MAPPING SEURUNE 3

Senin, 27 Maret 2017

No Room Name MedRec Diagnosis Laboratorium Treatment DPJP Planning

Lab 25/03/2017
H b/Ht/E/L/T
7,1/21/2,4/15,5/167
Terapi Obgyn
Lab 24/03/2017
Cefadroxil 2x500mg Obs KU, TTV
LDH : 136
As.Mefenamat 3x500mg Diet MB TKTP
Kol tot/ HDL/ LDL/ Trigliserida
POD III post laparotomy Sohobion 1x1 Mobilisasi bertahap
184/20/ 108/ 253 Fc 1x24 jam
histerektomi salfingo
HbA1c: 6,40 GV hari ke-7
oforektomi bilateral ai mioma Terapi IPD
1 Hayati, 49 th 0-96-79-35 Lab 23/03/2017 YS Transfusi PRC sampai
1a/Gyn uteri multipel, defek fascia+ Diet DM 1700kkal Hb >10gr/dl
CT/BT = 10/5
DM type 2 + anemia Levemir SC 0-0-0-6 U Evaluasi perdarahan,
Ca125 = 66,93 KGDP/hari
normokrom normositer Atorvastatin 1x 20mg
HBsAg (-) Rencana PBJ
Lab 22/3/2017
Terapi B.Digestif
GDS 237
IVFD Futrolit 20gtt/i
Ur/Cr/Na/K/Cl
17/0,7/140/3,7/109

1b/Gyn
2
 Obs KU, TTV,
Lab 25/03/2017 perdarahan
Hb/Ht/E/L/T kontraksi
P1 post partus spontan, post Cefadroksil tab 2x500 mg Diet TKTP
11,4/35/4,4/11,6/348
Maulidia perineoraphy ai ruptur Metrodinazol 3x500 mg
3 2a/Obs 1-12-37-28 HbsAg/CT/BT RZ Hygiene vulva &
23 tahun perineum grade 3, akseptor As.mefenamat tab 3x500 mg perineum
-/3/9
IUD Sohobion tab 2x1 Motivasi ASI eks
Ur/Cr/Na/K/Cl/GDS
11/0,30/140/3,9/113 Mobilisasi dini

POD V POST laparotomy

Lab 26/3/2017
surgical staging ai ca ovarium Cefadroxil 2x500 mg
Na/K/CL/Ur/Cr Obs KU, TTV
dengan permasalahan: As.mefenamat 3x500 mg
128/4,7/111/119/1,60 Mobilisasi bertahap
1. Elektrolit imbalance Drip Albumin 25% 100cc/hr
Lab 24/3/2017
2. Ulkus pada Drip metronidazole 500mg/8
Na/K/Cl/Ca/Ur/Cr Saran IPD:
Cut Faridah selangkangan jm
4 2b/Gyn 1-12-06-45 129/4,8/111/7,9/114/1,90 HSD Urinalisa
Zulfikar, 59 thn 3. Hipoalbumin, AKI
Lab 22/3/2017 Ur,cr ulang
stage 1 pre-renal Saran IPD:
Hb/Ht/E/L/T Elektrolit, albumin post
4. Hiponatremia Diet 1800kkal +48 gr
10,7/34/4,0/287/33,7 koreksi
hipoosmolar protein/hari + ekstrak telur
SGOT/SGPT/Ur/Cr/Na/K/Cl Rencana PBJ
hipovolemik putih
50/26/96/1,60/128/4,9/102

Lab 25/3/2017 Obs KU, TTV

Ij.Ceftriaxone 2gr/24 jam
POD2 P1 Post SC a.i. janin Hb/Ht/E/L/T Evaluasi perdarahan
Ij.Ketorolac 1 amp/8 jam Bila Hb dibawah
7,7/25/3,4/16,7/171
Laili Fitriani gemeli letak sungsang + IUD Ij.OMZ 40mg/ 12jam dibawah 8 transfusi
3a/Obs 0-99-38-92 CT/ BT : 9/3 NAU sampai dgn HB >10
25 tahun trans Cessaria Drip oksitosin 20IU dalam
5 HbsAg (-) gr/dl
500cc RL 20 gtt/i selama
Na / K /Cl/ Ca : 136/4,3/118/ 8,3 Diet MB TKTP
24jam post OP
GDS/ Ur/ Cr : 88/12/ 0,60

Cefadroxil 2x500mg
POD III Post SC + tubektomi As.mefenamat 3x500mg
Lab 25/3/2017
ai impending eklampsia OMZ 2x1
Hb/Ht/E/L/T
Adalat oros 1x30mg Obs KU, TTV
11,7/35/4,6/ 18,8/ 269
6 3b/Obs Nurbaiti, 42 th 0-83-29-44 Bayi NICU lv IIA : Sohobion 1x1 YS Obs. perburukan PEB
MCV/MCH/MCHC/RDW/MPV
Laki-laki
75/25/34/13,2/11,3
BBL: 3200 gram Saran Pulmo:
A/S: 7 / 8 Symbicort 1x24 jam
 Lab 26/3/2017 Cefadroxil 2x500mg
Suci Hb/Ht/E/L/T As.mefenamat 3x500mg
7 4a/Gyn Rahmayani 0-83-68-28 Abortus inkomplit 12,5/39/4,9/19,6/428 Sohobion 1x1 YS Obs Ku, TTV
29 tahun GDS/Ur/Cr/Na/K/Cl Metargin 3x1
117/15/6,50/142/4,0/112

Lab 26/03/2017
Ij. Ceftriaxone 2gr/24 jam Obs Ku TTV
Hb/Ht/E/L/T
Ij. Ketorolac 1amp/8 jam Bila Hb kurang,
Nurmala sari Distosia PK I aktif 11,5/36/4,5/16,4/226
4b/Obs 1-12-37-85 Drp Oksitosin 20 IU dalam YS transfusi PCR sampai
20 tahun Ur/ CR/ Na/K/Cl
500cc RL habis dalam 8 jam >10g/dL
8 15/0,54/141/4,2/111
Ij. Ranitidin 1amp/8jam GV hari ke-3

6
4c/Obs
 POD1 P3 post SC ai BSC 2x Lab 25/3/2017
Hb/Ht/E/L/T Obs KU, TTV,
+ akseptor IUD kontraksi, perdarahan
14,0/41/4,6/20,2,217 Cefadroxyl 2x500mg
10 Mobilisasi bertahap
Siti Nurlatifah, Lab 22/3/2017 Asam mefenamat 3x500mg
4d/Obs 1-12-16-16 Bayi Rooming in : MNW Motivasi ASI-KB
29 th GDS 124 Sohobion 1x1 tab Diet MB TKTP
Perempuan
Ur/Cr: 0,3 PBJ hari ini (
BBL: 3400 gram Na/K/Cl 27/3/2017)
A/S: 9/10 139/3,8/113

11 5a/Obs

Lab 25/3/2017
POD V P6A3 post SC + Hb/Ht/E/L/T
histerektomi subtotal ec atonia 9,7/29/3,6/13,5/102 Metronidazol 3x500mg
uteri + acute pulmonary Lab 23/3/2017 Cefadroxil 2x500 mg
insufficiency following non Hb/Ht/E/L/T Obs KU, TTV
As mefenamat tab 500 mg3x1
thoracic surgery (post intubasi) 9,6/28/3,4/78/16,0 Transfusi PRC sampai
Sohobion tab 360 mg 2x1
5b/Obs Nurhasnita, 35 th 1-12-34-00 + syok (post CVC) PT/APTT/D-Dimer MA Hb>10 gr/dl
12 SF 2x1 PBJ hari ini (27-3-
10,6/31/2392,34
HBsAg (-) Prosogan FD 2x1 2017)
Bayi NICU lv IIB :
Laki-laki /Prot. Total/Alb/Glb
BBL: 2700 gram 4,54/3,07/1,47
A/S: 7/8 Na/K/Cl/Ca/Mg
137/4,1/115/8,7/1,4
Ur/Cr 22/0,90
 P2 post ekstraksi vakum a/i Lab 25/3/2017 Cefadroxil 2x500mg Obs KU, TTV,
distosia PK II ec ibu lelah Hb/Ht/E/L/T
Ria Ceriana As.mefenamat 3x500mg kontraksi, perdarahan
1-12-37-56 meneran, post perineoraphy a.i 10,8/33/4,6/11,8/367 RZ Rencana PBJ hari ini
13 5c/Obs 30 tahun Na/K/Cl Sohobion 1x1
ruptur perineum grade II, (27-3-2017)
akseptor IUD 144/3,0/111

14 5d/Obs

Lab 25/3/2017
Hb/Ht/E/L/T
Curcuma tab 2x1 Obs. KU, TTV, nyeri
15 6a/Gyn Saripah, 70 th 1-11-69-23 Ca Ovarium 12,4/37/4,2/5,4/125 HSD
Persiapan Kemoterapi
Prot. Total/Alb/Glb
6,55/3,08/3,47

Clinimix +ivelip / 24jam

Ceftriaxone 2 gr/hari
Ketorolac 3% amp/8 jam
Lab 23/3/2017 Obs. KU, TTV
POD IV Post Kaltropensupp 2/8 jam
Hb/Ht/E/L/T Mobilisasi bertahap,
Laparotomi Sohobion 2x1
Antiah, 38thn 1-12-27-96 13,0/40/5,0/15,4/757 HSD Drain evaluasi/24jam
6b/Gyn debulking tumor ai
16 MCV/MCH/MCHC/RDW Aff bila <500cc,
NOP Susp. ganas 80/26/33/15,1 Saran B. Digestif:
Inj. Metocloperamide
1amp/8jam
Fosen enema 1fls/hari
 Lab 21/3/2017
HB/Ht/E/L/T
12,1/37/4,7/9,9/316
27/3/ 2017
17 6c/Gyn Irayana/ 26thn 0-75-90-32 Kista ovarium SGOT/SGPT/Alb MA Obs KU, TTV
Tindakan Laparoskopi
15/11/4,42
GDS/Ur/Cr
95/15/0,47

Lab 14/3/2017 27/3/2017

Zainah
6d/Gyn 0-96-07-78 Adenomiosis + DM tipe 2 Hb/Ht/E/L/T Tindakan reseksi Adenomiosis YR Obs KU, TTV
18 43 tahun
13,0/41/5,7/10,3/347 atau Histerektomi

Lab 25/3/2017
Hb/Ht/E/L/T
9,4/30/3,8/25,5/90
Inj. Ceftriaxone 2gr/24jam
Susp. Ca Ovarium dengan PT/APTT : 16,5/36/6
Inj. Ketorolac amp/6jam
permasalahan: D dimer: 6067,70
Inj. Lansoprazol vial/12jam
1. Anemia mikrositik
KSR 3X1
hipokrom Lab 20/3/2017 Ondancetron 1 amp/8 jam
2. Leukositosis Ca125 = 1400,22 Obs KU, TTV
19 6e/Gyn Nurmala, 39 th 1-12-27-74 Flumucy; tab 3x1 HSD
3. Trombositopenia Bil.Total/Direct/Indirect/SGOT/SGPT Pasang WSD (+)
PCT 3x1
4. Hipoalbumin 0,40/0,23/0,17/13/5 Ij. Metronidazole 3x500mg
5. Hipokalemia
Pradaxa 1x75 mg
+ Efusi pleura sinistra pro Lab 19/3/2017
evaluasi HbsAg (-)
Na/K/Cl: 139/3,2/103
Alb/SGOT/SGPT : 2,55/13/5
Prot.Total/Glb: 5,82/3,27
 Lab 23/3/2017
Hb/Ht/E/L/T
12,2/36/4,7/6,7/290
Fera Fitriani 27/3/2017
20. 6f/Gyn 1-12-35-62 Kista Ovarium SGOT/SGPT/Alb MA Obs KU, TTV
19 tahun Rencana Laparoskopi
15/10/4,93
UR/Cr/Na/K/Cl
22/0,42/140/3,9/108

Lab 22/3/2017
Hb/Ht/E/L/T
21 Nazariyah binti 11,8/35/4,4/8,4/276
27/3/2017
7a/Gyn Hasbi 0-67-39-47 Mioma Uteri SGOT/SGPT/Alb YS
Rencana Miomektomi
36 tahun 13/39/4,20
Ur/Cr/Na/K/Cl
38/0,72/142/3,5108

Lab 25/3/2017
Hb/Ht/E/L/T Cefadroxil 2x1
10,0/31/4,1/15,6/294 As.mefenamat 3x1 Obs KU, TTV
Sohobion 1x1 Diet MB TKTP
Lab 17/3/2017 OMZ 2x1 Mobilisasi
PODIII POST laparotomy GDS 155
JuniWarniati, bertahap
22 7b/Gyn 0-98-83-49 surgical staging ai tumor SIK
43 th EMD: FC 1x24 jam
ovarium residif Lab 15/3/2017 Diet DM RG 1900kkal GV harike 7
Hb/Ht/E/L/T Sc humalog 8-8-8-0 U KGDP /hari
6,6/20/2,6/264 Sc levemir 0-0-0-12 U Rencana PBJ
GDP/GD2PP/Hb-A1c Atorvastatin 1x20mg
193/312/6,90

7c/
23
 7d/
24

Lab (23/3/2017)
Hb/Ht/E/L/T
11,0/35/4,8/13,3/216
Obs. KU, TTV,
Lab (20/3/2017) perdaraham
POD III post laparotomy Hb/Ht/E/L/T
Cefadroksil 2x1 Mobilisasibertaha
Kamariah, 58 surgical staging + 8,9/30/4,2/8,0/306
1-12-28-08 As.mefenamat 2x1 SIK p
7e/Gyn th adhesiolisis + pemasangan LED/CT/BT
25 105/8/2 Sohobion 1x1 Diet MB TKTP
DJ stent kiri
CA 125: 2292,00 PBJ 27/3/2017
SGOT/SGPT/kols.tot./HDL/LDL
16/8/251/43/189
Na/K/Cl/Ca/Ur/Cr/as.urat/GDS
145/4,4/110/9,8/29/123/6,0/106

7f/
26

Lab 25/3/2017
Hb/Ht/E/L/T
11,6/35/4,1/14,8/237
Lab 24/03/2017 Obs KU,TTV,
Inj. ceftriaxon 2gr/24jam
Bil.tot/bil dir/SGOT/SGPT kontraksi uterus,
PODII POST SC ai G4P2A1 Inj. ketorolac 1 amp/ 8jam
ISO1/O KhairunNisa, 0,81/0,40/19/11 perdarahan.
27 bs 28 th 1-12-35-03 Hamil 36-37 minggu Inj. kaltropen supp II/8jam MNW
Alb/Glob : 3,15/3,27 Mobilisasi bertahap
JPKTH + ODHA Oksitosin 20 IU dalam 500cc
Na/K/cl : 138/2,7/119 Motivasi ASI eksklusif,
Lab 23/3/2017 RL /8jam selama 24jam
GV(26/3/2017)
HBsAg (+)
GDS/Ur/Cr
90/10/0,40
 ISO2/
28 Gyn

DPJP Rekapitulasi Pasien DPJP Obs Gyn

Dr. dr. Hasanuddin, Sp.OG(K) 4 - 2B, 6A, 6B, 6E
dr. Yusra Septivera, Sp.OG 5 3B, 4B 4A, 6D, 7A
dr. Rajuddin, Sp.OG(K) 0 - -
dr. Tgk. Puspa Dewi, Sp.OG 0 - -
dr. Sarah Ika N, Sp.OG(K) 2 - 7B, 7E,
dr. Niken Astri Utami, Sp.OG 1 3A -
dr. Cut Meurah Yeni, Sp.OG 0 - -
dr. Munawar, Sp.OG 2 4D, ISO1 -
dr. Munizar.Sp.OG 0 - -
Dr.dr.Mohd.Andalas, Sp.OG 3 5B 6C,6F
dr. Roziana, Sp.OG 2 2A, 5C -

Total 8 11
Total Pasien Obgyn 19 orang