MAPPING RUANG OBSTETRI ARAFAH 2

Rabu, 28 Februari 2024 Pukul 22.00 WIB

DPJP JUMLAH KAMAR

PASIEN
Dr. dr. Hasanuddin, Sp.OG(K)-Onk

dr. Yusra Septivera, Sp.OG

Prof. Dr. dr. Rajuddin, Sp.OG(K)-FER

dr. Tgk. Puspa Dewi, Sp.OG(K)-Obginsos 3 1B,5C,6A

dr. Sarah Ika Nainggolan, Sp.OG(K)-Onk 1 1A,4A

dr. Niken Asri Utami, Sp.OG(K)-FM 2 5A, ISO-2

Dr. dr. Cut Meurah Yeni, Sp.OG(K)-FM 2 3B, 6B

dr. Munawar, Sp.OG(K)-Obginsos

dr. Munizar, Sp.OG(K)-Onk 1 7C

dr. Roziana, Sp.OGK(K)-Urogin

dr. Dewi Karlina Rusly, Sp.OG

dr. Cut Rika Maharani, Sp.OG 3 4D,6F, ISO-1

dr. Ima Indirayani, Dr.Obgyn, Sp.OG

dr. Rusnaidi, Sp.OG(K)-FER

dr. Rizka Aditya, Sp.OG 1 3A

TOTAL PASIEN 14
Kamar Identitas Hari Diagnosis Pemeriksaan Tatalaksana DPJP Planning
Pasien rawatan Penunjang
1B Chumair Hari POD 2 P5A0 Lab 26/02/24 - IV Ceftriakson TPD - Obs KU,
a binti rawatan - post sc a/i bsc Hb/Ht/E/L/T: 2 gr/24j TTV,
hanafiah, 3 1x (idt 18 bulan) 8,7/28/4,2/24,6 - IV perdarahan,
34 th, inpartu 1/307 Metronidazol kontraksi
1126433 MCV/MCH/ 500 mg/8j
MCHC : - IV ketorolac
66/21/31 30 mg/8j
Diftel : - IV omeprazole
0/0/0/85/8/7 40 mg/12j

Lab 26/02/24
Hb/Ht/E/L/T:
10,1/34/5,0/14,
87/317
MCV/MCH/
MCHC :
67/20/30
Diftel :
0/0/0/86/11/3
HbsAg : NR
GDS :93
SGOT/SGPT:
13/7
Albumin : 3,86
Ur/cr :12/0,33

3A Hastuti Hari G3P2A0 hamil Lab 27/02/24 - PV RA - Obs Ku,

Susanti, Rawatan 7-8 minggu, Hb/Ht/E/L/T: misoprostol TTV,
36,09722 ke 1 BSC 2x (IDT 22 11,6/36/4,4/19, 800 mcg/3 jam perdarahan
11 bulan) 32/303 - PV ketorolac 1 - Induksi
perdarahan MCV/MCH/ amp/8 jam abortus
pervaginam ec MCHC : - PO dengan
abortus insipien 82/27/33 metronidazole misoprostol
Diftel : 500 mg/8 jam 800 mcg/3
0/0/0/90/9/3 - Misoprostol jam PV
HbsAg : NR 800mg/3jam sampai
GDS : ekspulsi
SGOT/SGPT: - Pantau
Albumin : tanda
Ur/cr : ekspulsi
janin
3B Rouzann Hari -G2P1A0 hamil Urinalisis - PO Adalat CMY - Obs ku, ttv,
a Safitri, rawatan 16-17 minggu, 26/2/24 oros 30 m g/24 djj
30 th, 3 JTHiu, ibu Dalam batas jam - Obs tanda
0911806 dengan normal - PO aspilet 80 impending
hipertensi mg/24 jam eklamsia
kronik Lab 26/2/24 - PO tablet - Terapi fdo
Hb/Ht/E/L/T: tambah
11/35/4,2/15,8 darah/24 jam
4/388 - PO metildopa
MCV/MCH/ 250mg/12j
MCHC :
83/26/32
Diftel :
1/0/1/74/20/4
PT/APTT :
0,94/1,04
D-dimer:
680,00
HbsAg : NR
SGOT/SGPT:
11/9
GDS : 127
Albumin: 3,58
Ur/Cr: 13/0,52
Na/K/Cl:
139/3,9/105
4A Zulema Hari POD 2 P3 Lab 27/02/24 IV ceftriakson SIK -Obs KU,
binti M Rawatan (AH1) a/i Hb/Ht/E/L/T: 2g/24j TTV,
Zubair, 3 inkompetens 8,5/27/3,3/10,3 IV ketorolac 1 kontraksi,
24 th, serviks 1/261 amp/8j perdarahan
1303732 MCV/MCH/ IV omeprazole -tranfusi
MCHC : 40mg/12j PRC 2 kolf
80/26/32 IV transamin + cek DR
Diftel : 500 mg/8j post
1/0/1/70/20/8 Kaltrofen sup tranfusi
II/8j
Lab 27/02/24
Hb/Ht/E/L/T:
10,5/35/4,2/7,1
8/293
MCV/MCH/
MCHC :
83/25/30
Diftel :
1/0/1/56/33/9
PT/APTT :
0,99/0,96
HbsAg : NR
SGOT/SGPT:
31/11
GDS : 81
Albumin: 3,19
Ur/Cr: 10/0,54
Na/K/Cl:
139/3,3/103
 Lab 26/02/24
Hb/Ht/E/L/T: -
11,0/32/3,7/24,
59/301
MCV/MCH/M
CHC :
85/30/35
Diftel :
0/0/0/88/9/3

Lab 24/02/24
Hb/Ht/E/L/T:
11,3/33/3,8/9,8
5/359
MCV/MCH/
MCHC :
87/30/34
Diftel :
2/1/0/75/17/5
PT/APTT :
13,0/31,1
HbsAG : NR
SGOT/SGPT :
18/9
Alb: 3,29
Ur/cr : 19/0,64
GDS : 143
Na/K/Cl :
134/3,8/105

4D Agustina Hari G2P3A0 hamil Lab 26/02/24 - PO Paracetamol CRM - Obs KU,
Binti rawatan 10-11minggu Hb/Ht/E/L/T: 500mg/8j TTV
Ridwan, ke 3 JTHIU 14,2/41/4,9/11, - PO Asam folat - Aff infus
1278982, hiperemesis 30/323 400mg/24j
35 th gravidarum MCV/MCH/ - PO sukralfat
dengan MCHC : CII/8j
dehidrasi ringan 84/29/35 - PO
sedang Diftel : ondansentron
1/0/1/74/17/7 3x4mg
PT/APTT : - PO lansoprazol
1,01/1,067 2x30mg
HbsAg : NR - PO cetirizine 1
SGOT/SGPT: tab ekstra
21/15
GDS : 84
Ur/Cr: 19/0,63
Na/K/Cl:
138/4/102

5A Surya Hari G3P2A0 hamil Lab 26/02/24 NAU - Observasi

− PO
Ningsih, rawatan 26-27 minggu, Hb/Ht/E/L/T: KU, TTV
39 th, ke-11 JTHIU, BSC 2x 9,1/26/3,0/9,20 Lansoprazole
1361651 (IDT 6 th) ibu 5/260 1 tab/12j
dengan MCV/MCH/ − PO Sukralfat
hiperemis MCHC :
syr 3xCI
gravidarum 84/30/36
− PO Glutrop
dengan Diftel :
dehidrasi ringan 10/0/0/68/3/19 1x1
sedang, Albumin ; 2,74 − 500 mg 2x1
Ibu dengan DM Na/k/cl:
tipe II 131/3,60/99 − PO Vastral
360mg/12j
Lab24/02/24
Ca: 8,0 − PO
Na/K/Cl: Ondansentron
132/3,3/102 8mg/8j
Albumin: 2,76
− PO Cetirizine
Lab22/02/24 1 tab/12j
Ca: 8,4 − PO neurobion
Na/K/Cl:
130/2,7/100 2x1 tab
− PO
Lab18/02/24
vipalbumin
Hb/Ht/E/L/T:
2x1tab
12,3/34/4,2/10
41/397 − IV ranitidine 1
MCV/MCH/ amp/12j
MCHC :
80/29/37 − IV
Diftel : metokloprami
5/0/0/74/16/5 d 10mg/8j
SGOT/SGPT :
15/35
Ur/cr : 14/0,30
GDS : 173

Lab 19/02/24
HbA1c : 6,30

Lab20/02/24
Urinalisis
Makroskopik:
Warna :
kuning muda
Kerjenihan :
keruh
pH : 7,0
leukosit : +
protein : -
glukosa : -
keton : -
nitrit : -
urobilinogen :
-
bilirubin : -
darah : -
Mikroskopik :
Leukosit : 10-
25
 Eritrosit : 0-2
Epitel : 0-1
5C Ika Hari G5P4A0 hamil Lab 27/2/24 -PO Nifedipin TPD - Obs ku,ttv,
Yufina rawatan 35-36 minggu Hb/Ht/E/L/T: 10 mg/8 jam his,djj
S, 36 th, ke 2 ancaman partus 11,6/37/4,7/26 -Kaltropen Supp - Terapi
1360989 prematurus ec 0 II/ 8 jam sesuai FDO
susp. ISK belum MCV/MCH/ -PO Adalat oros
inpartu MCHC : 30mg/24 jam
78/25/32 Kaltopren I
Diftel : Supp/8jam
1/0/0/71/18/10
PT/APTT :
12,90/28,90
Albumin : 3,47
Ur/Cr : 18/0,43
Na/K/Cl :
138/4,2/106
HbSag : NR
Sgot/Sgpt :
12/9
GDS : 101
6A Nuri Hari Eklampsia post Lab 28/2/24 -Drip MgSO4 TPD -Obs TTV,
Anjali, rawatan partus POD 4 Albumin : 2,93 40% 1 gr/jam KU
26 th, 2 P1 post SC a/i LDH : 371 dalam 500 cc -Obs tanda-
1364142 PEB di luar RS RL tanda
Lab 27/2/24 -PO Adalat oros impending
Hb/Ht/E/L/T: 30 mg/24 jam Terapi sesuai
11,3/36/5,4/11, -PO vip albumin FDO
25/299 1 gr/12 jam
MCV/MCH/ -Vitrolenta 5x1
MCHC : gtt ODS
67/27/31 eyedrop
Diftel :
1/0/0/72/2/1/6
Ur/Cr : 25/0,58
Na/K/Cl :
138/3,6/104
HbSag : NR
Sgot/Sgpt :
42/24
GDS : 112

Urinalisis
27/2/24
Warna kuning
muda keruh
pH 6
protein +1
Darah +
6B Mutia Hari Abdominal pain Lab 28/02/24 - IV CMY - Obs KU
Muharifa rawatan ec susp KET Ruangan: omperazol TTV,
, 33 th, ke1 Hb/Ht/E/L/T: 40mg/12j Perdaraha
1364259 10,8/35/4,25,7 n
7/389 - Rencana
MCV/MCH/ laparotom
MCHC : i
83/26/31 eksplorasi
Diftel : cito jika
3/1/0/59/31/6 Hb
semaki
IGD: turun
Hb/Ht/E/L/T: - Cek ulang
11/36/4,3/6,8/3 DR tiap
63 14.00/hari
MCV/MCH/
MCHC :
83/26/31
Diftel :
4/1/0/62/27/6
PT/APTT:
14,5/27,1
Hepatitis B NR
SGOT/SGPT:
20/20
GDS:99
Ur/Cr: 22/0,68
Na/k/
cl:140/3,8/104
Beta HCG:
94,5
Urinalisa:
Darah(+)
6F Cut Hari G5P3A1 Hamil Lab 28/2/24 -IV CRM - Obs Ku,
Darniati, rawatan 31-32 minggu, GDP : 174 dexametason 6 TTV, His,
35 th, 3 JPKTH, G2PP : 268 gr/12 jam DJJ
1364083 ancaman partus -PO nifedipine - CTG/hari
prematurus Lab 27/2/24 10 mg/8 jam - USG
(bebas kontraksi HbA1C: 8,7 -Kaltopren II / 8 fetomater
8 jam) ec dd Ferritin : 19,87 jam nal
1. Overdistensi GDS: 259 -SC Levemir 0- (28/2/24)
2. Fluor albus 0-0-10 - Observasi
susp. BV Urinalisis -Nifedipine 1 tokolitik
3. Susp. ISK, 27/2/24 amp extra maksimal
belum inpartu Glukosa : +2 -Kaltopren II / 8 - Amnio
pH: 6,5 jam supp reduksi

Lab 26/2/24
Hb/Ht/E/L/T:
12/36/4,4/10,9
4/349
MCV/MCH/
MCHC :
82/27/33
Diftel :
2/0/1/70/2/2/5
Ur/Cr : 14/0,36
Na/K/Cl :
135/4,3/101
HbSag : NR
Sgot/Sgpt : 9/8
GDS : 204
7C Nilawati Hari Abdominal Pain Lab 28/02/24 - IV ketorolac MZ - Observasi
binti Rawatan (VAS 3-4) ec Ur/Cr : 37/1,77 30mg/8j KU, TTV
Mahmud ke 7 Massa - IV - Terapi
, 37 th, Intraabdomen Lab 26/02/24 omeprazol sesuai FDO
1040896 dd/NOK Susp Hb/Ht/E/L/T: 40mg/12j - Surgical
Malignancy + 10,3/33/4,0/9,9 - Kaltrofen staging
AKI + anemia 7/307 supp II/8j
NN (Hb MCV/MCH/ - PO bicnat
7,6gr/dL) MCHC : 500mg/8j
84/26/31 - PO KSR
Diftel : 600mg/12j
1/1/0/65/22/11 - PO asetyl
Ca : 7,7 systein
Na/K/Cl: 600mg/12j
138/3,9/108

Lab 23/02/24
Ca 125 : 119,6
LDH: 163
AFP : 3,01

Lab 22/02/24
Hb/Ht/E/L/T:
7,6/24/2,9/9,12
/369
MCV/MCH/
MCHC:
83/27/32
Diftel :
0/0/1/68/21/10
PT/APTT :
15,50/27,30
HbsAg: Non
Reaktif
SGOT/SGPT :
7/16
GDS: 168
Ur/Cr : 52/2
Na/K/Cl :
131/3/103
Iso-1 Lena Hari POD 0 P2A2, Lab 28/02/24 - PO CRM - Obs KU,
Puji Rawatan post SC a/i janin Hb/Ht/E/L/T: nifedipine TTV,
Lestari, -1 letak oblique ibu 10,9/34/4,1/12, 3x10mg kontraksi,
33thn, dengan PEB dan 27/275 - Drip MgSO4 perdarahan
1021537 obesitas grade 2 MCV/MCH/ 1gr/24 jam - Balance
MCHC : - IV cairan
82/26/32 ceftriaxone - Cek DR 2
Diftel : 2gr/24jam jam post op
0/0/0/83/11/6 - IV - Aff DC jam
pT/Aptt : Transamin 6 pagi
13,5/29 amp/8jam besok
HbsAg : non- - Drip
reaktif oksitosin 20
Sgot/Sgpt : IU dalam
16/4 500cc NaCl
Albumin : 3,39 (20tpm)
GDS : 77 - IV Ketorolac
Ur/Cr : 11/0,42 1 amp/8jam
Na/K/Cl: - Kaltopren
137/3,9/103 sup II/8 jam
- IV
Metoclopram
ide 1 amp/12
jam
- IV
Lansoprazole
1 vial/12 jam
- Drip PCT
500mg/8jam
ISO 2 Nanda Hari G5P3A1 hamil Lab 28/02/24 - IV NAU - Obs KU,
Afriani, rawatan 11-12 minggu, Hb/Ht/E/L/T: ondancentron TTV
31 th, ke1 JTHIU, BSC 12,5/36/4,3/9,7 4mg/8j
1127561 2x(IDT 1,5 th) 7/296 - IV
ibu dengan MCV/MCH/ pantoprazole
hyperemesis MCHC : 1 vial/24j
gravidarum 84/29/35 - PO as folat
Diftel : 400 mcg/24j
1/0/0/77/17/5 - PO
pT/Aptt : microgest
15,2/25,2 100 mg/12j
HbsAg : non-
reaktif
Sgot/Sgpt :
17/14
Albumin : 4,11
GDS : 111
Ur/Cr : 15/0,43
Na/K/Cl:
133/3,3/99

Urinalisa:
Darah(+)