MAPPING SEURUNE 3 Rabu, 14 SEPTEMBER2016

NO

Kamar

Nama

CM

1a/Gyn

Irdawati/31th/H3

0978479

1b/ gyn

Asmawati/63 th/H3

1100749

2a/Gyn

Nurmina/45th/H14

2b/Obs

Ramadhani/28th/
H8

3a/Obs

Darlini Ramadhani
Harahap/32th/H2

3b/Obs

Nur Malahayati/
33 thn/H3

Diagnosa

Abortus incomplete pada G1

hamil 9-10 minggu

Susp. Ca endometrium

Laboratorium
lab 12/09/2016
Hb/Ht/E/L/T :
14,0/43/5,5/15,6/360
Na/K/Cl:141/3,8/104
KGDS: 120, Ur/Cr: 21/0,50

Terapi dan planning

Drip paracetamol 1 gr, inj. Tramadol 1

amp

Lab 29/08/2016
Hb/Ht/E/L/T :
10,7/35/4,4/6,1/408
Ca 125: 56,69, alb: 2,21

DPJP

Ket

SIK

SIK

Op hari ini
(14/9/2016)

P/ Observasi TTV, KU, kemoterapi bila

KU stabil, transfusi PRC target HB >
10gr/Dl, drip albumin 20%

Ca ovarium residif+ anemia

normositik normokrom+
hipoalbuminemia

Lab 7/9/16
Hb/ht/E/L/T
7,4/22/2,9/8,6/495
Ca125 :903,50, Ur/Cr:79/1,53
Lab 11/9/2016
Alb : 1,81
Na/K/Cl : 137/3,3/100

0823829

POD3 P1 Post SC ai HAP ec

PPT dengan permasalahan
anemia normositik
normokrom
Bayi Lahir Perempuan bbl:
1550 gr. A/S 7/8

Lab 13/09/2016
Hb/Ht/E/L/T:
8,0/25/3,5/8,7/155

Cefadroxil 2x500mg, asam mefenamat

3x500mg,Sohobion 2x1

NAU

1015564

POD2 P2 post SC ai fetal

distress + HAP ec solutio
plasenta

Lab 12/09/2016
Hb/Ht/E/L/T:
10,6/32/3,7/15,1/218
Ur/Cr: 20/0,46, alb: 2,89

Ceftriaxone 2gr/24jam, inj. ketorolac

30mg/8jam, profenid 100 mg supp/
8jam, sohobion 2x1

NAU

Transfusi
target
>10gr/dl

Lab 11/09/16
Hb/Ht/E/L/T :
10,2/33/4,1/19,3/299

Cefadroxil 2x500 mg, As. Mefenamat

3x500 mg, Sohobion 1x1

SIK

Rencana PBJ

0816730

POD 3 P2 Post SC ai KPD ,

BSC 1x, Belum Inpartu
1079926
Bayi Lahir Perempuan, bbl:
3400 gr. A/S 9/10

Th/Pungsi asites dengan guiding USG,

Informed consent DIUR, O2 4L/menit

SIK

Terapi Penyakit dalam :

Drip lasix 1 cc/jam, drip albumin 25%
100 cc/hari, metilprednisolon 8 mg 2-11 tappering per 2 minggu, simvastatin
1x20 mg, captropil 3x6,25mg

Perbaikan
KU pro
kemoterapi,
Rencana
Punksi
Ascites

POD 2 P3A2 post SC ai KPD,

tubektomi
7

4a/Obs

Marlianty/43th/H3

0793183
Lahir bayi laki-laki BBL 2800
gr A/S 8/9

4b/Obs

Yusniar/32 thn/ H2

4c/Obs

Kudria/31 Th/ h4

10

4d/Obs

Untari/22th/H3

11

12

5a/Obs

5b/Obs

Virdha Rahmi/26 th/

H2

Mulhamah/29 th/ H4

1102137

1101954

0928140

POD 1 post SC a/i KPD 24

jam
Bayi lahir laki-laki, bbl: 2800
gr, a/s 8/9

Cefadroxil 2x500mg, asam mefenamat

3x50mg, sohobion 1x1

SIK

Lab 13/9/2016
Hb/Ht/E/L/T:
11,1/35/4,5/16,2/239

Inj. ceftriaxone gr/24 jam,

inj.ketorolac/8 jam, profenid supp100
mg/8 jam

NAU

Rencana PBJ

Lab 10/9/2016
Hb/Ht/E/L/T
12/38/4,8/19,9/283

Cefadroxil 2x500 mg, As. Mefenamat

3x500 mg, Sohobion 1x1

TPD

Status sudah
di setor ke
rekam
medik, pasien
blm pulang

POD 3 P1 post SC a/i

oligohidramnion berat, belum
inpartu

Lab 12/9/2016
Hb/Ht/E/L/T
10,9/34/4,2/13,0/304

Ceftriaxone 2gr/24jam, ketorolac 3 % 1

amp/8jam, kaltropen supp/ 8jam, inj
ranitidin 1 amp/ 8 jam

SIK

Rencana PBJ

POD 1 P1 post SC ai distosia

PK I aktif

Lab 13/9/2016
Hb/Ht/E/L/T
9,7/32/4,7/11,6/385
MCV/MCH/MCHC/RDW
67/21/31/19,5

Inj Ceftriaxone 2 gr/24 jam, Inj

ketorolac 1 amp/8 j,inj ranitidine 1
amp/8 j, inj transamin 1 amp/8 j,
kaltropen supp II/8 j, drip oxytocin 20
IU dalam 500cc RL habis dalam 8
jam

SIK

GV hari ke-3

Cefadroxil 2x500 mg, asam mefenamat

3x500 mg, sohobion 1x1

NAU

Rencana PBJ

Cefadroxil 2x500mg, asam mefenamat

3x500 mg, sohobion 1x1

SIK

Rencana PBJ

POD 4 Post SC a/i Gagal

Induksi

1102172
Lahir bayi perempuan, BBL
3700 gr, A/S:9/10

1102066

Lab 12/09/2016
Hb/Ht/E/L/T:
11,0/34/4,3/17,5/368

POD 3 P3 Post SC ai KPD 6

Jam, Air ketuban berkurang,
ICA 5,9, BSC 1x

Lab 11/09/2016
Hb/Ht/E/L/T:
12,5/39/4,4/9,9/342

Lahir bayi laki-laki BBL

2850gr A/S 8/9

13

5c/obs

Falmuriati/26 Th/
H4

0957045

POD 3 P1A1 Post SC ai KPD

12 jam, Non reasuring Fetal
status
Lahir bayi laki-laki, BBL
2850 gr, A/S 7/8

Lab 11/9/16:
Hb/Ht/E/L/T:
11,6/38/5,8/17,7/107

14

15

16

17

5d/ Obs

6a/gyn

6b/obs

6c/obs

Siti Maya
Sari/22th/H2

Nurnawati/49th/H
4

Juriana/30th/H6

Nurul Hayati/ 38
th/ H4

0603061

NH0 pada P1 Post partus

normal
Lahir bayi perempuan, BBL
2960 gr, A/S 9/10

1102040

Sistoma ovarium sups

malignancy+efusi pleura
bilateral

1101615

P5 post partum spontan di

luar dengan Janin IUFD
(NH 6) dengan
permasalahan :
- sepsis berat, DIC
ec sepsis, ikterik
ec cholesistitis
dd:
Acute fatty liver
HELLP syndrome
Hepatitis viral
Drug Induced
- Anemia berat
normokrom
normositik ec
perdarahan
dd: AKI stage I
prerenal

1077373

POD 1 post kuterase ai

kematian mudigah pada
G4P3 hamil 16-17 minggu
dengan permasalahan
anemia normokrom
normositer ec hemolitik

Lab 13/9/2016
Hb/Ht/E/L/T
11,9/36/4,1/14,9/240

Kimia Klinik 11/9/2016

Alb 2,90
Lab 10/9/16
Hb/Ht/E/L/T
12,6/39/4,4/12,8/619

Ceftriaxone 2 gr/24 j, asam mefenamat

3x500 mg, sohobion 1x1

Terapi Pulmo:
Ceftriaxone 1gr/12 jam, Vectrin 3x1
tab

SIK

HSD

Lab 13/9/2016
Hb/Ht/E/L/T
12/35/4,2/16,3/160
Lab 11/09/16
Hb/Ht/E/L/T
9,9/30/3,5/27,8/148
Alb 3,34
Na/K/Cl 140/3,7/109
Ur/Cr 43/0,65
Bilirubin direct/total :
6/4,8
9/9/2016
Pt/aptt : 9,8/36,4
CRP : (+) Prokalsitonin :
6,45
D-dimmer 513,80, Anti
HCV (-), fosfatase alkali :
200

Meropenem 1gr/8jam (H6),drip

Metronidazole 500mg/8jam, Vit K
1amp/8 j, Lansoprazole 30 mg/12 j,
, curcuma tab 3x1, kalitake sachet
3x1, sukralfat syr 3x C1

Lab 13/9/2016
Hb/Ht/E/L/T
7,0/22/2,6/4,5/115
MCV/MCH/MCHC/RDW
84/27/32/15,7/10,1

Curcuma 1x1, sistenol 3x1

NAU
Terapi GH:
Kalitake sachet stop
Adalat oros 1x30 mg
Usul aff kateter

HSD

USG
konfirmasi
Poli Gyn
pada hari
kerja
Pre op hari
kamis.
Rencana
Punksi
pleura (dari
bagian
pulmo):
14/9/16

Lab 10/09/16
Hb/Ht/E/L/T :
6/19/2,3/7,2/227
PT/APTT : 12,7/67,9
Bilirubin total: 3,89
6d/
18

Lab 13/09/16
Ca: 5,1

19

6e/gyn

Zainab
Li/48th/H10

0969570

Infeksi Luka Operasi H-22

post op laparotomi +HT
SOB ai susp sarkoma uteri

Lab 06/09/2016
Urinalisis dalam batas
normal
KGDS 173

Nebacetin powder, drip

paracetamol 100 mg/12jam,
vancomycin 2x1 gr IV, kalsium
1x1000 mg

SIK

Ceftriaxone 2gr/24jam, drip

metronidazole/8 jam, ketorolac 3 % 1
amp/8jam, inj ranitidin/8 jam

SIK

Cefadroxil 2x500 mg, Asam

mefenamat 3x500 mg, Sohobion
1x1

NAU

Gv 2x/hari

Lab 05/09/2016
Hb/Ht/E/L/T:
9,8/31/4,1/17,2/371
20

21

6f/

7a/Obs

Rika
Layali/19th/H3

1102111

POD 2 P1 post SC ai
distosia PK I aktif, non
reasuring fetal status +
IUD
P5A0 post partum

22

7b/Obs

23

7c/

Rahmiati/36 th/H2

1102166

Lahir bayi perempuan;

BBL 2810 gr; PB: 48 cm;
A/S: 9/10

Lab 12/9/16:
Hb/Ht/E/L/T
10,2/33/4,1/19,3/387
Na/K/Cl: 139/3,7/105

Lab 13/09/16
Hb/Ht/E/L/T
11,7/35/3,9/12,0/209
Na/K/Cl: 141/4,1/106

Rencana
PBJ

24

7d/obs

Evi Juniati/36
th/H3

1102120

POD 1 P5A0 post SC ai

oligohiramnion, low pelvic
score + tubektomi +
hipertiroid + anemia ec dd
defisiensi besi +
hipokalemia
Lahir bayi laki-laki BBL
2300 gr; A/S: 8/9
POD 1 P2A0 post SC ai
distosia PK 1 aktif

25

7e/obs

Sabariah/29 th/H3

0727809
Lahir bayi perempuan,
BBL 3100 gr; A.S: 9/10

26

7f/obs

Lailal fajri/27 th/

H6

1101977

POD 4 P1 Post SC ai non

reassuring fetal status
+akseptor IUD
Lahir bayi perempuan;
BB: 3200 gr; A/S:9/10

27

28

ISO 1/
gyn

ISO 2/
gyn

Nurti Wardani
AMD/41th/H4

Rodiyah/31 thn/
H1

0808022

ILO dengan permasalahan:

Anemia mikrositik
hipokrom,Leukositosis,
AKI, trombositopenia

0980667

POD1 post laparotomi

eksplorasi, salphingektomi
sinistra, tubektomi dekstra
a/i ruptur tuba sinistra pars
ampullaris ec KET + HIV
(B20) on ARV

Lab 13/09/16
Hb/Ht/E/L/T :
10,2/33/4,7/17,2/328
MCV/MCH/MCHC/RDW
70/22/31/17,6
Eo/Ba/NB/NS/L/M
0/0/0/96/3/1
Ca: 8,1
Ur/Cr: 12/0,35

Lab 13/09/16
Hb/Ht/E/L/T :
13,1/38/4,2/24,8/220

Lab 10/9/16
Hb/Ht/E/L/T
12,9/41/5/17,8/260

Lab 10/9/16
Hb/ht/E/L/T
7,3/24/3,3/20,2/794
Na/K/Cl: 132/3,1/89
Ur/Cr: 31/1,97, alb: 3,11

Lab 13/9/2016
Hb/Ht/E/L/T:
4,00/12/1,1/8,8/175

Inj Ceftriaxone 2g/24 jam, Inj

Ketorolac 30 mg/8 jam, Profenid
Supp /8 jam, sohobion 2x1

MZ

Transfusi
PRC target
Hb > 10
g/dL
Terapi lain
sesuai TS
IPD

Inj Ceftriaxone 2 gr/24 jam, inj

asam traneksamat 1 amp/8 j, Inj
ketorolac 1 amp/ 8 j, ranitidine 1
amp/12 j, kaltropen supp 3x100 mg,
oxytocin drip dalam 500cc RLhabis 8 jam

MZ

Aff kateter
1x24 jam
GV hari Ke3

Cefadroxil 2x500mg tab, asam

mefenamat 3x500 mg, sohobion
2x1

MZ

Rencana
PBJ

HSD

Obs TTV,
Transfusi
PRC 2 kolf
rencana
PBJ

Gentamicyn 1 amp/12jam,
metronidazol 500mg/8 jam,
vancomicyn 1amp/8jam

Inj. ceftriaxone 2 gr/24 jam, inj.

ranitidine/ 12 jam, kaltropen
3x100mg

SIK

dr. Hasanuddin, Sp.OG (K)

dr. YusraSeptivera, Sp.OG
dr. Rajuddin, Sp.OG (K)
dr. Tgk. PuspaDewi, Sp.OG
dr. Sarah IkaNainggolan, Sp.OG (K)
dr. NikenAsriUtami, Sp.OG
dr. Cut MeurahYeni, Sp.OG (K)
dr. Munawar, Sp.OG
dr. Munizar, Sp.OG
Dr. dr. Mohd. Andalas, Sp. OG
dr. Roziana, Sp.OG
Total Gyn
Total Obs

6a,7d, Iso 1
0
1
1
8
4
0
0
1
1
0

7c
4c
1a,2a,3b,4a, 4d,5c,6e,7a
3a,2b,5b,6b
7f
1b
6
13