MAPPING RUANG GINEKOLOGI (ARAFAH 2)

Jumat, 13 April 2018

No. Bed Nama Med.Rec Diagnosis Laboratorium Treatment/Terapi DPJP Planning
Lab 09/04/2018
Hb/Ht/Eri/Trom/Leu
12,1/35/4,1/395/9,9
CT/BT : 8/2
Iramarnika, 37 T3 total : 1,30 - Inj. Ceftriaxon 2 gr/24 jam
P0A1 post kuretase a/i
1 1A thn, POD 1 (tgl 1143774 TSH : 1,26 - Inj. Transamin 1 amp/8 jam HSD Mobilisasi bertahap
Blighted ovum
op 12/04/18) Beta HCG Darah : 1500,00 - Drip oksitosin 2 amp/8 jam
SGOT/SGPT/Alb
17/5/4,23
Ur/Cr : 16/0,65
Na/K/Cl : 138/3,3/107
Lab 11/04/18
Hb/Ht/Eri/Leu/Trom
Yusmawati, 48 7,1/25/3,4/7,4/453
NOK dengan bagian SGOT/SGPT : 24/8 Transfusi sampai Hb > 10
2 1B thn, AD 1 (tgl 1168199 HSD
padat suspek malignan Alb : 3,21 gr/dl
12/04/18)
Ur/Cr :21/0,80
Na/K/Cl : 141/2,9/110
3 2A
4 2B
5 3A
Lab 11/04/18
Hb/Ht/Eri/Leu/Trom
11,1/35/5,1/8,1/309

POD 1 post laparotomi
reseksi adenomiosis,
Yusnidar, 42 thn,
kistektomi a/i kista
6 3B POD 1 (tgl op 1168162
endometrium,
12/04/18)
rekonstruksi uterus,
Adhesiolisis
Lab 09/04/2018
Hb/Ht/Eri/Leu/Trom
9.4/30/4,5/9,2/323 - Inj. Ceftriaxon 2 gr/24 jam
HbsAg negatif - Inj. Ketorolac 1 amp/8 jam Transfusi bila Hb < 8
CMY
SGOT/SGPT 15/11 - Kaltrofen supp/8 jam perectal g/dl
Alb 3,76
Kolesterol total 172
HDL/LDL/TG
48/90/81
GDP/GD2PP : 92/111
Ur/Cr : 22/0,77
Na/K/Cl : 134/3,8/109
 Lab 11/04/2018
- Inj. Ceftriaxon 2 gr/24 jam
POD 2 post laparotomi Hb/Ht/E/Tr/L - Inj. Ketorolac 1 amp/8 jam
Rosmila, 37 thn, salphingektomi sinistra a/i 10,9/31/3,5/352/14,3 - Kaltrofen supp/8 jam perectal
7 4A POD 2 (tgl 1168449 ruptur tuba pars ampularis PT/APTT 9,1/34,0 MN Mobilisasi bertahap
- SF 2x1
masuk 11/04/18) sinistra GDS 116
- Asam folat 1x400 mg
Ur/Cr 15/0,44
Na/K/Cl 142/4,1/106
Lab 10/04/2018
Hb/Ht/Eri/Leu/Trom
12,9/38/4,3/9,5/469
Post menopousal
Aisyah, 57 thn, SGOT/SGPT : 28/26 - Rencana kuretase
bleeding ec Hiperplasia
8 4B AD 2 (tgl op 0985588 Albumin : 3,67 MN bertingkat
endometrium
12/04/18) HDL/LDL/TG (13/04/18)
44/107/122
Ur/Cr : 14/0,73
Na/K/Cl : 134/3,7/115
Lab 11/04/18
Hb/Ht/Eri/Leu/Trom
8,7/30/4,3/6,3/455
Asmawati, 47 SGOT/SGPT : 21/11
Mioma uteri + tumor
9 4C thn, AD 1 (tgl 0885437 Alb : 4,08 HSD Perbaikan KU
ovarium kanan
masuk 12/04/18) Na/K/Cl : 140/4,0/108
Ur/Cr : 18, 0,64
Asam urat 3,2
GDP/GD2PP : 95/97
Lab 10/04/2018
Hb/Ht/Eri/Trom/Leu
- Inj. Ceftriaxon 2 gr/24 jam
Nuraida, 33 thn, POD 1 post kistektomi 13,4/40/4,8/382/13,3
- Inj. Ketorolac 1 amp/8 jam
10 4D POD 1 (tgl 1113325 perlaparoskopi a/i Kista PT/APTT 10,0/38,2 MA Mobilisasi bertahap
- Kaltrofen supp/8 jam perectal
masuk 12/4/18) dermoid dextra Gds 126
Ur/Cr 10/0,54
Na/K/Cl 145/3,4/107
POD 2 post kuretase a/i
late PPH ec sisa plasenta Lab 11/04/2018 - Inj. Ceftriaxon 2 gr/24 jam
pada P5A1 post partus Hb/Ht/Eri/Leu/Trom - Drip metronidazol 500 mg/8 jam
Ismiati, 40 thn,
spontan diluar 25 hari 6,7/19/2,2/14,1/221 - Inj. Ketorolac 1 amp/8 jam
11 5A POD 2(tgl Op 1128310 MN Cek darah rutin
yll, ibu dengan GDS 170 - Sohobion 2x1
11/04/18)
permasalahan CKD on Ur/Cr ; 138/8,49 - Pantoprazol 1 vial/12 jam
HD reguler + anemia Na/K/Cl :138/4,4/101 -
normositer normokrom
12 5B Winda safitri, 25 0869780 POD 2 post kistektomi Lab 29/03/2018 - Inj. Ceftriaxon 2 gr/24 jam HSD
 Hb/Ht/E/L/T
12,7/38/4,5/6,6/239
- Inj. Transamin1 amp/8 jam
HbsAg: Negatif
thn ovarium bilateral, - Inj. Ketorolac 1 amp/8 jam
GDS:124
POD 2(tgl op adhesiolisis a/i kista - Inj. Ranitidin 1 amp/8 jam
Sgot/sgpt: 15/7
11/08/18) ovarium bilateral - Kaltrofen supp/8 jam perectal
Prot tot : 8,14
Ur/cr : 28/0,76
Na/K/Cl : 140/3,3/109
POD 4 post laparotomi Lab 11/04/2018
eksplorasi debulking Hb/Ht/E/L/T
tumor a/i Ca ovarium 8,4/24/2,8/6,9/192
post kemoterapi Na/K/Cl 137/3,4/103
omentektomi
adhesiolisis a/i Lab 09/04/18 - Cefixim 2x100 mg
Safariah, 31th, perlengkatan genitalia SGOT/SGPT : 51/34 - Metronidazole 3x500 mg
POD 4 (tgl op eksternum. Ibu dengan Albumin : 3,66 - Na diklofenak 3x50 mg - Obs KU, TTV,
13 5C 1147788 HSD
09/04/18) permasalahan Ur/Cr : 14/0,32 - KSR 2x600 mg Perdarahan.
- Lansoprazole 2x30 mg
1. HbsAg Na/K/Cl : 141/3,3/105
- Fluimucyl syr 3 x C1
2. Anemia
normositik
normokrom ec
blood loss
3. hipokalemia
Lab 11/04/2018
AUB ec Mioma uteri Hb/Ht/E/T/L
multipel + kista ovarium 7,4/23/3,0/238/6,2
Ferdina,50 thn, - Obs ku ttv
14 5D 1168371 unilateral dengan PT/APTT 9,4/29,8 SF 2x1 MN
AD 2 ( - Transfusi PRC
permasalahan anemia GDS 104
makrositik hipokrom Ur/Cr 21/0,65
Na/K/Cl : 138/3,7/111
Lab 07/04/2018
Hb/Ht/Eri/Leu/Trom
- Inj. Ceftriaxon 2 gr/24 jam
12,1/35/4,5/10,7/494
POD 2 post secondary - Drip metronidazole 500 mg/8
PT/APTT 11,5/36,3
Juana,48 thn, hecting a/i ILO post jam
GDS 128 Mobilisasi
15 6A POD 2 1165860 TAH a/i cervisitis - Inj. Ketorolac 1 amp/8 jam CMY
Ur/Cr 21/0,63 bertahap
(13/04/18) kronis 18 hari yang - Sohobion 2x1
Na./K/Cl 130/2,9/104
lalu - Curcuma tab 2x1
Lab 11/04/2018
Na/K/Cl 144/4,1/109
 Lab 10/4/2018
Hb/Ht/E/Leu/Trom
- Inj. Ceftriaxon 2 gr/24 jam
Rusiani, 12,7/38/4,6/11,1/193
POD 1 post - Inj. Ketorolac 1 amp/8 jam - Higienitas vulva
38tahun, PT/APTT : 9,3/37,4 TPD
16 6B 1168367 marsupialisasi a/i kista - Inj. Ranitidin 1 amp/12 jam dan uretra
POD 1 HbsAg : Negatif
bartholini - Sohobion 2x1
(12/04/18) GDS : 97
- Vit C 2x1
Ur/Cr : 22/0,66
Na/K/Cl : 143/3,8/109
Lab 11/04/2018 - Cefadroxyl 2x500 mg
Hb/Ht/E/Tr/Leu - Asam mefenamat 3x500 mg
Nadia Zulfa, 29 14,2/4,1/5,0/389/7,8 - Misoprostol 3x200 mg
POD 1 post kuretase a/i
17 6C thn, POD 1 (tgl 1004971 PT/APTT 9,8/35,7 - Methergin 3x0,125 mg MA
blighted ovum
op 12/04/18) GDS 114 - Sohobion 1x360 mg
Ur/Cr 6/0,14
Na/K/Cl 142/4,0/102
POD 3 post laparotomi
eksplorasi adhesiolisis, Lab 11/04/2018
suboptimal debulking Hb/Ht/E/Tr/Leu - Inj. Fosmycin 2 gr/12 jam
omentektomi a/i tumor 11,8/36/4,5/646/28,2 - Drip metronidazole 500 mg/8
Salawati, 48 thn, ovariium susp. jam - Mobilisasi bertahap
PT/APTT 12,1/45,8
18 6D POD 3 (tgl op 1167202 Malignancy dgn - Drip tramadol 1 amp/8 jam SIK - GV hari ini
SGOT/SGPT : 32/19
10/04/18) permasalahan : - Inj. Ranitidin 1 amp/12 jam
Albumin : 3,02
- Kaltrofen supp II perrektal
1. Trombositosis Ur/Cr : 29/0,63
(K/P)
2. Leukositosis Na/K/Cl : 139/4,3/105
3. hipoalbuminemia
POD 3 post laparotomi
histerektomi total a/i Lab 11/04/2018 - Inj. Ceftriaxon 2 gr/24 jam
mioma uteri. Ibu dengan Hb/Ht/E/Tr/L - Inj. Ketorolac 1 amp/8 jam
permasalahan : 10,6/34/4,6/341/16,4 - Inj. Ranitidin 1 amp/12 jam
1. HbsAg positif - Mobilisasi
Suryani, 48 thn, PT/APTT 9,9/32,2 - Kaltrofen supp 3x100mg
bertahap
19 6E POD 3 (tgl 1167857 2. Anemia HbsAg Positif** peerectal SIK
- PBJ hari ini
10/04/18) normositik SGOT/SGPT 21/16 - Curcuma 2x1
normokrom Albumin : 3,59 - Sohobion 2x1
3. Leukositosis Ur/Cr : 24/0,47 - Vit C 2x1
4. Hipomagnesium Na/K/Cl : 142/3,9/103
5. Hiperglikemi
20 6F Nazariah , 37 thn 0892708 POD 2 post laparotomi Lab 11/04/2018 - Inj. Ceftriaxon 2 gr/24 jam HSD - GV hari ke-3
POD 2 (tgl op eksplorasi a/i dislokasi Hb/Ht/E/L/Tr - Inj. Ketorolac 1 amp/8 jam
11/04/18) IUD + adhesiolisis 10,9/33/4,1/23,9/343 - Inj. Omeprazol /12 jam
- Kaltrofen supp 3x100mg
 Lab 02/4/2018
Hb/Ht/E/L/T
11,1/34/4,2/9,3/404
CT/BT : 2/7
peerectal
SGOT/SGPT/Alb: 17/17/4,23
HbsAg negatif
Na/k/cl : 144/3,8/107
GDS :106
Ur/Cr : 14/0,73
Na/K/Cl : 140/3,8/110
21 7A
Lab 04/04/18
- Laparotomi
Hb/Ht/Eri/Leu/Trom
miomektomi s/d
Nila Wardani, 49 11,8/38/5,3/311/6,0
YS histerektomi
22 7B thn, AD 1 (tgl 1167401 Mioma uteri + HHD SGOT/SGPT : 34/64 - Amlodipin 1x5 mg
(13/04/18)
masuk 12/04/18) Albumin: 4,19
- Regulasi TD <
Ur/Cr : 20/0,76
150/90 mmHg
Na/K/Cl : 141/3,7/111
23 7C
24 7D
25 7E - -
Lab 12/04/18
Mei Lan, 49 thn, AD Hb/Ht/Eri/Leu/Trom
Ca Ovarium + - Inj. Leukogen/hari sampai
26 7F 1 (tgl masuk 0801029 10,7/34/5,2/2,9/337 SIK Perbaikan KU
12/04/18) Leukopenia leukosit > 4000/mm3
Albumin : 4,48
GDS : 134
ISO
27
1
28 ISO Murniah, 35 thn, 1143571 POD 3 post secondary Lab 11/04/2018 - Inj. Ceftriaxone 2 gr/24 jam SIK - Obs KU, TTV,
2 POD 3 (tgl op hecting ec burst Hb/Ht/E/L/Tr - Drip Metronidazole perdarahan, atasi
10/04/18) abdomen a/i post 5,5/16/1,9/30,5/183 500mg/8jam hipoalbumim
optimal debulking tumor - Drp Klinimix 1 fls/hari - Mobilisasi
incomplete, incomplete Lab 9/4/2018 - Drip albumin 1 flc (octalbin 2%) bertahap
resection, adhesiolisis, Protein total : 5,05 1 fls/hari
omentektomi , reseksi Alb/glob : 2,49/2,55 - Inj. Ketorolac 3% 1 amp/8 jam
nodul a/i Ca ovarium - Inj. Transamin 1 amp/12 jam
progresif + Ca recti Lab 5/4/2018 - Inj. Ranitidine 1 amp/12 jam
Hb/Ht/E/L/Tr - Inj. ondansetron 1 amp (4
10,3/29/3,6/278/36,2 mg)/8jam
- Sohobion 2x360mg
 Lab 4/4/2018
Hb/Ht/E/L/Tr
7,6/22/2,7/15,3/101
Na/K/Cl: 137/4,6/106
Ca/Mg: 7,7/2,0

Lab 3/4/2018
Hb/Ht/E/L/Tr
6,8/20/2,3/17/279
HBsAg: negative
SGOT/SGPT/Prot total
38/24/4,62
Alb/Glob: 2,10/2,52
GDW: 144
Ur/Cr: 37/0,80
Na/K/Cl: 135/3,4/107

DPJP Jumlah
Dr. dr.Hasanuddin,Sp.OG (K) 6 1A, 1B, 4C, 5B, 5C, 6F
dr. Yusra Septivera,Sp.OG 1 7B
dr. Rajudin,Sp.OG - -
dr. Tgk. Puspa Dewi, Sp.OG 1 6B
dr. Sarah Ika N, Sp.OG(K) 4 6D, 6E, 7F, ISO 2
dr. Niken Astri Utami, Sp.OG - -
Dr.dr. Cut MeurahYeni, Sp.OG (K) 2 3B, 6A
dr. Munawar, Sp.OG 4 4A, 4B, 5A, 5D
dr. Munizar, Sp.OG - -
Dr.dr.Mohd.Andalas, Sp.OG 2 4D, 6C
dr. Roziana, Sp.OG - -
dr. Dewi Karlina R,Sp.OG - -
Dr. Cut Rika Maharani, Sp. OG - -

Total Pasien 19 -