DR.

ADK P :COC 3x1tab

Inj Asam tranexamat 1gr/8jam/iv
1.Ny. Novi Dwi Lestari Transfusi sd Hb 10
RM 02230744
BUG 1/1 Lapor dr. ADT, advis:
Progynova 2x1 2 hari, dilanjutkan
A :Cancer Pain, Kistoma Ovarii susp Norelut 2x5 mg 10 hari
Malignancy,anemia,hipoalbumin, imbalance Inj Asam tranexamat 1gr/8jam/iv
elektrolit (hiperkalemia, hiponatremia) Ca Servix Transfusi sd Hb 10 gr/dl
IIB Bulky Post Kemo NACT 3x, P1A0 Tablet tambah darah 2x1tab/po
Vit C 2x500mg/po
P :Perbaikan KU
Transfusi PRC, target Hb preop > 10 g/dl
Koreksi hiperkalemia, target K 3.5-5.0 mmol/L 5.Ny. Fifin Nafisah
Koreksi hiponatremia, target Na > 135 mmol/L RM 02241747
Pro Laparotomi, kistektomi, Frozen section (ca PJT 4
cervik inoperable) setelah perbaikan KU
A :Kistoma Ovarii Suspek
Malignansi,Ascites,Suspek Peritoneal
2.Nn. Dwi Istiyaningsih Carcinomatosis, efusi pleura dextra, sinus dd
RM 02236534 atrial takikardi P3A0
BUG 1/9 P :Pro-Laparotomi USO + Frozen Section s/d
Surgical Staging (Ditunda)
A :Post laparotomi TAH BSO ai low grade - Bisoprolol 2,5 mg / 24 jam / p.o.
endometrial stromal sarcoma, P0A0, HT gr I, BLPL, Penjadwalan Ulang Operasi
obese gr I, riw. kuretase 3 bln yll H3 usul: NAC 3x200mg, Cek elektrolit, EKG
P :Cefixime 2x200mg
Asam Mefenamat 3x500mg, DR. DIN
Obs KU VS BC UO PPV
usul 1.Ny. Nasikhatud Diyanah
Aff DC, BLPL RM 02234357
BUG 1/3
3.
Ny. Nunung Hartati A :Post laparotomi suboptimal debulking
RM 02246470 (salphingooforektomi D) ultra low anterior
BUG 1/5 resection hemikolektomi D, adhesiolisis tajam,
ileocolostomy double barrel ai ca ovarii klinis
A :Ca Serviks Advanced Stage (Stadium IVA), std IIIC,adhesi gr iV, DVT ext inf. bilateral P0A0
P0A0, Asidosis Metabolik, Hipoalbuminemia, H1
Hidronefrosis Bilateral, Aki dd acute on CKD, P :Inj. as. tranexamat 500mg/8j
Ascites Permagna Inj. Vit K 1A/8j
P :IVFD Tutosol 20 tpm AB ~ B. Digest
Inj. Ceftazidime 1g/12j Analgetik ~ Anestesi
Inj. Furosemide 1A/12j Rawat SICU ~ Anestesi
Inj. Spironolakton 1x100mg Cek panel DIC (D-Dimer fibrinogen DLO Alb
Obs KU/VS/BC-UO/Perburukan kondisi elektrolit)
Perbaikan KU sesuai TS terkait Obs KU VS PPV BC UO

Konfirmasi TS UPD Gastro terkait rencana 2.Ny. Sudiyem

tapping ascites --> Kesan Ascites Permagna RM 02228312
BUG 1/10
4.Anssi Riana Sari
RM 02247107 A :Post laparotomi panhisterektomi
IGD omentektomi appendektomi adhesiolisis ai ca
ovarium st IVA, adhesi gr III, P2A0, post NACT
A :Anemia gravis, AUB A dd/ L, P0A0 3x, H3, Perioral dermatitis
P :Cefixime 2x200mg dan Asam Mefenamat P :Perbaikan KU
3x500mg, Transfusi Hb sd > 10 gr/dl (2/4 PRC)
Aff DC, BLPL Transfusi Albumin s/d Alb > 2.5
Gentamycin cr Tx ~ HOM
Obs KU VS BC UO Akut abd
7.Ny. Pujiyanti
RM 01939582
3.Ny. Erna Tri Ismarani BUG 1/8
RM 02045319
BUG 1/10 A :Obs. Febris H2, ILO, Susp. Fistula Entero-
cutan, Susp. Fistula Rectovagina Letak Tinggi dd/
A :Anemia Mikrositik-Normokromik, Ca Serviks Dehisensi Tunggul Vagina. Hipoalbuminemia,
Stadium IIA, P2A0, Post-CCRT dan Brakhiterapi Insufisiensi Renal, Hidronefrosis Dextra Grade II-
(Oktober 2023), Stenosis Total Ureter Distal III. Post Laparotomi Total Abdominal
Sinistra on Nefrostomi Bilateral, AKI dd Acute on Histerektomi Bisalphingooforektomi,
Chronic Renal Failure, Riwayat Laparotomi Omentektomi, Appendektomi, Adhesiolisis a.i
Radikal Histerektomi 1 tahun yang lalu Sarcoma Uteri Stadium IVB, H.15. Imbalance
Elektrolit. P2A1
P :Perbaikan KU P :Perbaikan KU
Transfusi PRC sd Hb 10 --> TRANFUSI 1 PRC LAGI Transfusi albumin 1 flc
Inj Cefotaxime 1 gr/12 jam/IV Inf. Paracetamol 1 gr/8j/iv
Pasang NGT sebagai rute makan Inj. Metronidazole 500 mg/8j/iv
Inj. Ceftriaxon 1 gr/12j/iv
usul: Nutrisi parenteral dengan IVFD Kabiven Kultur dasar luka + cek sterkobilin dari dasar
20tpm luka
K/S darah
4.Ny. Dewi Sumaenah Rawat luka pagi-sore
RM 02243904 Konsul Digestif (Lacak)
BUG 1/10 Lacak hasil PA
Obs KU/VS/BC-UO/Tanda-tanda akut abdomen
A :Low grade ESS (endometrial stromal
sarcoma), P3A0, HT on terapi Lapor dr. DIN: Advis;
Belum acc konsul urologi
P :Pro Laparotomi TAH BSO Lain-lain acc dx tx
Sabtu 06/07/24

8.Ny. Siti Warsiyah

5.Ny. Murtirahayu RM 02233653
RM 02235024 BUG 1/11
BUG 1/9
A :ca ovarii 1C1 (high grade serous carcinoma),
A :Anemia Gravis normo-normo, Ca Serviks P1A0, riwayat relaparotomi panhisterektomi,
Stadium IVA (Infiltrasi Bulli), Hidronefrosis appendektomi, omentektomi 2 minggu yang
Bilateral on Nefrostomi Bilateral, AKI dd Acute lalu, stress hiperglikemi dd dm tipe 2
on CKD, P2A0
P :Perbaikan KU P :pro-Kemoterapi SS 2 (Regimen paclitaxel
Tranfusi PRC sd Hb >10 (1/4 180mg, carboplatin 450mg)
- Inj. Cefotaxim 1 gram/12 jam IV
- Inj. Ranitidin 1A/12 jam IV 9.Ny. Sri Hartanti
- Inj. Paracetamol 1 gram/8 jam IV RM 02229513
BUG 2/8
6.Ny. Siti Suwarni
RM 02236688 A :ca ovarium IIB (malignant peripheral nerve
BUG 1/9 sheath tumor (mpnst) non resectable

A :Ca Vulva Stadium III (Vulvar Melanoma), DM P :Pro-Kemoterapi BEP ke-3 (H3/H3)
tipe 2, Anemia, Hipoalbuminemia, P4A0
(Bleomycin 15 mg, Etoposide 100 mg,
Carboplatin 400 mg)
10.Nn Sri Wahyuni
RM 02217030
PJT 3
A :Post Laparotomi TAH BSO ai multiple mioma
uteri, P0A0, riw. mastektomi 1 th yll ai ca
mammae (ER dan PR+) riw. hemoroidektomi 17
th yll. riw. kemo 8x, H2
P :Inj. Cefotaxime 1g/12j
Inj. Ketorolac 30mg/8j
Inj. As. Tranexamat 500mg/8j (3x)
Obs KU VS BC UO Akut abd
Mobilisasi bertahap
DR. FAH
1.Ny. Ponirah
RM 02245212
BUG 1/9
A :PSCBA (Hematemesis) ec susp stree ulcer
Ascites permagna ec susp related malignancy,
Uremicum, Sepsis ec ISK Bakterial, abdominal
pain ok Tumor Padat Ovarium Dextra Suspek
Malignansi, P2A0, Efusi Pleura Dextra,
Hidronefrosis Bilateral Grade II, AKI dd Acute on
CKD, Anemia
P :Perbaikan KU
Pro-Transfusi s/d Hb > 10
IVFD Kabiven : NaCl 0,9% 20 tpm
-Inj Cefotaxime 1gr/12jam/iv
-Inj. Omeprazole 40 mg/24 jam/iv
-Inj Ketorolac 30mg/8jam/iv
-Inj Ranitidin 50mg/12jam/iv
-Inj Ondansetron 4mg/8jam/iv
Mulai Diet Susu (03.07/24)
Obs KU, VS, BC, UO, produk NGT
Lacak Hasil Sitologi Ascites (Diambil 01/07/24)
Cek Kultur Darah dan Urine
2.Ny. Ngatilah
RM 02243150
BUG 1/7
A :Post re-laparotomi TAH BSO, adhesiolisis ai
kistoma ovari dextra, kista coklat sinistra,
hydrosalping bilateral, adenomyosis, adhesi
grade IV, P0A0, Riw. laparotomi kistektomi 10
tahun yg lalu, H3
P : cefixime 2x200mg
asam mefenamat 3x500mg,
observasi produk drain 24jam
Obs KU/TTV/BC/UO/Tanda akut abdomen
Diet dan mobilisasi bertahap
3.Ny. Wartinem
RM 02240497
PJT 5
A :Post laparotomi panhisterktomi,
omentektomi, apendektomi, adhesiolisis ai ca
ovarli klinis stadium IVA, adhesi grade III P1A0
H1
P : Inf. RL 30 tpm
- Inj. Cefotaxime 1 gr/12 jam/iv
- Inj, Asam Tranexamat 500 mg/8 jam/iv 3x
pembenan
- Inj. Ranitidin 150 mg/12 jam/iv
- Inj. Ketorolac 30 mg/8jam/iv
- Inf. Paracetamol 1 gr/8 jam/iv 3x pemberian
double AG
cek elektrolit, albumin, DLO postop
4.Ny. Margaretha Sri Utami
RM 02247100
PJT M
A :Post Laparotomi Salpingooforektomi Dextra,
Kistektomi sinistra, adhesiolisis ai Kista Ovarium
Dextra, kista coklat sinistra, adhesi grade II-III,
P0A0 Ibu dg HT H1
P:
Inj. Cefotaxim 1gr/12 jam/IV
- Inj. Ketorolac 30mg/8jam/IV
- Inj. Asam tranexamat 1gr/8jam/IV (3x)
- Observasi KU/VS/BC/UO/PPV/Tanda akut
abdomen
- Mobilisasi bertahap
- Diet TKTP
5.Ny. Myati
RM 01435936
IGD
A :Kista Ovarium Bilateral, P3A1, Insufisiensi
Renal dd Akut CKD
P :perbaikan KU
- inj cefotaxim 1 gram/12 jam/iv
- Inj paracetamol 1 gram/8 jam/iv selama masih
nyeri
- Inj ranitidin 50 mg/12 jam/iv
- Inj asam traneksamat 500 mg/8 jam/iv selama
masih perdarahan
- Kalitake 1 sach/12 jam/oral
- Tranfusi target Hb >10 gr/dl (2 PRC)
- Konsul TS UPD Nefro terkait CKD
- Konsul TS Urologi terkait pertimbangan RM 02248089
tindakan Urologi BUG 2/4
- Cek CA125 di bangsal
- Obs KU/VS/BC/UO/tanda syok A :ca ovarium stadium IIB Ca Ovarium stad IIB
riw laparotomi tah bso, appendektomi 3 minggu
yll
PROF. H
P:
1.Ny. Fitriatun Imroah Nur Ismiyati Pro Kemoterapi SS 1 seri (Paclitaxel 230mg +
RM 01956579 carboplatin 450mg/3minggu)
BUG 1/1
6.Ny. Wartinem
A :TPO susp malignansi dd mioma uteri, P1A1 RM 02240497
P :Pro PMT + Fz sd Surgical Staging PJT 1
Sabtu 6/7/24
A :Post laparotomi panhisterktomi,
omentektomi, apendektomi, adhesiolisis ai ca
ovarli klinis stadium IVA, adhesi grade III P1A0
2.Ny. Amiatun Nasihah H1
RM 02244853 P : Inf. RL 30 tpm
BUG 1/6 - Inj. Cefotaxime 1 gr/12 jam/iv
- Inj, Asam Tranexamat 500 mg/8 jam/iv 3x
A :GTN High-Risk,Anemia Normositik- pembenan
Normokromik,Hipertiroid, P0A0 - Inj. Ranitidin 150 mg/12 jam/iv
P :Perbaikan KU - Inj. Ketorolac 30 mg/8jam/iv
Tansfusi 2 PRC sd Hb > 10 gr/dl (2/4) - Inf. Paracetamol 1 gr/8 jam/iv 3x pemberian
Inj Ketorolac 30 mg/8jam/iv double AG
Inj asam traneksamet 500mg/8jam/iv cek elektrolit, albumin, DLO postop
Inj ranitidin 1 amp/12 jam/iv
Obs KU, TTV, PPV 7.Ny. Sumartini
Pro EMACO post perbaikan KU (jadwalkan di RM 02240275
poli) PJT K

A :Post Laparotomi Ooforektomi Dextra ai

3.Ny. Margaretha Sawiyem Tumor Padat
RM 02233481 Ovarium Dextra, P1A1, Riwayat SC 6 Tahun yang
BUG 2/10 lalu,
Riwayat Kuretase 8 Tahun yll H2
A :ca ovarii stadium IIIC, post-kemoterapi ss 3 P :Inj. Cefotaxime 1g/12j
seri I, P2A0 Inj. Ketorolac 30mg/8j
Obs KU VS BC UO Akut abd
P :Pro Kemoterapi SS 4 seri I (Paclitacel Mobilisasi dan diet bertahap
200mg+Carboplatin 450 mg)
8.Ny. Sudi Hastuti
4.Ny. Ponisih RM 02048191
RM 02228123 IP 1/512
BUG 2/4
A :Ascites Permagna, hiponatremia, anoreksia,
A :ca ovarii stadium IC (endometrioid Ca Ovarii Stadium IV A, Metastasis
carcinoma) P6A0, riw operasi laparotomi uso Adenocarcinoma Ovarium, P2A1(AH3), Post SS 1
dextra ai kistacoklat bilateral 10 bulan yll, post Seri, Riwayat Laparotomi Biopsi Nodul
SS 3 seri 1 Peritoneum 1 Tahun yang lalu

P :pro-Kemoterapi SS6 Seri 1 dengan Regimen P :Inj. Cefotaxime 1gr/12jam/iv

Paclitaxel 230 mg dan Carboplatin 450 mg - Inj. Ranitidine 50mg/12 jam/iv
- Inj. Ketorolac 30 mg/8jam/iv
5.Ny. Eny Tudiyanti - Obs KU/VS/BC/UO/Tanda-tanda distress napas
DR. ADT

1.Ny. Siti Eni Tarwiyah

RM 02233749
BUG 1/8

A : Post kuretase dx tx dilanjutkan laparotomi

miomektomi biopsi endometrium rekonstruksi
uterus ai mioma uteri subserosa, EIN, P1A0,
leukhorea membaik, hemangioma VL4, riw. inj.
GnRH agonist 3.75mg 3 bln, H2
P :Inj. Cefotaxime 1g/12j
Inj. As. Tranexamat 1g/8j
Inj. Ketorolac 30mg/8j
Mobilisasi dan diet bertahap
Obs KU VS BC UO

usul:
Diet mulai bubur lunak mulai 05/07/24 pagi

DR. MIA

DR. SAR

DR. WDD

1.Ny. Artika Anindiyani Nursejati

RM 02229940
BUG 1/2

A :Post-Laparotomi myomektomi ai mioma uteri

multiple ( myoma degenerasi kistik dan
degenerasi fat), P1A0 (AH 0), Riw injeksi GnRH
agonist 3.75 mg 3 bulan, obesitas grade 1, H3
P :Cefixime 2x200mg dan Asam Mefenamat
3x500mg,
- Obs KU/VS/TTV/BC/UO/Tanda-tanda akut
abdomen
- Mobilisasi dan diet bertahap
usul
Aff DC, BLPL