case 1 bobby kala 2 lama

7/25/2019 Case 1 Bobby Kala 2 Lama

1/25

1

I. Rekam Medis

A. Anamnesis

1. IdentifikasiNama : Ny. AliviaMR/Reg : 412965/10017883

Umur : 21 tahu

!u"u #ag$a : %alem&ag

Agama : '$lam%e(i(i"a : !)*%

%e"er+aa : '&u rumah tagga

Alamat : %alem&agMR! : 21 ,uli 2010 -u"ul 23.00 '#

2. Riwayat Perkawinanai 1 "ali lama 1 tahu

3. Riwayat Reproduksi

Mear$ -a(a u$ia 14 tahu lama hai( 7 hari $i"lu$ hai( 28 hari teratur

hari -ertama hai( tera"hir 08 "t&er 2009 ta"$ira -er$alia 15 ,uli

2010.

4. Riwayat Kehamilan / Melahirkan

1. amil ii

. Riwayat Penyakit !ahulu

ia&ete$ Mellitu$ hi-erte$i -eya"it +atug

". Riwayat #i$i / %osioekonomi

!e(ag / !e(ag

&. Anamnesis Khusus

Keluhan 'tama (Mau melahir"a

Riwayat Per)alanan Penyakit (

urag le&ih (ua hari $e&elum ma$u" rumah $a"it -a$ie megeluh

-erut mule$ yag me+alar "e-iggag hilag tim&ul ma"i lama ma"i

$erig (a "uat. Riayat "eluar (arah le(ir Riayat "eluar airair


2/25

2

%a$ie mega"u hamil u"u- &ula (a gera"a +ai ma$ih

(ira$a"a.

*. Pemeriksaan +isik

1. %tatus Present

a. Keadaan 'mum

e$a(ara : m-$ meti$*i-e &a(a : A$tei"u$

#erat #a(a : 55 "g

*iggi #a(a : 155 m*e"aa arah : 120/80 mmg

Na(i : 80 ; / meit

%era


3/25

3

%emeri"$aa alam(%r$i lua" aterir e


4/25

4

#. Penamatan an)ut

anal Pemeriksaan +isik dan !ianosis erapi

2207201003.00 i&

Keluhan 'tama (

Mau melahir"a

%t. Present (

U : $e(ag !e$ : =M * : 120/80 mmg N :

80;/mt RR : 20;/mt t : 366 =

%t. -,stetri (

Fut 3 +&; 30 m mema+ag -u"a "e-ala

-eurua 2/5 i$ 4;/10 meit/40 (eti".t&+ 2700

gr.C* : -rti lua"aterir e


5/25

5

92;/mt RR : 20;/mt t : 366 =%t. -,stetri (

Fut 3 +&; 30 m mema+ag -u"a "e-ala

-eurua 1/5 i$ 4;/10 meit/40 (eti"

leg"a- "etu&a +erih &au "e-ala '''

UU "aa e-a

C* : %rti ta" tera&a leg"a- "etu&a

+erih &au ter&aah "e-ala ''' UU

"aa (e-a.!ianosis (

E1%0A0 hamil aterm i-artu "ala'' )ama +ai

tuggal hi(u- -re$eta$i "e-ala.

22072010

06.20 i&

)ahir (ega ?"$tra"$i Ca"um eatu$ hi(u-

-erem-ua 3200 g %# 49 A/! 8/9 F* AEA

2207201006.30 i&

% la$eta lahir leg"a- #- @@0 gr %*% 48 m 18 ; 19 m.

ila"u"a e"$-lra$i -rti ita" (a ti(a" ti(a"

(i+um-ai -erlua$a lu"a e-i$itmi

)u"a e-i$itmi (i+ahit $eara +elu+ur (ega

hrmi atgur 2.0u i&u -$t -artum &ai" -er(araha .

aporan 0kstraksi 9akum

taggal 22072010

%u"ul 04.00 i& *am-a" -arturie igi mege(a "uat -a(a -emeri"$aa (alam

(i(a-at"a :

-rti ta" tera&a

leg"a-

etu&a +erih &au

*er&aah "e-ala

'''

UU "aa (e-a

!/ E1%0A0hamil aterm i-artu "ala '' +ai tuggal hi(u- -re$eta$i "e-ala

/

%im-i -er$aliaa

?-i$itmi me(ilateral

%u"ul 06.00 i& $etelah (i-im-i mege+a 2 +am &ayi ta" lahirlahir (i-utu$"a

utu" (ila"u"a e"$tra"$i va"um


6/25

6

!/ E1%0A0hamil aterm i-artu "ala '' lama +ai tuggal hi(u- -re$eta$i "e-ala

*h/ A"hiri "ala '' (ega ?"$tra"$i Ca"um

ila"u"a -ema$aga u- va"um u"ura $e(ag -a(a uu" me+auhi uu&

!etelah (iya"ii ti(a" a(a +ariga yag ter+e-it te"aa va"um

(ituru"a 02 "g/m2$elama 2 meit lalu 04 "g/m2 $elama 2 meit

lalu 06 "g/m2

ila"u"a evalua$i ulag ti(a" (i+um-ai +ariga i&u yag ter+e-it (a

va"um ter-a$ag (ega &ear.

ila"u"a tra"$i "e&aah $am-ai -ua" hi(ug &era(a (i &aah

$im


7/25

7

24072010

06.00 i&

a&i$ melahir"a

%t. Present (

U : $e(ag !e$ : =M * : 120/80 mmg N :80;/mt RR : 20;/mt t : 365 =

%t. -,stetri (

Fut 2 +&-$t "tra"$i &ai" -er(araha a"ti


8/25

8

2. Mega-a -a(a "a$u$ ii memilih e"$tra"$i va"um utu" megahiri "ala

'' G

III. Analisis Kasus

1. A-a"ah %eatala"$aaa "a$u$ ii $u(ah te-atG

%e(erita $erag i&u Ny. A 21 tahu (atag (i(iag$i$ (ega E 1%0A0

hamil aterm i-artu "ala '


9/25

9

%egamata $ela+utya -a(a -u"ul 03.00 i& (i(a-at"a !t.

&$tetri Fut 3 +&; 30 m mema+ag -u"a "e-ala -eurua 2/5 i$

4;/10 meit/40 (eti" ta"$ira &erat +ai 2700 gr -a(a -eri"$a (alam

(i(a-at"a -rti lua"aterir e


10/25

10

ita" (a ti(a" ti(a" (i+um-ai -erlua$a lu"a e-i$itmi lu"a e-i$itmi

(i+ahit $eara +elu+ur (ega hrmi atgut 2.0 ea(aa umum i&u -$t

-artum &ai" -er(araha a"ti< .a$u$ ii ter+a(i "ala '' lama (i(alam R!M ala '' a(alah

iterval atara -em&u"aa $ervi" leg"a- $am-ai lahirya &ayi. !e&agai

-er&a(iga -a(a %ar"la( $-ital $elama tahu 1999 haya 6 -er$e

ter+a(i "ala '' lama. !am-ai $e"arag telah me+a(i "e-utu$a &er$ama

yag (iteta-"a leh (uia "e&i(aa Ameri"a $eri"at aal a&a( 20.

a"tu "ala '' -a(a ulli-ara &ata$ya 2 +am (a me+a(i 3 +am &ila (alam

regial ae$te$i utu" multi -ara 1 +am (a 2 +am &ila &era(a (i&aahae$te$i regial. =he 1977 mela"u"a -eelitia e


11/25

11

1996 $am-ai 1999. a$il terlihat (alam ta&el (imaa ag"a "ematia (a

"e$a"ita eatal ti(a" &erhu&uga (ega -a+ag "ala ''.1

*a&le 1. )uara lii$ yag &erhu&uga (ega ura$i ala ''

ura$i ala ''

)uara lii$ H 2 +am

I 6259

@

24 +am

I 384

@

B 4 +am

I148

@

!= 12 92 345

%er$alia

#er&atu

34 160 351

*rauma -erieum 36 134 267%er(araha %$t

-artum

23 50 91

riamiiti$ 23 89 142

i"uti< (ari =uigham FE1

A(a &ermaammaam


12/25

12

,h$ (a *$hah 1954 meggua"a $uatu met(e utu" mea"$ir

&erat +ai (ega -egu"ura *FU tiggi


13/25

13

ultra$gra


14/25

14

!e(ag"a


15/25

15

tem-at $am&uga $elag. i ata$ mag"u" ter(a-at "atu- utu" megatur

te"aa hi$a- yag (iha$il"a.123678

I. P0R%8ARAA> 0K%RAK%I 9AK'M1?2?4??@??16

1. Informed Consent

!nformed Consent &eri$i -e+ela$a megeai -erluya $atu

ti(a"a me(i$ haru$ (ila"u"a ma


16/25

16

#ila -$i$i (a (era+at -eurua +ai ma$ih &elum +ela$ ma"a

(a-at (ila"u"a -emeri"$aa ultrasonografi transvaginal atau

transperineal terle&ih (ulu. Ultra$gra!IKA%I !A> K->RA I>!IKA%I 0K%RAK%I 9AK'M

A. Indikasi1. ala '' mema+ag

o %a(a Nuli-ara 2 +am

o %a(a Multi-ara 1 +am

2. Mem-er$ig"at ala ''

o elaia +atug

o elaia $ere&rva$"uler

o elaia eurmu$"uler

o '&u lelah

3. Eaat +ai.

*. Kontraindikasi

"ter ti(a" memili"i "m-ete$i utu" mela"u"a

ti(a"a ?C


17/25

17

A-li"a$i aa -eghi$a- $eara te-at ti(a" (a-at

(ila"u"a.

Riayat gaggua "ema+ua -er$alia "ala ' yag yata.

'(i"a$i ti(a"a ?C ti(a" +ela$.

%$i$i (a -eurua "e-ala +ai ti(a" (a-at (itetu"a

(ega +ela$.

*er(a-at (ugaa gaggua im&ag $e-al-elvi".

elaia leta" leta" mu"a leta" (ahi

. Kontraindikasi Relatif

ehamila -reterm

Ma$ih lua"ya "e-ala (a retaya va$"ulari$a$i "e-ala

+ai -rematur. Riayat -egam&ila (arah (ari "ulit "e-ala +ai

$e&elumya.

A-li"a$i uam $e&elumya gagal.

!tru"tur (a "$i$te$i "e-ala +ai -a$a a-li"a$i uam

yag $u(ah &eru&ah. !elai itu "egagala a-li"a$i ter$e&ut

(a-at mem&u"ti"a &aha ter(a-at gaggua im&ag

$e-al-elvi".

Mla$e (a -em&etu"a a-ut $ua(eum yag

&erle&iha.ea(aa ii $erig ter+a(i -a(a "a$u$ gaggua im&ag

$e-al-elvi".

ugaa ma"r$mia #erat &a(a +ai B 4.5 "g.

,ai mati.

leh "area ti(a" (a-at ter&etu" a-ut $u"$a(eeum.

III. APIKA%I A:A> P0>#I%AP

%etelah prasyarat tindakan ?C (i-euhi ma"a haru$ "em&ali

(ila"u"a -emeri"$aa vagial utu" meetu"a ulag -$i$i (era+at

-eurua station (a $i"a- habitus +ai $erta le&ih (ulu

memeri"$a -er$ia-a i$trume yag a"a (igua"a.


18/25

18

ambar %& Mesin va'um

ambar (& )iagram tabung penghubung Cawan penghisap

a. Protokol tindakan 09

1. hosting -a$ie (alam -$i$i litthmi (i(e-a -eratr.

-eratr memegag aa -eghi$a- (i(e-a -a$ie (a

mem&ayag"a &agaimaa "e(u(u"a aa -eghi$a- -a(a

"e-ala +ai atiya (i(alam +ala lahir. %$i$i +ai (a-at

(i-a$ti"a le&ih la+ut (ega -emeri"$aa ultra$gra


19/25

19

Eam&ar 4: hosting

2. !nsersi aa -eghi$a- (ilumuri (ega +elly atau aira-elii. #ila $i


20/25

20

1. !etelah aa -eghi$a- $u(ah &era(a -a(a -$i$i yag te-at

(i&uat te"aa va"um $eu"u-ya agar aa ti(a" &erge$er

(a (i-a$ti"a &aha ti(a" a(a &agia +ala lahir yag ter+e-it

2. %u$at (iameter aa -eghi$a- haru$ &era(a (i $atu titi"

-eetu &eru-a titi" ima+ier aatmi$ yag &era(a (i $utura

$agitali$ "ira "ira 6 m (i &ela"ag u&u u&u &e$ar atau 1 > 2

m (i (e-a u&u u&u "eil titi"


21/25

21

1. !ema"i +auh titi" -u$at aa -eghi$a- &erge$er (ari $utura

$agitali$ $ema"i &e$ar -ula "egagala ti(a"a e"$tra"$i

va"um (a $ema"i &e$ar -ula teaga yag (i-erlu"a utu"

mela"u"a tra"$i leh "area arah tari"a mirig a"a

meye&a&"a ter+a(iya (e


22/25

22

2. !elama tra"$i taga "iri non dominan hand (item-at"a

(alam vagia (ega i&u +ari -a(a aa (a $atu atau (ua

+ari -a(a "e-ala +ai. A"tivita$ ii (ila"u"a utu" meegah

terle-a$ya aa (ari "e-ala.3. Umumya (ega tra"$i -ertama $u(ah (a-at (i"etahui

a-a"ah "e-ala +ai $ema"i turu atau ti(a". #ila ti(a" ma"a

-eratr (a-at mela"u"a $atu "ali tari"a lagi utu"

mema$ti"a a-a"ah ti(a"a e"$tra"$i va"um (a-at

(ila+ut"a atau (iheti"a.%a(a 85@ "a$u$ -er$alia (i$ele$ai"a (ega "urag (ari 3 "ali

tra"$i.

m-li"a$i va"um

Materal

)a$era$i -erieum -er-a+aga e-i$itmi e(era +ariga lua" +ala

lahir.

'"tie$ia uri $tre$$ itiee (a alvi

Neatu$

%er(araha retial

=e(era "raial


23/25

23

hinon: e(ema "ulit "e-ala terl"ali$ir yag ter&etu" (ari te"aa

egati< yag ter+a(i (i &aah mag"u" va"um

A,rasi dan/atau laserasi"ulit "e-ala

%efalhematoma: &er"um-ulya (arah (i &aah -eri"raium a"i&at

la$era$i -em&uluh (arah $u&-eri$teal *era&a "era$ &er&ata$ tega$

ter&ata$ -a(a $atu tulag "raial imm&il -a(a -al-a$i "ulit "e-ala.

=e(era eatu$ yag megaam +ia:

Perdarahan su,aleal: &er"um-ulya (arah atara -eri$teum

(ega a-eur$i$ e-i"raial. Megaam +ia "area ruag

-te$ial tem-at megum-ulya (arah lua$. a-at meye&a&"a

-em&eg"a"a "ulit "e-ala (i


24/25

24

2. %emiliha ?"$tra"$i va"um ii $u(ah te-at $e$uai (ega teri

(a evidence baseyag a(a.

9. Ru)ukan

1. =uigham FE )eve , #lm !) auth ,= Eil$tra- )=e$trm . illiam$

&$tetri. 23(e(. Ne r": MEraillO 2010.

2. Ei&$ R! arla # aey AF Nygaar( '. a


25/25

25

im 5aa

Ra,u? 21 )uli 266 pukul 14.66 %/! Kamis? 22 )uli 2616 pukul 6&.66 wi,

Konsulen )aa (

!r. . Ri$al %anif?%p-# K7

Residen 5aa (

1. !r. handra mahyudin

2. !r. 0dy kurniawan

3. !r. %a$ili

4. !r. !odi enrdra

. !r. !wi >urriana

". !r. +ri$a >oCriansyah&. !r. 8o$a firdao$

@. !r. 0do ,rendo steCano

. !r. %uiono

16. !r. *enyamin R. italey

11. !r. Phindo Mawardinata

12. !r. :iasni Aprilia

case 1 bobby kala 2 lama

Documents