MAPPING RUANG GINEKOLOGI (ARAFAH 2)

Selasa, 17 Juli 2018

No. Bed Nama Med. Rec Diagnosis Laboratorium Treatment/Terapi DPJP Planning
1. 1A Ainul Mardhiah, 68 1142090 CA ovarium pro kemo siklus V Lab 15/07/2018 Inbumin 2x1 HSD Transfusi TC
thn Dengan Anemia, Trombositopenia, Hb/Ht/E/L/T : 11/34/4,2/5,9/60 Curcuma 3x1] Hingga Tr >100.000
Hipoalbuminemia Metilprednisolon 2x1
2. 1B Sri Wahyuni, 31 thn 1178390 G3P2 Hamil 12-13 minggu Kematian Lab 15/07/2018 Omeprazole 2x1 SIK Rencana Kuretase
Mudigah Hb/Ht/E/L/T: 13/38/4,7/424/12 Sucralfat 3xc1
Ur/Cr : 7/0,43
GDS 129
Na/K/Cl: 144/3,8/111
3. 2A Maryamah, 47 th 1178254 G3P2 Hamil 10-11 minggu JTHIU + LB 13/07/2018 IVFD RL 20 gtt/i HSD Senin cek IgG, IgM,
febris ec. Dd Tifoid fever dd DD dd Hb/HT/E/L/T : Drip PCT 500 mg/8 jam Widal, urinalisa
Tonsilofaringitis 13,8/39/5,0/8,8/281 Asam folat 1x1
GDS ; 89 mg/dl Sohobion 1x360 mg
Ur/Cr : 13/0,47* Uterogestan tab 2x100 mg
Na/Cl : 139/109* Ampisilin Sulbaktam 1,5
gr/8j
4. 2B Anita, 53 tahun 1165837 Ca ovarium pro kemoterapi siklus V Lab 16/07/2018 Curcuma 2x1 HSD Tranfusi PRC
dengan permasalahan anemia normositik HB/HT/E/L/T : SF 2x1
normokromik 9,2/28/3,4/4,4/283
Alb: 3,85
GDS: 121
5. 3A Rosmiati, 55 tahun 1079502 Kanker ovarium residif post kemoterapi Lab 13/7/2018 Inbumin 2x1 HSD
kanker 19 kali dengan asites Hb/Ht/E/L/T Sucralfat 3x1
10,8/28/3,4/8,7/351 Omprazole 2x1
Alb/glob 2,62/4,02 Ondansentron 2x1
6. 3B Hanifah, 48 thn 1103843 Ca mammae post radikal mastektomi Lab 12/7/2018 HSD Rencana operasi BSO
Hb/Ht/E/L/Tr
13,0/38/4,4/8,0/200
CA 125 : 4,20
Sgot/sgpt : 27/11
Ur/Cr: 22/0,70
7. 4A -

8. 4B -

9. 4C Rasyidah, 67 thn 1177494 POD 1 Post total vaginal histerektomi a.i Lab 10/07/2018 Inj Fosfomycin MUN Cek Hb 2 jam post op
Prolaps Uteri Grade IV, sistokel grade II Hb/Ht/E/L/T: 13,5/41/5/7,6/312 Inj. Ketorolac
BT/CT: 2/7 Inj. Ranitidin
Gds 137 Sohobion
/Na/K/Cl : 150/4,2/104 Vit C
Ur/Cr : 18/0,67 FC 1x24 jam
10. 4D Ainul Mardhiah, 68 1142090 Ca ovarium post kmoterapi siklus keV Lab 13/7/2018 Inbumin tab 2x1 HSD Transfusi WB sampai
tahun dengan permasalahan: Hb/Ht/E/L/T 8,1/24/2,9/6,4/13 Metilprednisolon 2x1 Hb>10
1.anemia (8,1) Gds 176 Curcuma 3x1 Kemo bila Hb>10 Tc
2.trombositopenia (13) Alb 3,20 >100.000
3.hipoalbumin (3,20) IPD Cek Urinalisa MDT HbA1c
4. DM tipe 2 normo weight Sc insulin Lantus 0-0-0-8 unit
5. Pansitopeni ec dd :
1. Kemoterapi induced
2. Anemia aplastik
3. Leukimia
11. 5A Yatinem, 49 th 1168988 POD 7 post radikal histerektomi a.i Ca Lab 10/07/2018 Inj fosfomisin 2gr/24 jam SIK GV luka dgn aquacell
Cerviks stadium IIB dengan permasalahan Hb/ht/E/L/Tr Inj transamin 1 amp/8 jam Vaginal wash metronidazole
Leukositosis, DM tipe 2, Hipoalbuminemia, 12,4/37/4,4/19,3/189 Inj ranitidine 1 amp/ 12 jam Tranfusi PRC
Anemia Nebul fentolin 1 amp/12 jam
Curcuma 3x1
Octalbin20%/hari
dexketoprofen 100 mg/12 jam
12 5B Nurmala, 33 thn 1126691 1. Susp. NOK Lab 8/7/2018 Albumin 20 % 1 fls/hari SIK Obs TTV, KU
2. Susp. Sirosis hepatis St. Decompensata Hb/Ht/E/L/Tr: Furosemide 2 amp/8 jam Transfusi PRC s/d Hb>10
3. CHF NYHA FC III-IV 6,2/19/2,5/6,4/80 Spironolakton 1 x 25 mg Cek darah lengkap dan USG
4. Ascites ec dd hipoalbumin dd sirosis Alb 1,66 Propanolol 2x20 mg abdomen
hepatis T3/T4: 1,75/175,73 Thyrozol 1x20 mg Pasang CFC + USG tiroid
5. Grave disease Lab 7/7/2018 CPG 1 x 75 mg 16/07/2018
Hb/L/Tr : 5,9/5,5/67 Atorvastatin 1x40 mg CT scan abdomen 1/08/2018
Lab 4/7/2018 Aspilet 1x 80 mg USG Abd Pelvis
Hb/L/Tr : 7,5/4,0/7,8 n. pulmicort 1 rep/12 jam
GDS : 165 n. ventolin 1 resp / 12 jam
Ur/Cr : 21/0,30 Bicnat 2x1
Lab 10/7/2018 KSR 1x600mg
Hb/L/Tr : 6,4*/6,4/52* Curcuma 3x1
ERITROSIT : mikrositer O2 2-4 L / menit
hipokrom, anisotosis Diet Sonde 6x200 kkal
PT/APTT: 15,7*/47,4*
Feritin : 45,46
T4 total : 225,26
AFP/CEA/CA 125 :
0,66/3,94/224,81
Ca/Na/K/Cl : 7,4*/147*/3,6/115*
Lab 11/07/2018
T3 : 1,74
T4 :175,73
13. 5C -
14. 5D Roza,39 th 1177173 POD 1 Post laparotomy Miomektomi Lab 06/07/2018 TPD Cek Lab post operasi
multiple reseksi uterus, rekontruksi uterus Hb/Ht/E/L/T
a.i mioma uteri + infertile primer 11 tahun 14,2/42/4,9/12,3*/302
Gdp 115*
G2PP 204*
INR 0,89
Alb 4,16

15 6A -

16. 6B -

17. 6C Mawarni, 38 th 1178455 G1 hamil 9-10 minggu JTHIU Lab 16/7/2018 Inj Lansoprazole DK` Rehidrasi Cairan
Hiperemesis Gravidarum Hb/Ht/E/L/Tr Inj Ondansetron
12,5/36/4,4/238/7,8 Drip Neurobion
GDS 103
Ur/Cr: 16/0,49
Na/K/Cl: 141/3,8/109
Proteinuria: Negatif
Ketonuria : Negatif
18. 6D Darmiyati, 34 th 1177827 Mioma uteri Lab 10/07/2018 IVFD RL 20 gtt/i CMY Obs KU,TTV, perdarahan
Hb/Ht/E/L/T Sohobion 1x360 mg mg/dl
7,9*/27/5,9/5,4/342 SF 2x300 mg Konsul anastesi
PT/APTT : 10,3/33,3 Operasi 17/07/2018
GDS : 107 gr/dl
Na/K/Cl : 144/4,4/111

Lab 12/07/2018
Hb/Ht/E/L/T
8,9*/29*/4,1/7,0/303

Lab 13/07/2018
Hb/Ht/E/L/T
10,3*/34*/4,7*/6,8/299

Lab 14/07/2018
Hb/Ht/E/L/T
11,6*/36*/5,0/6,9/268

19. 6E -

20. 6F -
21. 7A Ridha Faridha, 39 thn 1159944
23. 7C -
24. 7D -
25. 7E -
26. 7F -
27. ISO 1 -
28. ISO 2 Syamsiar, 55 thn
DPJP
Dr. dr.Hasanuddin,Sp.OG (K)
dr. Yusra Septivera,Sp.OG
dr. Rajuddin,Sp.OG
dr. Tgk. Puspa Dewi, Sp.OG
dr. Sarah Ika N, Sp.OG(K)
dr. Niken Astri Utami, Sp.OG
Dr. dr. Cut MeurahYeni, Sp.OG (K)
dr. Munawar, Sp.OG
dr. Munizar, Sp.OG
Prof.Dr. dr. Mohd. Andalas, Sp.OG FMAS
dr. Roziana, Sp.OG
dr. Dewi Karlina R,Sp.OG
dr. Cut Rika Maharani, Sp. OG
TOTAL PASIEN
Mioma uteri dengan permasalahan Lab 13/7/18 SF 2x1 HSD Tranfusi PRC
Anemia mikrositik hipokrom Hb/Ht/E/L/Tr: 7,4/25/4,1/4,5/517 Ketorolac 3% /8j Operasi Laparotomi
Ca 125 : 9,68 setelah KU baik
SGOT/SGPT : 33/29
ALB 4,47
1176965 Tumor ovarium susp. Ganas + Hepatitis B Lab 5/7/18 HSD Rencana Operasi
Hb/Ht/E/L/Tr Debulking tumor 16/7/18
13.9/43/5,3/9,4/370
HBSAG POSITIF
Anti HCV POSITIF
SGOT/SGPT : 60/84
CA 125 : 2007,35
CA 19-9 : 14,66
UR/CR : 58/1,10
JUMLAH PASIEN KAMAR PASIEN
8 1A, 2A,2B, 3A,3B, 4D, 7A, ISO2
- -
- -
1 5D
3 1B, 5A,5B
- -
1 6D
1 4C
- -
- -
- -
1 6C
-
15