" 6'KP.
