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  • Morning Report OK 9 (12!3!14)

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    Ade Siti Rahmawati
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    1. A 42-year-old female patient named Ny. Wartini was admitted with a diagnosis of uterine myoma. Physical examination showed a mass measuring approximately 10cm in her abdomen that was smooth, round, and mobile. 2. Laboratory tests and ultrasound showed elevated hemoglobin and hematocrit levels, and an enlarged uterus measuring 10.1 x 5.6 cm containing a mass consistent with multiple uterine fibroids. 3. The conclusion was that she would undergo an exploratory laparotomy for her diagnosed uterine myoma.

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    1. A 42-year-old female patient named Ny. Wartini was admitted with a diagnosis of uterine myoma. Physical examination showed a mass measuring approximately 10cm in her abdomen that was smooth, round, and mobile. 2. Laboratory tests and ultrasound showed elevated hemoglobin and hematocrit levels, and an enlarged uterus measuring 10.1 x 5.6 cm containing a mass consistent with multiple uterine fibroids. 3. The conclusion was that she would undergo an exploratory laparotomy for her diagnosed uterine myoma.

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    4 views8 pages

    Morning Report OK 9 (12!3!14)

    Uploaded by

    Ade Siti Rahmawati
    1. A 42-year-old female patient named Ny. Wartini was admitted with a diagnosis of uterine myoma. Physical examination showed a mass measuring approximately 10cm in her abdomen that was smooth, round, and mobile. 2. Laboratory tests and ultrasound showed elevated hemoglobin and hematocrit levels, and an enlarged uterus measuring 10.1 x 5.6 cm containing a mass consistent with multiple uterine fibroids. 3. The conclusion was that she would undergo an exploratory laparotomy for her diagnosed uterine myoma.

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    of 8

    Morning Report

    OK 9
    Rabu 12 Maret 2014

    1. IDENTITAS
    Nama Usia JK No RM Ruang BB Dx Tindakan : Ny. Wartini : 42 Tahun : Perempuan : 557832 : Teratai : 72 kg : Mioma Uteri : Eksplorasi laparotomi

    ANAMNESIS
    Riwayat asma :Riwayat jantung :Riwayat alergi : + Penicillin Riwayat hipertensi :Riwayat DM :Riwayat OP sebelumnya : -

    PEMERIKSAAN FISIK
    KU / Kesadaran: Baik / Composmentis Tanda Vital TD : 120/80 HR : 84 RR : 18 S : 36 C

    Status Generalis
    Kulit

    Mata
    Hidung

    Telinga Mulut
    pucat /

    : Turgor kulit cukup : Konjunctiva anemis (+/+), sklera ikterik (-/-) : Deviasi septum (-), discharge (-), sekret (-) : dbn : MP (1), gipong (-), gisu (-), mukosa sianotik (-)

    Dada Paru : Ketinggalan gerak (), SD vesikuler, Wh (-/), Rh(-/-) Jantung : S1 > S2, reguler, M (-), G (-) Abdomen I : Datar A : BU (+) N P : NT (-), teraba massa uk 10cm, permukaan rata, mobile P : Timpani Akral : Hangat,oedema(-)

    LABORATORIUM
    Hemoglobin : 13,7 Leukosit : 7970 Hematokrit : 43 Eritrosit : 5,6 Trombosit : 249000 PT : 13,4 APTT : 35,1 Ureum : 22,0 Kreatinin : 0,76 GDS : 81 SGOT : 24 SGPT : 32 HbsAg Non reaktif

    RADIOLOGI
    Ro thorax : bentuk dan letak jantung N, pulmo tak tampak kelainan USG : tampak uterus membesar ukuran 10,1 x 5,6 cm, tampak gambaran massa di corpus posterior kesan multiple mioma

    KESIMPULAN
    ACC ASA I

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