08/07/2018 MAPPINGAN BANGSAL 4A

4A 1.3 4A 1.4

4A 1.2 4A. 1.5

4A 1.1 4A 1.6
Ny. Nurkhikmah/45th/C712721/dr. Endy C Ny. Sukarti/49 th/C685028/dr. Mirza

A/ P1A0 45th A/ P1A0 49th

Mioma Uteri Ca Epidermoid Cervix Uteri IIIB
Post ER 25x
P/ Pro Operasi TAH (Kamis, 11/10/2018) Lors df follow up 4 bulan
Ijin tindakan Pasca AL I (2/10/2018)
Konsul anestesi
Rencana maju Rapat bagian rabu 10/10/2018 P/ Pro AL II (9/10/18)
Pengawasan KU, TTV, PPV Ijin tindakan
Konsul TS radioterapi
Cek lab lengkap = menunggu hasil
Lab : 5/10/18 Pengawasan KU, TV, PPV
Hemoglobin : 13,1
Leukosit : 6,4 Lab 29/9/18
Trombosit : 286 Hemoglobin : 10,7
Ur/Cr : 17/0,6 Leukosit : 7,6
HbsAg: - Trombosit : 564
GDS: 87 Ur/Cr : 31/1,0
SGOt/Pt: 37/62 GDS: 110
Na/K/Cl/;141/3,7/103 SGOt/Pt: 30/45
PPT/PTTK : 13,3/32,4 Na/K/Cl/;138/4,1/99
PPT/PTTK : 10,3/37,3
4A2.3 4A 2.4
Sukimah/54 th/C452244/Dr. Mirza

A/ Ca Epidermoid cervix uteri std III B

Riw NAC III
PRC (2014)
Partial Respon (des 2014)
Riw Platosin adj V
PRL tamb (sep 2016)
Riw paxus carbo adj VI (april 2018)
Riw Paxus Carbo Adj I (19/8/18)
Riw paxus carbo adj II ( 9//9/18)

P/Pro Kemo Paxus carbo adj III (3/10/18)

H/1 daftar kemo paxus carbo

Lab : 6/10/18
Hemoglobin : 11,4
Leukosit : 8,1
Trombosit : 255
Hematokrit : 35,6
Eritrosit : 4,25
MCH : 26,8
MCV : 83,8
MCHC : 32
RDW : 19,2
MPV : 9,5

4A2.2 4A2.5

4A2.1 4A2.6
4A3.3 4A3.4
Ny. Muzaroah/51th/B423923/dr. Endy

A/ P5A0 51 th
High grade scory ca ovarii stad IIIC
Riw susp optimal aebulking (21/5/18)
\CTAH + BSO + omatektomi + sitologi +adneksiolisis
Pasca paxus carbo II (18/9/18)

P/ pro paxus carbo III (9/10/18) acc

Ijin tindakan
Usaha obat
Diet biasa
Pengawasan ku ttv ppv

Lab 8/10/18
Hb 11,5
Leukosit 7600
Trombosit 318000
Gds 99
Sgot/sgpt 25/32
Ur/cr 21/0,6
Na/k/cl 144/4,1/104

4A3.2 4A 3.5

4A 3.1 4A 3.6
Ny. Indri Dwi/22th/C644026/dr. Endy

A/ P0A0 22 tahun
Cystaderma ca muscirosum ovarii inadequate staging
Riw ooforektomi dextra (5/2017)
Riw paxus carbo III
Riw laparatomi biopsy (21/8/18) RSDK
Pasca paxus carbo F (17/9/18)
Anemia ringan (9,3)

P/ perbaikan KU
Rencana paxus carbo II (9/10/18) = tunda
Transfuse PRC sd Hb >= 10 g/dl
Usaha 2 PRC
Premed inj dexamethasone 1 amp (iv)
Ijin tindakan
Usaha obat
Pengawasan KU TTV PPV

Lab 8/10/18
Hemoglobin : 9,3
Leukosit : 8,8
Trombosit : 484
Ur/Cr : 19/0,5
GDS: 103
SGOt/Pt: 21/16
Na/K/Cl/;141/3,7/107
4A4.3 4A4.4
Ny. Ifa Santi/35th/C716194/dr. Endy C

A/ P1AO 35th
Ca epidermoid cerviks uteri std III B (suspek IV A)
Hidronefrosis duplex
Pasca nefrostomi (7/10/18) + systoskopi
Anemia sedang (hb 7,1)
Azotemia

P/ perbaikan KU
Inf. NaCl 0,9 % 20 tpm
Transfuse PRC sd Hb >=10 gr % - usaha PRC
Usaha 3 PRC = sudah masuk 1 PRC
Inj. Asam tranexamat 500 mg/24 jam
Raber dr. Arwedi
PO asam folat 1mg/24 jam
CaCo3 500 mg/8 jsm
Bicnat 500 mg/8 jam
Inj omeprazole 40g/24 jam
Diet anemia
Melengkapi pemeriksaan, EKG, konfirmasi hasil VDRL TPHA
Usul prodiagnostik

Lab : 8/10/18
Hemoglobin : 7,1
Leukosit : 10.700
Trombosit : 204
Ur/Cr : 51/2,8
Na/K/Cl/;135/4,6/107

4A4.2 4A 4.5
Ny. Warsidah/47th/C703129/dr. Endy

A/P2A0 48 th
Squamous cell ca cervix uteri st IIIB
Anemia sedang (hb 8)
Trombositosis (739.000)

P/ pro ER I + plastosin 3 weekly I (tunda)

Tranfusi PRC sd Hb >= 10 g/dl, usaha 2 PRC
Premed inj dexamethasone 1 amp
Konfirmasi radioterapi setelah perbaikan KU
Ijintindakan
Usaha obat
Diet biasa
Pengawasan KU TTV PPV

Lab 3/10/18
Hb 8
Leukosit 11,5
Trombosit 739
Gds 160
Ur/cr 32/0,6
Na/k/cl 140/4,5/106

4A 4.1 4A4.6
Ny. Siti Maesaroh/47th/C615325/dr. Mirza
4A5.3 4A5.4
Ny. Sudiroh/62th/C679687/dr. Endy

A/ P3A0 62 th
Adult granulosa cell ca ovarii st IV A
Riw SOS si Rs Tidar (sept 16)
Metastasis pulmo
Ascites
Riw pleuroderis bleomycin (27/3/18)
Pasca paxus carbosin III (25/9/18)

P/ pro paxus carbo IV (16/10/18)

Pro pungsi ascites
Ijin tindakan
Cek lab = tunggu hasil
Diet biasa
Pengawasan ku ttv ppv

Lab 22/9/18
Hemoglobin : 10,8
Leukosit : 8,9
Trombosit : 534
Ur/Cr : 26/0.9
GDS: 87
SGOt/Pt: 21/12
Na/K/Cl/;142/4,7/106

4A 5.2 4A 5.5

4 A 5.1 4A 5.6
Ny. Titik Wahyuni/47 tahun/dr. Edi WibowoAmbari,
Sp.OG(K)

A/P0A0 47 tahun
Cystadeno Ca Ovarii muscinocum papiliferum st III C
Riw. Optimal debulking ( TAH+BSO+omentektomi ) juli
2018 di RS Sultan Agung
Pasca paxus carbo II
Hipertensi grade II TD 160/90
Gizi kurang
Ascites

P/ Pro paxus carbo III – acc lab baik

Usaha obat, ijin tindakan
Diet biasa TS gizi klinik
Pengawasan KU, TV, PPV
Po amlodipine 10 g/24 jam
Pro pungsi asites

Lab : 8/10/18
Hemoglobin : 11,4
Leukosit : 8,6
Trombosit : 625
4A 6.3 4A 6.4
Ny. Damariyah/36th/C631268/dr. Mirza Ny. Umini/50th/C710339/dr. Mirza

A/ P2A0 36th A/ P8A0 50 th

Ca Epidermoid cervix uteri std IIA NOK curiga ganas
(2017) Abdominal pain
Obstruksi colon
P/ Pro AL I (9/10/18)
P/acc pasang DL
Lab : 5/10/18 Acc hemodialisa
Hemoglobin : 10,5
Leukosit : 11,1 Lab 6/10/18
Trombosit : 192 Hemoglobin : 11
Leukosit : 13,9
Trombosit : 428
Ur/Cr : 148/9,5
Albumin : 2,9
Na/K/Cl/; 137/4,8/108
Mg/Ca : 0,91/2,2
Phospat anorganik : 5

4A 6.2 4A 6.5

4A 6.1 4A 6.6
Ny. Marini/ 35 tahun/ C710176/dr. Erwinanto

A/ P4A1 35 th
Pasca repair uretara , vesicouretra junction, uteroraphy H+4

P/ po. cefadroxil 500mg/12 jam

Paracetamol 500 mg/ 8jam
Antasida cyr C1/8jam
Diet biasa
Mobilisasi aktif
DC dipertahankan 3 minggu (27/10/18)
Pengawasan KU,TV,PPV
Usul pulang

Lab 28/09/2018
Hb/L/Tr : 13.5/6.7/335
GDS/OT/PT : 80/73/59
UR/CR : 30/0.90
Na/K/Cl : 138/3.8/103
PPT/K : 12.6/13.8
PTTK/K : 32.5/31.4
HbsAg neg