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ArlinAnnisaR Rmik4A Tugas5ChapterXV

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ARLIN ANNISA RAMDANIAH
RMIK 4A (E79119003)
TUGAS 5 CHAPTER XV MATERNAL CODING
MRS = 16/2/2012 jam 11.45
Dikirim = dr .x KU : mules2 AK : G1 P0 A0 hamil 7 bln, his + jarang, ± 12 jam SMRS, Show –
, ketuban – sejak tanggal 30/1 /2012, riwayat dirawat3 x, telah mendapat obat pematangan paru 4
x dan obat anti biotik.
Menikah
:♀ 27 th, S1, PNS ♂ 26 th, STM, wiraswasta
KB = (-)
: HPHT = 16/7/2011 , TP = 23/4/2012, PNC =SPOG 7 x
Status praesen : TFU = 20 cm, LP 81 cm
D/ G1 P0 A0 gravida 34-35 minggu, premature kontraksi, ketuban pecah dini Advice dr :
proneron, histolon, observasi his Tg 17/02/2012 pasien pulang dalam keadaan baik.
Jawaban !
D.U  His + jarang
Labor
-
False
- before 37 completed weeks of gestation O47.0
D.T Ketuban Pecah Dini
Rupture,ruptured
-
Membranes (spontaneous)
- premature
- - onset of labor
- - - delayed by therapy O42.2
T.U  Injection Antibiotik
Injection (into)(hypodermically) (intramuscularly) (intravenously) (acting locally or
systemically)
-
Antibiotic 99.21
TT  Ultrasonography
Ultrasonography
-
Uterus 88.79
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