MAPPING RUANG OBSTETRI ARAFAH 2

Senin, 23 Desember 2019

DPJP JUMLAH PASIEN KAMAR PASIEN

Dr. dr. Hasanuddin, Sp.OG(K)
dr. YusraSeptivera, Sp.OG
Dr. dr. Rajuddin, Sp.OG(K)
dr. Tgk. PuspaDewi, Sp.OG
dr. Sarah IkaNainggolan, Sp.OG(K)
dr. NikenAsriUtami, Sp.OG (K)
Dr. dr. Cut MeurahYeni, Sp.OG(K)
dr. Munawar, Sp.OG
dr. Munizar, Sp.OG
Prof. Dr. Dr. Mohd. Andalas, Sp.OG, FMAS
dr. Roziana, Sp.OG
dr. DewiKarlinaRusly, Sp.OG
dr. Cut Rika Maharani, Sp.OG
dr. Hilwah Nora, Sp.OG (K)
dr. ImaIndirayani, Sp.OG
TOTAL PASIEN
2 2B, 5B
5 1B, 4A, 4D, 5A, 6A
1 2A
2 1A, 6F
1 5D
KETERANGAN
HAMIL : 2
1 6B POST SC: 6
POST PV: 4
POST VAKUM : 2
ILO: 1
4 4B, 4C, 6D, 6E POST MANUAL PLASENTA: 0
2 6F, ISO1 PASIEN GINEKOLOGI : 1
16

No Kmr Nama CM Diagnosis Terapi Penunjang Bayi DPJP Rencana

1 1A leni andeka, pr, 1098239 POD 4, Post SC, para 1 a/i janin - Na. Diklofenat 3x 50 mg Lab 19/12/19 BY. CMY Rencana PBJ
24th, Aceh Pidie dengan omfalokel - Sohobion 2x1 tab Hb/Ht/E/L/T LK Obs KU TTV
8,9/28/3,9/19,6/336 2700
Lab 17/12/19 gr A/S
Hb/Ht/E/L/T : 8/9
8,9/29/3,9/12,1/357
Na/K/Cl: 141/4,2/108
Hbsag: negatif
Ct/bt: 7/3
GDS : 88
2 1B Rina Ariani, 29 0994140 NH2 P2 post ekstrasi vakum -cefadroxil 2 x 1 tab Lab 21/12/19 By laki YS Obs Ku TTV kontrasi
th, Kuta Alam ai percepat kala dua post - Na. Diklofenat 3x1tab Hb/Ht/E/L/T : – laki Folley kateter 24jam
10,5/32/4,2/8,3/271
perinografi ai ruptur - Sohobion 2x1 tab 3300
Na/K/Cl: 141/5,0/111
perineum grade II Hbsag: negatif gram
Ct/bt: 2/8 A/S
GDS : 92 8/9
3 2A Epi Juita, 37 th, 1118261 POD 2 P2 post sc a/i bsc 21x - Inj ceftriaxon Lab 21/12/19 By laki TPD Obs Ku TTV kontrasi
Panga IDT 2,5 tahun, inpartu 2gr/24jam Hb/Ht/E/L/T : laki Pendarahan
11,4/35/4,1/10,2/190 3500gr
- Inj ketorolac Terapi sesuai FDO
 30mg/6jam Na/K/Cl: 145/4,0/111 , A/S mobilisasi bertahap
- Inj omeprazol Hbsag: negatif 8/9 Aff kateter 1x24jam
Ct/bt: 3/9
20mg/12jam GDS : 103 Cek lab 2jam post sc
- Drip metrodinazol
500gr/12jam
- Kaltropen supp II/8jam
- Drip oxytocin 20IU
selama 12jam post sc
- Inj transamin extra
1000mg
4 2B Afdhaliah Zym spd , 1229131 POD 3, post laparotomy Ceftriaxone 2 gr/ 24 jam Lab 20/12/2019 HSD Obs KU, TTV, Drainn
48 th, Labuhan Haji histerektomi total, Ketorolac 1 amp/ 8 jam HbA1c: 8,10 Transfusi 500cc PRC
Timur salphingoforektomi bilateral ai Transamin 1 amp/ 8 jam Lab 16/12/2019 Pantau produksi drain
susp Ca endometrium Lansoprazol 1 vial/ 12 jam GDP/GD2PP:121/229 Anjurkan ibu makan
Kaltropen supp II/ 8 jam Lab 27/11/2019 sedikit tapi sering
Humalog mix 25, 10-0-12 IU Hb/Ht/L/T Anjurkan ibu minum air
(sebelummakan) 10,7/7,3/325 hangat
CT/BT 3/8
CEA 2,24
HbsAG non reaktif
SGOT/SGPT 23/18
Alb 4,22
LDH 146
GDS/GD2PP : 205/436
Ur/Cr : 21/0,61
Na/K/Cl : 143/5,0/106
5 3A
6 3B
7 4A Milda Syahputri, 25 0961854 POD 2 P1 post SC a/i CPD IV ceftriaxon 2gr/24 jam Lab 21-12-2019 Bayi YS Cek dr post sc bila Hb <
th, syiah kuala inpartu IV ketorolac 30mg/8jam Hb/Ht/E/Leu/Trom peremp 8gr/dl tf pRC sampai
Kaltropen supp /8jam 11,1/34/4,2/19.1/287 uan 10gr/dl
IV omeprazol 20mg/12jam A/S Mobilisasi bertahap
Transamin 1000mg/12jam Lab 21-12-2019 8/9 FC 1 x 24jam
Sohobion 2x1 Hb/Ht/E/Leu/Trom GV hari ke 3
10,8/33/4,1/13.3/283
Ct/bt: 2/8
Hbsag: non reaktif
Gds: 89
Na/K/Cl 145/4,0/112
8 4B Rauzatul Munar, 1232034 NH2 P1 post partus spontan, Cefadroxyl 500mg/12jam Lab 21-12-2019 Bayi CRM Obs KU, TTV,
pr, 27 th, aceh post perineorafi a.i rupture Na. diclofenac 50mg/8jam Hb/Ht/E/Leu/Trom peremp kontraksi dan
9,9/32/4,1/11.8/212 uan,
besar perineum grade 2 + retensio Sohobion 360mg/12jam Ct/bt: 2/7 perdarahan
2800gr
urin Misoprostol 200mg/8jam Hbsag: non reaktif FC 1X24 jam
Gds: 81 , A/S
Terapi sesuai FDO
Na/K/Cl 143/3,09/110 8/9
9 4C Desi kemala sari, 0975493 G3P2 hamil 24-25 minggu Paracetamol 3x1 Lab 21-12-2019 CRM Obs KU TTV
29 th, Kuta baro JTHIU obs febris ec ISPA Flumucyl 3x1 Hb/Ht/E/Leu/Trom Terapi sesuai FDO
11,3/33/4,3/6,2/222
Inj. Omeprazol /12jam GDS 114
Cefixim 2x1 Na/K/Cl : 138/3,8/106
Ambroxol 2xC1
Cetirizin2x1
Andalat oro 1x30mg
Nifedipin 10mg titrasi
10 4D Rahma Yunita, 32 1231582 G4P3 hamil 16-17 minggu Paracetamol 3 x500mg Lab 20/12/2019 YS Obs KU TTV
th, Aceh pidie JTHIU ibu dengan obs febris Omeprazol 1 vial/12jam Hb/HT/E/L/T Tf PRC 2 kolf
hari ke 9, trombositopenia ec dd As. Folat 1 tab/ 24 jam 8,6/25/2,9/5,5/74 Terapi sesuai FDO
- Demam dengue PT/APTT : 11,50/35,60
- Typhoid fever Ur/cr 13/0,50
- ISK
- ITP Lab 20/12/2019
- Chingkungya Hb/HT/E/L/T
9,2/26/3,1/6,1/43
MDT
Eritrosit:
normokromanisositosis
Leukosit: normal
Trombosit: menurun,,
Kesimpulan: anemia
normokromnormositik
Lab 19/12/2019
Hb/HT/E/L/T
11,5/33/3,9/25/10,1
Ct/bt: 3/10
HBsAg : Negatif
GDS : 105
IgM negatif
IgG positif
Urinalisis
Protein: negaif
Keton: negatif
11 5A Lilis suryani, pr, 24 1231858 POD 3 P2A0 post SC ai BSC 1 Cefriaxone 2 gr/24 jam Lab 20/12/2019 By YS Obs KU, TTV, kontraksi,
th x (IDT 13 bulan) inpartu Ketorolac 1 amp/ 8 jam Hb/HT/E/L/T peremp perdarahan
Omeprazol 40 mg/12 jam 10,3/32/4,1/15,6/238 uan Motivasi ASI
Kaltropen supp II/8 jam Lab 20/12/2019 BBL
Sohobion tab/12 jam Hb/HT/E/L/T 3000
Oksitosin 20 IU/12 jam 10,2/33/4,1/10,9/249 gr,
CT/BT: 3/8 A/S:
Na/K/Cl: 142/4,9/110 8/9
Hbsg: negative
12 5B Zarina M. Yahya, 1231992 POD 2 P4 post sc a/I BSC Inj. Ampicillin 1,5gr/6jam Lab 22/12/2019 By HSD Obs KU, TTV
pr, 34 th 1x dssitosia PK 1 aktif a/I Inj. Ceftriaxone 2gr/24jam Hb/HT/E/L/T laki- Mobilisasi bertahap
 popp, Ibu dengan Inj. Ketorolac 30mg/8jam 5,9/18/2,4/18,9/46 laki
trombositopenia, anemia Inj. Omeprazole 40mg/12 jam BBL
Lab 21/12/2019 3200
mikrositik hipokrom Inj. Transamin/8 jam
Hb/HT/E/L/T gr,
Inj. Vit. K/12 jam 8,7/27/3,5/28,3/24 A/S:
Kaltropen sup II k/p Ca/mg: 7,8/1,6
8/9
Paracetamol 500mg/8jam Ur/cr: 20/0,70
Na/k/cl: 142/4,6/113

Lab 21/12/2019
Hb/HT/E/L/T
10,4/33/4,4/16/26,1
Pt/apt: 0,84/1,32
Anti dengue igM: positif
Anti dengue igG: positif
Na/K/Cl: 140/4,1/110
Hbsg: negative
13 5C
14 5D Siti aminah, pr, 27 1231853 NH 3, P3 post partum di luar Oksitosin 20 IU/ 24 jam Lab 20/12/2019 MWR Obs KU, TTV,
th dengan riwayat PPH Methergin 1 map/8 jam Hb/HT/E/L/T perdarahan
Na. diklofenac tab/ 8 jam 7,3/21/2,5/34,5/152 Tranfusi PRC 1 kolf lagi
Gentamisin 1 amp/24 jam CT/BT: 3/8 FC 2x1
Ceftriaone 2 gr/24 jam Ur/Cr: 9/0,40
Metronidazol 500 mg/8 jam Na/K/Cl: 132/3,9/105
FE 400mg/12jam GDS: 132
Hbsg: negatif
15 6A Mursyidah 1177183 POD 3 P4A2 post sc a/I Inj. Viccilin sx 1,5gr,6 jam Lab 20/12/2019 By YS Obs KU, TTV
Muhammad, pr, 40 plasenta previa totalis inpartu, Inj. Lansoprazole/24 jam Hb/HT/E/L/T peremp Mobilisasi bertahap
th, Bireuen akseptor tubektomi, Ibu dengan Dex ketropofen/8 jam 7,5/23/2,6/4,9/6 uan Diet tinggi kalori
permasalahan: Codein/8 jam BBL Transfusi PRC
1. Trombositopenia 2700 Transfusi TC
(tr:6000) post gr,
transfusi TC 10 kolf A/S:
ec ITP 8/9
2. Anemia normositik
normokrom (HB: 7,5)
ec blood lost
16 6B Febri yanti, 21 th, 1231958 NH2 P1 post pastusspontan , MgSo4 40% selama 24jam Lab 20/12/2019 By MA Obs KU, TTV, kontraksi,
Darul imarah post periniorafiai rupture Metildopa 2x1 Hb/Ht/E/L/T peremp perdarahan
perineum Gr II Cefadroxil 2x1 10,5/33,7/4,1/8,8/212 uan Diet mb TKTP
Na.Diklofenat 3x1 CT/BT: 2/8 BBL
Sohobion 2x1 SGOT / SGPT 15/3 2400
Paracetamol 3x1 Ur/Cr: 16/0,70 gr,
A/S:
Urinalisa 4/5 6/9
Protein +++3
17 6C DPJP IPD
18 6D Sukarni M. Nur, 1232037 NH1 P3 post pastus spontan Bromokiptin/8jam Lab 21/12/2019 CRM Ob KU, TTV,
pr, 32 th, Aceh a/I janin gemeli presentasi Paracetamol 500mg/8jam Hb/HT/E/L/T kontraksi dan
10,3/30/3,4/10,7/215
Besar kepala-kepala IUFD SF/24jam CT/BT: 2/8
perdarahan
keduanya, serviks belum Ur/Cr: 9/0,60 Mobilisasi aktif\bebat
matang (PS 3), belum Na/K/Cl: 144/3,8/113 payudara diet MB
inpartu Sgot/sgpt: 24/9 TKTP
GDS: 128
Hbsg: negatif
19 6E Nurlelatul Fajri, 1232078 NH1 P1 post partus ekstraksi Cefadroxyl 500mg/12 jam Lab 22/12/2019 By CRM Obs KU TTV
pr, 22 th, Aceh vakum a/I ibu lelah Na. diclofenac 50mg/ 8jam Hb/HT/E/L/T laki- Mobilisasi betahap
10,5/31/3,5/15,3/188 laki
Besar meneran, post perineorafi a/I Sohobion 360mg/12jam CT/BT: 2/7
Motivasi ASI
BBL
rupture perineum grade 2 Misoprostol 200mg/8jam Ur/Cr: 11/0,40
3060
Na/K/Cl: 137/3,8/109
GDS: 117 gr,
Hbsg: negatif A/S:
8/9
20 6F Oviani bukhari, pr, 1231200 ILO pada P1 post SC 9 hari Ceftriaxone 2 gr/ 24 jam Lab 20/12/2019 CMY Gantiperban / hari
21 th SMRS ai KPD Gentamicyn 500 mg/24 jm Hb/HT/E/L/T Terapi sesuai FDO
Metronidazol 1 fs / 8 jam 10,4/32/4,0/14,9/577
Vit C / 8 jam CT/BT: 2/8
Ur/Cr: 14/0,50
Na/K/Cl: 147/3,9/114
GDS: 89
21 7A DPJP ANAK
22 7B DPJP ANAK
23 7C DPJP ANAK
24 7D DPJP ANAK
25 7E DPJP ANAK
26 7F DPJP ANAK
27 ISO 1 DPJP IPD
28 ISO 2 DPJP ANAK -