AMPRAHAN PASIEN SERUNE 3 16/11/2015

Kamar

Identitas

No.CM

Diagnosa

Tatalaksana

1A/Gyn

Elly
malnawati,
H3

916840 AUB ec Mioma uteri dengan

perdarahan, anemia
mikrositik hipokrom, DM tipe
2

Obs.TTV, perdarahan, nyeri,

sohobion 2x1, durogesic patch
12,5 mcg, iv.transamin
500mg/8jam, novorapid 12-1212, levemir 0-0-0-22

1B/Gyn

Nani lydya
wati, 36th, H2

957565 post surgical staging a.i ca

ovarium std 3c post
kemoterapi 3x

obs ttv, nyeri, perdarahan,

cefixime 3x500 mg, paracetamol
3x500 mg, mobilisasi bertahap,
gv/3 hr, diet tktp

2A/Obs

Ernawati, 30
th, H2

1071014 P2A1 post SC ai distosia pk II

obs.ttv, perdarahan, nyeri, transfusi

prc s/d hb 10, iv ceftrixone 2gr/24
jam, profenid 3x100 gr, diet tktp, fc
1x24 jam

2B

3A

Utari Siti
hardianti, 17
thn

3B/Obs

Nurhafni, 50
th

1056087 G1P0A0 hamil 9 minggu,

Obs, TTV, KU, perdarahan, hari
gemeli, GS 1 abortus
USG di poli
iminens, GS 2 Blighted ovum

921137 Prolaps uteri grd.3

4A

4B/OBS Nana
Maryam, 22
th

1070947 P1 post sc ai infeksi intra

uterin

obs.ku, ttv, perdarahan,

iv.ceftriaxone 2gr/24 jam,
profenid supp 3x100 mg, diet
tktp, gv hr 3

4C/Obs

irawati, 26th,
H3

1070838 P1 post SC a/i distosi PK II

+fetal distress

obs KU,TTV, Nyeri, perdarahan.

Cefadroxil 2x300. asam
mefenamat 3x500, kaltrofen 3xI,
sohobion 1x360.

4D/Obs

ernawati,
31th, H4

1070800 para 3 post SC a/I BSC 1 +

CPD

obs KU, TTV, Perdarahan, nyeri,

cefadroxil 2x500mg, asam
mefenamat 3X500mg, sohobion
1x1

1070906 P1 Post SC a.i distosia PK I

aktif

Obs TTV , Ku, kontraksi,

perdarahan, iv. ceftriaxone
2gr/24jam, profenid 3x1supp,
sohobion 1x1, motivasi ASI,
hygiene luka operasi, GV hari ke
3, mobilisasi bertahap

928416 P1 post sc ai gawat janin

Obs, TTV, KU, perdarahan, IVFD

tramadol 2 amp/8 jam, profenid
3x1 supp, ceftriaxone 1 gr/24
jam, ranitidin amp/12 jam,
mobilisasi bertahap, hygiene
vulva gv/3 hr, realimentasi dini,
diet tktp, FC 1x24 jam

5A/Obs Suriati, 20 th,

H3

5B/Obs

Cut Sri
Sumarni, 23
thn

5C/Obs

Nurleli
ZA/35th/ H7

1070225 Post sc a.i bsc 1x + CPD

dengan anemia ringan.

obs KU, TTV, nyeri, perdarahan,

diet TKTP, cefadroxil 2x500mg,
kaltopren supp 3x100mg, asam
mefenamat 3x500mg, alinamin
2x1, sohobion 1x1, GV hari ke3.
transfusin PRC. Saran IPD : cek
Reticulosit count, ferritin serum,
SI-TIDC, feses rutin, morfologi
darah tepi. dr ulang Hb>8 pulang

5D/Obs

1070962 P3A1 post Sc a.i BSC 2x

Rita
Mutia/39th/H2

Obs TTv, Ku, pedarahan,

perhatikan tanda- tanda
alergi,kontraksi, cek hb 2 jam
post op, jika hb< 10g/dl transfusi
PRC, duragesic patch 12,5 s/d tgl
18/11/2015, diet TKTP,drip
metronidazole 500mg/8jam
Rawat luka

6A/gyn

sawami, 41
th, H4

Obs KU, TTV, perdarahan,Iv

omeprazole vial/12 jam,iv. asam
tranexamat 500 mg/8 jam, ro
abdomen 3 posisi, cek dr,
elektrolit, ekg. Folket Ketat

1015241 syok hipvolemik ai penyakit

trofoblas ganas

6B/Gyn

Agustina , 43
th, H9, POD 7

1069085 post laparotomi debulking

dilanjutkan histerektomi
radikal a/I Ca servik Ca servix
grade 2a dan ca ovarium stad
3c

6C/Gyn

Hendon, 59th, 1034072 Ca Ovarium pro kemoterapi

H6
siklus IX

Obs TTV, KU, Ondancetron 3x8

mg, omenprazole 2x1, codein
3x20mg, ciprofloxacin,
leucogen/hari

6D/Gyn

Khadijah,
53th, H6

obs ttv,ku, pungsi cairan asites,

echo kepoli hari selasa (17-112015) cek lab Ca125, CEA hari ini

1070435 massa intrabdomen dengan

asites masif dd 1.neoplasma
ovarium kistik 2. ca ovarium
3. sirosis hepar

Obs. Ttv, KU, nyeri, perdarahan,

cefadroxile 2x500mg, as.
Mefenamat 3x500mg, sohobion
2x1, profenid 3x1 supp,
mobilisasi berthp, gv, diet TKTP

6E/Gyn

Rahimah M.
1069601 post laparotomi debulking
Saleh, 47 thn,
adhesiolisis a/i NOP susp.
H1
maligna+ post repair buli
iatrogenik ec post debulking
tumor ovarium dengan
permasalahan diare akut dan
hipoalbuminemia

6F/Gyn

Sakiah, 25 th, 1070086 post laparotomi miomektomi obs. Ttv, ku, cefadroxil 2x500mg,
H4
a/I mioma uteri intramural
as.mefenamat 3x500mg,
sohobion 1x1,

7A/Gyn

Nurbaiti, 40
th, H24

1048628 Ca ovarium post kemoterapi

siklus VI dengan
permasalahan 1) cancer pain,
2) anemia dd -keganasan
-defisiensi besi, 3) efusi
pleura post pleurodesis

obs TTV, ku, nyeri, perdarahan,

cefixime 2x1, paracetamol
3x500mg, ondansetron 3x8mg,
sohobion 2x1, albumin 1 fls/hari,

Obs. TTV, nyeri,durogesic patch

25 mg, as.folat 1x1 tab, sohobion
1x1, laxadyn syr 3xC1, dulcolax
supp 2x100 mg, transfusi
albumin, Iv.ranitidin amp/12jam,
ketorolac drip/12 jam, profenid
supp

7B/Gyn

Ainol
Mardhiah, 63
thn, h15

1069174 Post surgical staging dan

adesiolisis a.i tumor ovarium
ganas dex. Susp. Metastase
paru + Dm Type 2m +
obesitas kelas 2

Obs TTV, ku, profenid 3x1,

cefixime 2x1, as.mefemanat
3x500mg, sohobion 2x1,
mobilisasi bertahap, gv per 3
hari, novorapid 8-8-8 iu. Sc,
levemir 0-0-0-18 iu. Sc , susul
hasil PA

7C/Gyn

rusni, 50 th,
H4

915444 Ca. ovarium stadium 3b +

post kemo siklus 1 dengan
permasalahan low intake,
nausea, vomitus

Diet tktp, Terapi TS IPD dan HD

dilanjutkan

7D/gyn

suminah,
46th, H1

1064222 Ca cervis stadium 3b post

kemo radiasi + anemia

Obtransfusi PRC s/d Hb > 10,

durogesic patch, dulcolax tab
2x1, persiapan kemoterapi ulang,
echo hari selasa, usg abdomen
hari ini

7E/

7F/gyn

Siti Aminah,
56th, H1

1004474 Ca endometrium dengan

permasalahan anemia, ca
pain, selulitis

Obs TTv, KU, Nyeri, perdarahan,

duragesic patch 25mcg, IVFD RL
s/s Clinimix+lipofundin, diet TKTP,
cek pt/aptt d-dimer, usg dopler,
echo selasa, usg abdomen hari
ini.

ISO
I/Obs

Rahmi, 36th,
H1

1070924 Preeklampsia pada G1 hamil

35-36 minggu JPKTH dengan
plasenta letak rendah, diare
tanpa dehidrasi

Obs TTV, His, DJJ, CTG/8

jam,perbaikan PEB, maintenance
MgSO4 1gr/jam, adalat oros
1x30mg, New Diatab 3x1, oralit,
NAC 3x600 mg, Iv.omeprazole
40mg/12 jam, Iv.ranitidin 50 mg
(ekstra)

ISO
II/Gyn

Kartini ismail,
40th, H3

Total Pasien
Gynecology

914028 infeksi luka operasi pada POD

9 post laparotomi debulking
tumor, adhesiolisi a/I tumor
ovarium ganas kiri

: 24 Pasien
: 14 Pasien

obs TTV KU Nyeri, inj ceftriaxone

2gr/24jam, metronidazole
3x500mg drip, GV 2X/hari, diet
TKTP+Ekstra putih telur. Kultur
pus menunggu hasil

Obstetri
dr. Hasanuddin, Sp.OG (k) Onk
dr. Tgk. Puspa, Sp.OG
dr. Munizar, Sp.OG
dr. Munawar, Sp.OG
Dr. Niken Asri Utami, Sp.OG
dr. Cut Meurah Yeni
Dr.dr. Mohd Andalas Sp. Og

: 10 pasien
1A,1B,6A,6B, 6C,6D,6E,7A,7B,7C,7D, 7F, ISO 2.
3B, 4D, 5C
2A, 4B,5A, 5B, 5D
6F
4C,ISO 1

15
Laboratorium

DPJP

Lab 13/11/2015 hb 8,3 dr. Hasanuddin,

ht 26 eri 3,7 trombo
Sp.OG (k) Onk
443 leu 13,8 na 134
KGDS 303

Lab 12/11/2015 Hb
13,2 Ht 40 Eri 5,0 Leu
21,9 Trom 272

dr. Hasanuddin
Sp.OG (k) Onk

Lab 15-11-2015 Hb 10,8 dr.munizar, sp.og

Ht 33 Erit 3,7 Leu 9,9
Trombo 229

dr. Munizar,
Sp.OG

Lab 28/10/2015 Hb
dr. Tgk.Puspa
13,7 Ht 42 Erit 4,8
Dewi,Sp.OG
Trombo 239 Leuko 5,9.

lab 15/11/15. hb 11,6;

ht 34; erit 3,8; leu
15,4; trom 178

dr.munizar, sp.og

lab 13/11/2015 HB
12,9; HT 37; Erit 4,3;
Leu 20,6; Trom 228

dr. Cut meurah

yeni, Sp.OG

Lab 13/11/2015 Hb 9,3 dr.Tgk Puspa

Ht 28 Eri 3,1 Leu 17,4 Dewi,Sp.OG
Trom 239 (12/11/2015)
HBsAG(-) Albumin 3,64
Na 140 K 3,9 CL 106
GDS 162 UR/CR
14/0,61
lab 15/11/2015 hb 11,5 dr. Munizar,
ht 37 eri 4,3 leu 19,3
Sp.OG
trom 272

Lab 14/11/2015 Hb 10
ht 32 eri 4,4 leu 10,8
trom 275

dr. Niken Asri

Utami, Sp.OG

Lab 13-11-2015 Hb 7,5 dr. Tgk Puspa

Ht 24 Erit 3,0 Leu 10,6 Dewi, Sp. Og
Trombo 232

lab 15/11/2015 hb 9,5

ht 31 eri 4,2 leu 33,4
trom 477

dr. Munizar,
Sp.OG

lab 15/11/2015 Hb 7,3

Ht 24 Eri 2,8 Leu 13,7
Trom 131

dr. Hasanuddin,
Sp.OG (k) Onk

lab 13-11-2015 protein dr. Hasanuddin,

5,4 alb 2,6 glb 3
Sp.OG (k) Onk

lab 14-11-2015 Hb
10,8 Ht 31 Erit 3,6
Leuko 2,1 Trombo 107

dr. Hasanuddin,
Sp.OG (k) Onk

lab 14/11/2015 hb 14,1 dr. Hasanuddin,

ht 44 eri 5 leu 10,1
Sp.OG
trom 151 alb 4,01 glo
3,89 ur/cr 29/0,61
hbsag (-)

lab 9-11-2015 Ur 86 Cr dr. Hasanuddin,

1,03 lab 6-11-2015 Hb Sp.OG(K)Onk
9,3; ht 28; erit 3,3; leu
16; trom 236. lab
12/11/2015: protein
total 5,7 alb. 2,94 glob
3,19

lab 13-11-2015 Hb
dr. niken Asri
15,2 Ht 44 Erit 4,9
Utami, Sp.OG
Leuko 17,8 Trombo 297

lab 14/11/2015 PT 14,2 dr. Hasanuddin,

aPTT 31,1 Fibrinogen
Sp.OG (k) Onk
133 D-Dimer 10000 lab
10-11-2015 Hb 9,0 Ht
26 Erit 3,0 Leuko 11,2
Trombo 127

Lab 13-11-2015 hb
dr. Hasanuddin,
10,1 ht 31 eri 3,8 leu
Sp.OG (k) Onk
9,7 trom 283 lab
9/11/2015 kolesterol
total 244 HDL 33 LDL
150 Trigliserida 151
GDP 147 Lab
8/11/2015 Hb 10,8 Ht
33 Eri 4,1 Leu 8,4 Trom
314.albumin 3,28, ur/cr
21/0,47

lab 15/11/2015 Na/K/Cl dr. hasanuddin

128/4,9/89 ur/cr
Sp.OG (k) Onk
237/5,30 lab
12/11/2015: hb 11,4 ht
35 eri 4,5 trombo 376,
leu 11,6

lab 15/11/2015 Hb 8,8

Ht 27 Eri 3,5 Leu 7,7
trom 540

dr.Hasanuddin
sp.OG (K)Onk

lab 13/11/2015 hb 10 dr. Hasanuddin,

ht 29 eri 3,5 leu 5,1
Sp.OG (k) Onk
trom 311 ct/bt 7/2
na/k/cl 117/3,2/88 ur/cr
28/0,82

lab 13/11/2015 hb 10,7 dr. Cut meurah

ht 32 eri 4 trom 190
yeni, Sp.OG
leu 13,1 ct/bt 7/2
hbsag (-) SGOT 14
SGPT 12 Prot tot 6,5
Alb 3,6 glo 2,9 GDS
120, protein negative
lab 13/11/2015 Hb 10,8 dr.Hasanuddin
Ht 34 Eri 4,0 Leu 9,3
sp.OG (K)Onk
Trom 401 Alb 3,85 GDS
105 ur/cr 23/0,59