MAPPING RUANG GINEKOLOGI ARAFAH 2

Rabu , 03 Januari 2018

No Room Name MedRec Diagnosis Laboratorium Treatment DPJP Planning

1 1A

2 1B

3 2A Yulidar 0871110 Ca Ovarium, ibu dengan Lab (2-1-2018) HAS Perbaiki KU

Rosmita anemia makrositik Hb/Ht/E/L/T PRC sampai HB diatas 10
50th hipokrom dan 9,6/32/3,6/4,9/331 Persiapan kemoterapi siklus ke IV
hypokalemia Na/K/Cl
139/3,5/102
Ur/Cr/GDS
9/0,58/205
4 2B Ainun 0884438 Ca ovarium residif Lab (27-12-17): IVFD RL 20 gtt/i SIK Obs ttv,ku
Mardiah, metastasis pro Hb/Ht/E/T/L: IVFD NaCL 0,9% 20 gtt/i GP dgn aqucell /12 jam
50thn kemoterapi 10,1/28/3,8/499/10,7 Ij. Ceftriaxone 2 gr/24 jam Raber bedah digestive (+)
Hiponatremia (120) Ca/Mg/Ur/cr: Drip neurobion 1amp/24 jam
HR 6 Hipokalemia (3,5) 9,1/1,3/62/1,43 Paracetamol tab 3x1
Hipoalbumin (2,47) Na/K/cl: Omeprazol 2x1
110/4,1/77 Vit C 2x1
Antasida 3x1
Lab (30-12-17) Oxyneo 2x1
Ur/Cr : 32/0,92 SF 2x1
Na/K/Cl: 120/3,5/88 KSR 2x 600mg
Alprazolam 1x0,5 mg (mlm)
Lab (1-1-2018) Metronidazole 2x1
Alb/Glo : 2,46 / 2,12 Lubumin 2x1
Na/K/Cl : 126/2,5/103

Lab (2-1-2018)
Hb/Ht/E/L/T:
10,7/31/4,1/9,9/369
5 3A Safriati 0877537 G3P1A1, hamil 6-7 Lab (2-1-2018) CMY Cek DPL, B-HCG kuantitatif
37 th minggu, KE tuba kanan Hb/Ht/E/L/T Cek elektrolit,GDS, Ur/Cr (+)
HR 1 riwayat laparotomi 12,6/38/4,4/9,8/194 Konfirmasi USG
salphingotomi (s) a.i Ur/Cr/GDS
KET 17/0,53/175
Na/K/Cl
140/3,5/103
6 3B

7 4A

8 4B

9 4C

10 4D

11 5A

12 5B Anisah 0955120 G6P5A0 hamil 10-11 Lab (2-1-2018) Inj. Ceftriaxone 2gr/24 j RZ Foto thoraks
35 th minggu , perdarahan Ur/Cr/GDS Inj metronidazole 1 fls/8 j EKG
HR 1 pervaginam e.c dd/1. 11/0,53/88 B-HCG kuantitatif
Molahidatidosa Na/K/Cl
2. Missed Abortion 139/4,2/103
13 5C
14 5D Adawiyah 1008647 AUB e.c Hiperplasia Lab (12-12-2017) CMY Jadwal OKA elektif rabu untuk
45th Endometrium Hb/Ht/E/L/T kuretase
HR 2 12,5/37/4,2/6,5/365
G2PP/GDS/Hb-A1c
110/106/5,40
Ur/Cr
19/0,67
CT/BT
7’/2’
15 6A Mardawati 1144762 AUB e.c DD Lab (1-1-2018) IV. Transamin 500mg/8 j DW Jadwal OKA elektif kuretase rabu
35th Hiperplasia Hb/Ht/E/L/T Vit K 1amp/12 j
HR 2 Endometrium 11,7/35/4,6/11,2/315 Ranitidin 1amp/12 j
CT/BT
7’/2’

Lab (2-1-2018)
Ur/Cr
12/0,85
Na/K/Cl
139/3,7/107
16 6B Habsah 1155639 Molahidtidosa Lab (28-12-2017) MU Jadwal OKA elektif kuretase rabu
21 th Hb/Ht/E/L/T
HR 2 13,1/39/4,7/12,1/250
CT/BT
7’/2’
T3/T4/TSHs
3,75/16,24/2,088
Na/K/Cl/ GDS
142/4,5/103/97

17 6C Aman 1154720 AUB Malignancy susp. Lab 31/12/2017 Diet TKTP RZ Raber IPD ( div geriatri) (+)
Farisyah CA Endometrium dg Hb/HT/E/T/L IVFD clinimix 1 fls 1500 ml selang Rabu PBJ
HR 3 permasalahan low 11/ 32/4,2/236/12,5 seling dengan Clindeic/24 j
intake, geriatri problem Albumin : 3,52 IVFD NaCl 0,9 % 20 gtt/i
Ur/Cr: 23/0,47 IV. Cefepime 1gr/12 j
Na/K/Cl : 118/4,7/90 IV transamin 1 amp/8 j
Pt/Aptt : 10.8/41,5 IV Ketorolac 1 amp / 8 j
Gds : 99 IIV ranitidin 1 amp/12 j
18 6D Habibah 1155444 Cancer pain VAS 6-7 ec Lab 28/12/2017 IVFD clinimix 1 fls 1500 ml / 24 SIK - Diet MII
Reufin, Neoplasma ovarium Hb/HT/E/T/L jam 20 gtt/i -Ct Scan abdomen pelvik (5-1-18)
49 th kistik susp malignancy, 10,6/32/4,0/431/10,2 IVFD albumin selama 3 hari -FotoThorak (+)
(RMI=9999) Albumin : 2,50 Inj. Ceftriaxone 1gr/12 jam -konsul anetesi (+)’
HR 9 -Asites Globulin : 4,35 Inj. Ondansetron amp/8 jam -OP rabu batal
- Trombositosis Prot. Total : 6,93 Inj. Omeprazole vial/12 jam
- Anemia ec keganasan Ur/Cr: 84/0,85 Inj. Ranitidin amp/12 jam
- AKI akut on CKD Tramadol drip 3x1amp
- hipoalbumin Urinalisa Kaltrofen sup 3x1
- ISK asimptomatis Protein +2 Sucralfat Syr 3xCI
Glukosa +1 Codipront 2x1 tab
Curcuma 2x1
Lab (31-12-17)
Alb/glob : 3,03/3,71
Protein total : 6,74 Th/IPD
IVFD NaCL 0,9% 30gtt/i
Fentanil patch 12,5 mg
19 6E Nur Asiah 1088515 Ca Ovarium Lab (2-1-2018) HAS Perbaaiki KU
HR2 Hb/Ht/E/L/T Transfusi PRC > 10
9,3/30/3,7/4,0/132 Dillanjutkan kemoterapi siklus ke III
Na/K/Cl
141/3,4/108
Ur/Cr
21/0,61
20 6F Nurlaili 1155734 Kista Ovarium sinistra, Lab (28-12-2017) AND Rencana OKA elektif rabu, untuk
33th Infertile sekunder 8 th Hb/Ht/E/L/T Laparoscopi
HR 2 13,9/41/5,0/8,4/320
Ur/Cr/GDS
7/0,59/108
Na/K/Cl
127/3,9/118

Lab (29-12-2017)
CA 125
23,48

Lab (2-1-2018)
 Na/K/Cl
137/3,7/109

22 7A -

23 7B

24 7C
27 7D
28 7E

29 7F
30 ISO
2
 DPJP Rekapitulasi Pasien DPJP Bed

Dr. dr. Hasanuddin, Sp.OG(K) 2 2A, 6E

dr. Yusra Septivera, Sp.OG 0 -

Dr. dr. Rajuddin, Sp.OG(K) 0 -

dr. Tgk. Puspa Dewi, Sp.OG 0 -

dr. Sarah Ika N, Sp.OG(K) 2 2B, 6D

dr. Niken Astri Utami, Sp.OG 0 -

Dr. dr. Cut MeurahYeni, Sp.OG 2 3A, 5D

dr. Munawar, Sp.OG 0 -

dr. Munizar.Sp.OG 1 6B

Dr.dr.Mohd. Andalas, Sp.OG 1 6F

dr. Dewi Karlina, Sp.OG 1 6A

5B, 6C
dr. Roziana, Sp.OG 2

DR. Cut Rika sp OG 0 -

Total 11