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  • Follow Up Mioma

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    Silvianti Budi
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    1. The patient presented with heavy bleeding from the birth canal, weakness, dizziness, and abdominal pain and was diagnosed with uterine myoma, left kidney stones (nephrolithiasis), and anemia. 2. Over the course of a week of treatment including IV fluids, antibiotics, pain medications, and 5 units of blood transfusion, the bleeding decreased and her symptoms improved. 3. She was discharged on the last day with instructions to follow up at the local health clinic for blood pressure and kidney stone monitoring and to return immediately if bleeding recurred.

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    1. The patient presented with heavy bleeding from the birth canal, weakness, dizziness, and abdominal pain and was diagnosed with uterine myoma, left kidney stones (nephrolithiasis), and anemia. 2. Over the course of a week of treatment including IV fluids, antibiotics, pain medications, and 5 units of blood transfusion, the bleeding decreased and her symptoms improved. 3. She was discharged on the last day with instructions to follow up at the local health clinic for blood pressure and kidney stone monitoring and to return immediately if bleeding recurred.

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    © All Rights Reserved
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    4 views2 pages

    Follow Up Mioma

    Uploaded by

    Silvianti Budi
    1. The patient presented with heavy bleeding from the birth canal, weakness, dizziness, and abdominal pain and was diagnosed with uterine myoma, left kidney stones (nephrolithiasis), and anemia. 2. Over the course of a week of treatment including IV fluids, antibiotics, pain medications, and 5 units of blood transfusion, the bleeding decreased and her symptoms improved. 3. She was discharged on the last day with instructions to follow up at the local health clinic for blood pressure and kidney stone monitoring and to return immediately if bleeding recurred.

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    © All Rights Reserved
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    of 2

    Follow Up

    Tanggal S O A P
    KU: Lemah
    GCS: 4,5,6
    TD: 130/80 mmHg
    - O2 nasal 4 lpm
    N: 80x/mnt
    -IVFD RL 28 tpm
    Masih terasa keluar RR: 20x/mnt P5005 + Obs.
    - Inj. Cefotaxime 3x1iv
    Selasa darah dari jalan lahir. To: 37oC AUB (Ddx
    Lapor dr. Haris,
    06/12/16 Badan lemas dan Teraba massa padat mioma dan
    Sp.OG:
    21.00 pusing. mual (-), kenyal 3 jari symp. malignancy) +
    a/p:
    muntah (-), sesak (-) Pubis, TFU tidak Anemia
    1. transfusi PRC 2 kolf
    teraba, perdarahan
    2. inj. Plasminex 3x1
    aktif, VT 1cm
    jaringan (+), darah
    (+).
    O2 nasal 4 lpm
    KU: Lemah -IVFD RL 28 tpm
    GCS: 4,5,6 - Inj. Cefotaxime 3x1iv
    TD: 100/70 mmHg -transfusi PRC 2
    N: 78x/mnt kolf/hari
    Masih keluar darah P5005 + Obs.
    RR: 19x/mnt - inj. Plasminex 3x1
    Rabu sedikit (+), pusing o o
    AUB (Ddx
    T : 36.5 C
    07/12/16 (+), lemas (+), Mual mioma dan
    Konjungtiva anemis, dr. Erva visite:
    (-), muntah (-), nyeri malignancy) +
    darah pervag (+), -R/ USG Radiologi
    perut (-) Anemia
    nyeri tekan perut -Inj. Kalnex 3x2amp
    bagian bawah, massa -transfusi hingga hb
    (+) 10gr.dl
    Pre transfuse lasix 1
    amp
    Kamis Keluar darah KU: Cukup P5005 +Mioma O2 nasal 4 lpm
    08/12/16 berkurang dari GCS: 4,5,6 uteri + -IVFD RL 28 tpm
    sebelumnya. Badan TD:130/90 mmHg Nefrolithiasis - Inj. Cefotaxime 3x1iv
    sudah mulai enakan. N: 83x/mnt sinistra+Anemia -transfusi PRC 2
    Nyeri pinggang RR: 19x/mnt kolf/hari
    o o
    pusing (-), lemas (-), T : 36.6 C - inj. Plasminex 3x2
    Mual (-), muntah (-), Darah pervag (+), -Pre transfusi lasix 1
    nyeri perut (-) massa abdomen (+) amp
    Ibu menggigil To:
    nyeri ketok flank area
    sinistra. 37.5OC, konsul dr. Eni:
    USG: Mioma Uteri + a/p Paracetamol

    Nefrolithiasis sinistra. 3x1tab


    O2 nasal 4 lpm
    KU: Cukup
    -IVFD RL 28 tpm
    GCS: 4,5,6
    - Inj. Cefotaxime 3x1iv
    TD:130/80 mmHg P5005 +Mioma
    Sudah tidak keluar -transfusi PRC 2
    Jumat N: 80x/mnt uteri +
    darah dari jalan lahir, kolf/hari
    09/12/16 RR: 19x/mnt Nefrolithiasis
    nyeri pinggang kiri. - inj. Plasminex 3x2
    To: 36.5oC sinistra+Anemia
    -Pre transfusi lasix 1
    Nyeri ketok (+),
    amp
    massa abdomen (+)
    - Paracetamol 3x1tab
    O2 nasal 4 lpm
    -IVFD RL 28 tpm
    KU: Cukup
    - Inj. Cefotaxime 3x1iv
    GCS: 4,5,6
    -transfusi PRC 2
    Tadi malam keluar TD:130/80 mmHg P5005 +Mioma
    kolf/hari
    Sabtu darah sedikit, Nyeri N: 84x/mnt uteri +
    - inj. Plasminex 3x2
    10/12/16 pinggang kiri. RR: 19x/mnt Nefrolithiasis
    -Pre transfusi lasix 1
    Keluhan lain (-) To: 36.5oC sinistra+Anemia
    amp
    Nyeri ketok (+),
    - Paracetamol 3x1tab
    massa abdomen (+)
    -inj. Ca Gluconas 1amp
    - cek Hb
    - ACC KRS setelah
    KU: Compos mentis
    transfusi PRC ke-5
    GCS: 4,5,6
    - KIE pasien untuk
    TD:130/90 mmHg P5005 +Mioma
    kontrol HT +
    Minggu Tidak ada keluhan. N: 85x/mnt uteri +
    Nefrolithiasis ke
    11/12/16 Perdarahan (-). RR: 21x/mnt Nefrolithiasis
    puskesmas
    To: 36oC sinistra+Anemia
    -Jika ada perdarahan
    Nyeri ketok (+),
    berulang segera ke
    massa abdomen (+)
    IGD.

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