Mapping 23-02-2023
OBSTETRI PERVAGINAM
Bed A1
Bed A3
Bed C2
Ny Reni Mauliani/ 24
th/01525568
MRS:21-02-2023
Alamat : Jln 9 novemver
P1A0 Post SC (H-1) ai KPD Preterm
+ Febris + Abnormal CTG Kat II
Lahir bayi tgl 21-02-2023 pkl 22.15
LK/24O5gr/45cm/AS6-7-8
Venflon
Aff DC
Inj Ceftriaxone 2x1 gr (H2)
Po : asam mefenamat 3 x 500 mg
Po : SF 2 X 300 mg
Rawat luka H3 (tgl 25-02-2023)
Bed A2
Bed A4
Ny. Misliana/ 43 thn/ 01525585
MRS :21-02-2021
Alamat : Sungai Lulut
P5A0 Post partum SptIUFD + Insersi
IUD (H1)
Bayi lahir SptI UFD tgl 22-02-2023 pkl
05.03 wita
LK/3700gr/52 cm
Po cefadroxil 2x500mg
Po SF 2x300mg
PO Asam mefenamat 3x500mg
PO bromokriptin 2X 5mg (H1/H5)
Bebat payudara
Mo KU/Kel/TTV/ Flx/ Kont uterus
Usul KRS
Bed C1
Ny. Minawati/28 th/01524751
MRS : 12-02-2023 (HP12)
Alamat : Balangan
P3A1 Posts SC (H-10) ai KPD >24 jam
+ PEB + HELLP Syndrome + Fetal
Distress + Trombositopenia (315.000)
perbaikan + Peningkatan LFT (OT/PT
32/74) perbaikan + Peningkatan
Bilirubin (T/D/I 5.21/0.88/4.33)
perbaikan+ AKI on CKD (146/4.9) +
Anemia (10.7 ) terkoreksi + Elektrolit
Imbalance (Na :131, K : 3.4) +
Hipoalbumin (3.0) dalam koreksi Syok
condition on NE perbaikan + Post HD
2X (H-2) + Riwayat penurunan
kesadaran ec koma hepatikum dd
B. OBSERVASI POST OPERASI
Bed B1
Ny. Asmah/50 th/ 01517848
MRS: 13-02-2023 (HP11)
Alamat : Taniran Selatan
P4A0 ATK 17 th
Post Op Laparatomi
Suboptimal Debulking (SVH-
BSO + Omentektomi +
Appendiktomi + Sitologi
Cairan Ascites) + Adhesiolisis
Tajam ai Ca Ovarium std IIIC
+ Adhesi gr III + Post Repair
Serosa Buli ai Cedera VU
(H8) + Hipoalbuminemia
(2.5)
Diet TKTP
IVFD RL:D5:NS (1:2:1)/24
jam ~ 30 tpm
Inj Ceftriaxone 2x1 gr IV (H9)
Inj Metronidazole 3x500 mg
IV (H9)
Inj As Traneksamat 3x500
mg IV
Po Vip Albumin 3x2 caps
Pertahankan FC sd 14 hari
(H8/H14)
Pertahankan drain 14 hari
(H8/H14)
Mo KU/Kel/TTV/Flx/Produksi
Drain/BC
Bed B5
Bed D1
Bed B2 (DOPS VIN-JOY)
Ny Marsubi/40thn/01483782
MRS:17-02-2023(HP7)
Alamat: Bukit Permai
P0A0 ATK(-)
Post Op Laparatomi SVH + Adhesiolisis
Tajam (H-2) ai Adenomiosis + Adhesi Corpus
Posterior Uterus dgn Colon Descendens dan
Omentum
IVFD RL:D5 2:1/24 jam
Inj Ceftriaxone 2x1 gr (H3)
Inj Ketorolac 3x30 mg
Inj As Traneksamat 3x500 mg
Inj Metoclopramid 3x1 amp
Inj Ranitidin 2x1 amp
Diet bertahap, mulai minum sedikit-sedikit
(+) Mulai diet susu
FC dipertahankan sd mobilisasi aktif
Mobilisasi miring kanan-kiri sd duduk
Rawat luka H3 (tgl 24-02-2023)
Bed B4 Bed B3
Bed D2
Ny. Nida Noor Azkia/25
th/01523224
MRS : 21-02-2023 (HP3)
Alamat : Kelayan B
P0A0 ATK (-)
G1P0A0 H 16 mgg + 6 hari +
Kista Ovarium Permagna
Pro Laparatomi (tanpa VC)
Kistektomi sd USO hari ini
dgn operator Dr. dr. Hariadi,
Sp.O.G, Subsp.Onk.
Po Microgest 2x200 mg
mulai hari ini&bawa ke OK
Sedia darah 2 PRC
1
 Mapping 23-02-2023

Mo Ku/Kel/TTV/Kont uterus intracranial lesion + Jaundice in dorong Ke OK pkl 08.00

pregnancy + Riwayat hematemesis
ec stress ulcer + ISK bacteriuria

Tgl. 12-02-2023 Pkl. 17.03 WITA,

Lahir bayi SC
LK /3125g/49cm/AS 4-6-7

O2 NK 2-4 lpm
Die TKTP, RG
IVFD ~ TS IPD
PO Cefadroxil 2x500mg (H8)
Po Metronidazol 3x500 mg (h8)
Po SF 2x300 mg
PO Vip Albumin 3x2 caps
Mo
KU/Keluhan/TTV/Fluxus/Kontraksi
Uterus

TS IPD Nefrologi :
Inj As Traneksamat 3x500mg
Inj Furosemid 1x40 mg IV
Po As Folat 1x5mg
Po CaCO3 3x500mg

TS Neurologi :
Inj Citicolin 2x250 mg iv

TS Gizi Klinik :
IVFD D5 : Aminofiusin Hepar (2:1) ~
1500 cc/24 jam

Bed C3 Bed C4 Bed D3 Bed D4

Ny. Milawati/41 th/01512227
MRS : 14-02-2023 (HP10)
Alamat : Rantau Nangka
P1A0 ATK 19 thn

NOK dgn bagian padat c Maligna + Obs

Dyspnea ec Efusi Pleura Masif (S) +
Hipoalbuminemia (2.4) dlm koreksi + ISK
Asimptomatik Bakteriuria + Post Pungsi
Cairan Pleura 2x (H2)

CEA : 34.17 ng/ml

Ca 125 177,45 U/ml

Diet TKTP Extra Putel

IVFD NS 10 tpm
O2 NC 3- 4 lpm
Kaltrofen supp II (k/p)
PO Vip Albumin 3x2 caps
Inj Ceftriaxone 2x1 gr IV (H10)  Usul ganti
Po Cefixime 2x200 mg
Trf Alb sd Alb > 2.5 g/dl
Pro USG Abdomen Upper Lower (tgl 10-03-
2023)

TS Paru
FU hasil analisa dan sitologi cairan pleura
(Perkiraan 01-03-2023)

Bed F3 Bed F4 Bed F1 Bed F2

Nn. Yuli Retnowati/ 59 th/ 01524863
MRS : 13-02-2023 (HP11)
Alamat : Jl. Sido Mukti
P0A0 ATK -

NOK c Maligna + Efusi pleura (D) +

Ascites Massif + Trombositosis
(702.000) + Hipoalbumin (2.9) +
Hiponatremia (130) + Underweight +
Post Pungsi Pleura (H9) + Anemia
(10.4) terkoreksi

2
 Mapping 23-02-2023
Bed G2
Ny. Henny Tri U/32 th/01520086
MRS : 21-02-2023 (HP3)
Alamat : Manarap
P4A0 ATK 2 th
Ca Cervix std IB3 + Post
Kemoterapi 1x (Reg. Fonkopac 230
mg + Carboplatin 450 mg) +
Anemia (7,0) dlm koreksi
Diet TKTP, NB
IVFD RL 20 tpm
Inj As Traneksamat 3x500 mg
Kaltrofen supp II (k/p)
Trf PRC sd Hb > 10 g/dl (Sudah
masuk 3 kolf
Cek DR Hari ini
Pro kemoterapi ke-2 (Reg.
Fonkopac 230 mg + Carboplatin
450 mg) bila syarat terpenuhi
Bed G3
Ny. Wati Binti
Dural/48th/01515007
MRS : 20-02-2023
Alamat : Desa Tambak 2
P4A0 ATK 10 th
Ca Cervix stad IIIB + post radiasi 5x
Diet TKTP extra putel
O2 3-4 lpm
IVFD RL: D5 (2:1) ~ 20 tpm
Inj Ketorolac 3x30 mg (k/p)
PO Vip Albumin 3x2 caps
FC Menetap
Alirkan drain pungsi ascites 3 L/hari
(1 L/8 jam)  jika TD > 100/70 mmHg
Mo KU/Kel/TTV/Drain
TS Paru
FU hasil analisa cairan & sitologi
pleura
Pro USG Thorax marker ulang tgl
24/02/2023
TS IPD-GEH
Inj Cefotaxime 2 gr/24 jam IV (H9)
Po Onoiwa 3x1
Po UDCA 3x250 mg
Inj. Antrain 3x1 amp (k/p)
Inj Lansoprazole 1x30 mg IV
Inj Ondancetron 3x8 mg IV (k/p)
TS Gizi klinik
inf gabaxan 100cc dalam NS 400cc :
Inf Aminofusin hepar : NS dg drip INB
(1:1:1) 1500cc/ 24 jam
PO Zinc 1x20mg
PO As folat 1x1 tab
PO Curcuma 3x1 tab
Bed G1 Bed G5 Bed G6
Ny. Paini/57 th/01461920 Ny. Sri Munirah/25
MRS : 14-02-2023 (HP9) th/01520461
Alamat : jl Trans Kalimantan MRS : 21-02-2023 (HP3)
P5A1 ATK 21 th Alamat : Ratu Zaleha Gg.
Fajar Sidik
Ca Cervix std IIIB + Post Radiasi P1A0 ATK 20 thn
Eksterna 35x (Residif) + Post
Kemoterapi 5x (Siklus ke-2) (Reg NOK c Maligna + Ascites +
Fankopac 230 mg + Carboplatin 450 Hipoalbuminemia (2.2) + Obs
mg) + Anemia (10.7) terkoreksi + Dyspneu ec Cardiomegali dd
Trombositopenia (85.000) + Gross Efusi Pleura dextra
Hematuria
Diet TKTP
Drip adona IVFD RL 20 tpm
Diet NB, TKTP Trf Alb 20% sd Alb > 2.5 g/dl
IVFD NS 20 tpm (sudah masuk 1 flash)
Inj As Traneksamat 3x500 mg IV Cek alb pagi ini
Kaltrofen supp II (k/p) Inj As Traneksamat 3x500
Pasang FC 3way  bila ada retensi mg (k/p)
urine Kaltrofen supp II (k/p)
Pro Kemoterapi ke-6 (Reg Fankopac Pro pungsi ascites hari ini
230 mg + Carboplatin 450 mg) Pro NAC bila syarat
Inj MP 3125mg (H2/H3) terpenuhi
Mo KU/Kel/TTV/Flx
TS Paru
TS Urologi Transfusi Albumin
Pertahankan FC 3 Way boleh dilepas Evakuasi pleura (menunggu
bila ada retensio urin  pasang FC USG thorax marker)
3way lagi + Spooling NS 30 tpm Analisis dan Sitologi Cairan
Pleura
TS IPD HOM USG Thorax Marker
Tidak ada tatalaksana khusus di Pasien kami ikuti
bidang IPD Hom
Bed G4 Bed G8 Bed G7
Ny. Rasiah/59th/01478781 Ny. Sukma kusuma/ 42
MRS:19-02-2023 (HP5) th/01-031548
Alamat: Jl. Rawa Sari MRS
Alamat : GG ramaji
Ca. Cervix Std IIIB + Post Kemoterapi P2A0 ATK 15 thn
5x (Reg Fancopac 230 mg + Ca Cerviks std II B + Post
Carboplatin 450 mg ) + Post RE 35x + Radiasi Eksternal 5x +
3
 Mapping 23-02-2023

+ post repair nefrostomi (1 bln yll)
+ Anemia (10.3) + leukositosis
(16.800) + HN Bilateral +
Trombositosis (495.000) + HN
bilateral + peningkatan LFT (OT/PT
71/61) + peningkatan RFT (Ur/Cr
150/3.69) + hiponatremai (130) +
DM Type II
Diet TKTP, Diet DM
IVFD NS 20 tpm
Inj As. Tranexamat 3x500mg (kp)
Kaltroppen supp II (kp)
TS IPD :
Cek GDP, GD2PP/hari
Po Gliquidone 1x30 mg (I-0-0)
Raber Div.Endokrin & HOM
Partial Respon + SOB ec Efusi Pleura + Anemia (6.6)
Post pungsi cairan pleura 2x (H2) ai
Efusi Pleura (D) + c Metastase Paru Diet TKTP
Po : NAC 3x1
Diet TKTP Pro tranf PRC sd Hb >10g/dl
O2 ~ TS Paru Premed inj dexametason
IVFD RL 500 cc/24 jam 1amp
Inj Asam Traneksamat 3x500 mg Inj as. Tranexamat 3x500mg
Kantrofen supp II (k/p) Kaltroppen sup II kp
Pro RE bila syarat memenuhi
TS Paru
FU hasil sitology cairan pleura
(Perkiraan 01-03-2023)
Pro CT Scan Thoraks dgn Kontras tgl
07-06-2023
Po NAC 3X400 mg

TS Urologi :
Spooling nefrostomi (D) (+)
Tidak raber
Konsul perpoli urologi

ANGLAM 3. Ny. Nurul Indriyani/ 40 th/ 01457737 4. Ny Ani/49 thn/01503289

1. Ny Farida /48 thn MRS MRS:22-02-2023
MRS :16-02-2023 (HP9) Alamat Jl. Maju Mulyo Alamaat : Ayani km 21
Alamat : Kurnia komplek P0A0 ATK – P3A0 ATK 12 thn
P3A0 ATK 23 thn
Post op relaparotomi eksplorasi + adhesiolisis Post complete surgical staging (3 bln yll ) ai
Ca Cervix std IIIB + Metastasis vagina distal + hieoatomi (H3) ai ileur paralitik ec perforasi ca endometrium ++ post kemoterapi 4x
Metastasis paru + Cancer pain + leukositosis rectum + post laparotomy adhesiolisis + (Fancopac 230 mg + Carboplatin 450
(10.900) perbaikan + Anemia (10.24) Histerektomi + repair ursus (H10) ai mg )Leukopenia (3300)
Perbaikan + Metastase Paru + Metastase os adenomiosis + kista coklat (D) + tba ovarial
Calvaria temporal kiri dan corpus VL 3 abses (S) + Post repair usus (H10) ai laserasi Diet biasa
seous usus + adhesi + anemi 911.4) Inf RL 20 tpm
Diet NB TKTP terkoreksi + hipoakbumin (2.4) dalam koreksi Pro kemoterapi ke 5 reg (Fancopac 230 mg +
IVFD RL: NS 1:1 2000 cc/24 jam ~ 30 tpm + imbalance elektrolit ( Na/K/Cl 147/3.4/114) Carboplatin 450 mg
Inj Ketorolac 3x30 mg terkoreksi Cek DR hari ini post inj leukogen hari ini
PO MST 2x1 tab
Pro Kemoterapi ke-1 (Reg. fancopac 230mg IVFD RL:D5 2000cc/ 24 jam
+ carboplatin 450mg) tgl 23-03-2023 Inj ceftriaxone 2x1 gr (H11) Tulip 2B : 14 pasien
Usul KRS Inj metronidazole 3x500mg (H11) Obstetri : 3 pasien
Inj VIT C 3x1 Gravid : 1 pasien
Inj metoclopramide 3x1 kp Gyn umum : 1 pasien
2. Ny. Dewi Yanti/40 th/00491419(DOPS Anti nyeri ~ TS anestesi Onkologi : 9 pasien
GOE) FU hasil PA
MRS : 21-02-2023 (HP2) FU kultur pus Anglam : 4 pasien
Alamat : Handil Basirih (Onkologi 3pasien, Gyn umum 1 pasien)
P2A2 ATK 20 thn TS IPD
Inj lansoprazle 2x30mg
PUA ec Leiomioma (Mioma Geburt) + SLE on
treatment + HT Kronis TS bedah digestive
Diet air putih 1-2 sdk/ jam
Pro Op Ekstirpasi Mioma Geburt + Kuretase IVFD RL:D5 2000cc/24 jam
PA, Hari INIMdgn operator dr. Ruth Widhiati Inj OMZ 2x1
R.P., Sp.O.G, Subsp.K.Fm INf metronidazole 3x500mg
Pasien diantar ke OK pkl 07.30 WITA (OK Inj ceftriaxone 2x1 gr
CITO)