MAPPING RUANG GINEKOLOGI ARAFAH 2

SABTU,13 Januari 2018

No Room Name MedRec Diagnosis Laboratorium Treatment DPJP Planning

1 1A
anak

2 1B Azizah, 44 th, 1157082 Mioma uteri dengan Lab (12/1/18) - HSD Transfuse PRC s/d Hb>10
permasalahan anemia Hb/ht/E/L/T gr/dl
H3 mikrositik hipokrom 9,4/32/4,6/14,1/421

3 2A

4 2B Zuhrawati , 54 1155561 POD 1 post total vaginal Lab (/1/2018) HSD FC 1x 24 jam
th histerektomi+ Hb/ht/E/L/T Inj cefriaxone 2gr/24 jam Mobilisasi bertahap
kolpooernoraphy ai 12,4/36/3,9/6,7/330 Inj ketorolac 3% 1 amp/8 jam
Prolaps uteri grade 3+ CT/BT Inj omeprazole 40 mg/12 jam
rectokel grade 2 2/8
SGOT/SGPT
23/14
Na/K/Cl
140/3,7/107
Ur/Cr/KGDN/PP
24/0,78/ 106/135
5 3A Sairah, 64th, 1156221 POD 3 post laparotomi Lab (10-1-2018) -ketorolac 1 amp/ 8j HSD Obs TTV
debulking tumor ai NOK Hb/ht/E/L/T -sohobion 2x1
degan permasalahan 10,9/33/4,1/18,5/726 -omeprazole 40mg/ 12 j
H4 1. Hipoalbumin Na/K/Cl -inbumin tb 2x1
2. Leukositosis 132/4,3/105
3. anemia Ur/Cr/
33/0,40/
6 3B Mailiati, 49th 0876282 Ca ovarium residif siklus Lab (9-1-2018) HSD Koreksi hipoalbumin
ke III seri ke II dengan Hb/ht/E/L/T
permasalahan hipoalbumin 12,9/37/5,0/12,4/287
Ca 125 ; 3520,17
SGOT/SGPT
28/15
Na/K/Cl
128/2,2/86
Ur/Cr/
20/0,47
Lab ( 12-1-18)
Alb : 3,29
7 4A
8 4B

9 4C Ernawati, 45 0614627 POD 2 Post Abd Lab (11/1/18) Inj.ceftriaxon 2 gr/24 jam RZ Obs TTV
th, histerektomi bilateral Hb/ht/E/L/T ketorolac 1 amp/ 8j
salpingektomi + adesiolisis 9,8/32/4,8/15,9/402 as traneksmat 1 amp/ 8 j (KP)
H4 ai Miomautteri kaltropen supp 3 x200mg
amlodipin 1 x 10mg
Dulculax supp extra
Lansoprazole tab 1x1
10 4D

11 5A

12 5B anak

13 5C saraf

14 5D saraf
15 6A Habibah 115544 POD 5 Post Op Laparotomi Lab (08/01/2018) Ivfd clinimix 20gtt/i Inj. HSD -obs KU, TTV, Perdarahan
Reuvin Eksplorasi + adhesiolisis + Hb/Ht/E/T/L Ceftriaxone 2 gr/24 jam - konsul nuerologi
49 thn P1A1 biopsy massa tumor, 9,7/31/3,7/192/10,7 Inj. Ketorolac 3% 1 amp/8
adhesive intestinal PT/APTT 11,0/36,7 jam
POD 5 peritoneum dengan D-dimer : 2101,34 Inj. Ranitidin 1 amp/12 jam
permasalahan Sgot/Sgpt 83/27 Inj. Ondansetron 1 amp/8
 1. hipoalbumin Ca/Mg 8,3/1,6 jam
Ur/Cr 44/0,66 Octalbin 20% 1 fls / hari
Na/K/Cl 132/4,1/102 Codein tab 3x1
Alb : 2,68
16 6B Hamamah 1155805 POD 3 Post kolporafi Lab post op : Cefixim 2x100 mg MW Obs KU,TTV
57 th anterior + kolpoperineorafi Lab (29/12/2017) Ketorolac 3x1 tab
ai. Sistokel grade 4, Hb/Ht/E/L/T Sf 2x1 tab
POD 3 Rektokel grade 3 12,2/37/4,8/8,3/401 Neurodex 2x1 tab
GDS 129
Ca 125 : <4,0
Sgot/sgpt : 24/19
Ur/Cr 25/0,70
Na/K/Cl 141/3,5/109
17 6C Anisah, 45 1157498 Mioma uteri multiple Lab (11/1/2018) MZ Transfusi PRC sampai HB >
tahun dengan anemia mikrositik Hb/Ht/E/L/T 10gr/dl
hipokrom ec peny kronik 6,5/25/3,9/3,9/329
Alb : 4,14
PT/APTT: 9,9/41,6
Na/K/Cl ; 140/3,7/108
Hba1C 4,30

18 6D Asnidar,15 1154752 POD 3 post laparotomi Lab (10-1-18) Cefriaxon 2gr/24 jam SIK Observasi TTV, KU
tahun debulking tumor ai Hb/ht/e/l/t Ketorolac amp/8 jam
neoplasma ovarium kisti 13,1/41/6,5/15,9/451 Ranitidin 1 amp/12 jam
desktra susp maligna HbsAg (-) Ondamsemtrom 1 amp/ 8 jam
Na/K/Cl :129/451/111 Vit C 2x1
Neurobion 2x1
Flumycil 2x1 tab
19 6E
20 6F Mariana, 60 1035367 POD 1 post laparotomi Lab (12-1-2018) Inj cefriaxone 2gr/24 jam SIK FC 1x 24 jam
th komplit surgical staging , hb/ht/e/l/t Inj ketorolac 1 amp/8jam Evaluasi drain jika produksi <
histerektomi total+ bilateral 11/34/4,5/16,7/269 Inj omeprazole 40 mg/12 jam 50 cc aff drain
pelvic limpadenotomi ai Ca Inj transamin 500mg/8 jam Mobilisasi bertahap
endometrium Lab (5-1-2018)
hb/ht/e/l/t
12,0/37/4,8/305/8,1
Na/k/cl
139/3,8/103
Ur/cr/gds
19/0,76/139
Alb 4,29
Ct/bt
2/7

22 7A Nurjanah, 67 1157599 NOK kiri susp malignancy Lab (11-1-2018) - Sf tab 2x1 SIK Perbaikan KU
th dgn metastase ke kulit + hb/ht/e/l/t Tranfusi PRC sd HB >10gr/dl
anemia 9,3/ 26/ 3,4/ 12,1/216
Na/k/cl
128/ 3,7/104
Ur/cr/gds
48/1,79/ 233

23 7B

24 7C Anak

27 7D Roslina, 56 th 1156360 POD 2 Post Lab (11/1/18) Inj.ceftriaxon 2 gr/24 jam RZ Obs KU, TTV
H3 salpingooverktomi sinistra Hb/ht/E/L/T Inj. omeprazole 1 amp/12 jam
kistektomi dextra 12/37/5/14,2/297 As traneksamat 1 amp / 8j
adesiolisis ai Kista Vit k 1 amp / 24 j
Endometriosis bilateral Ranitidin 1 amp / 12 j
perlengketan Kaltropen supp 3 x 200
Neurobion 2 x 1
Vit c 2x1
28 7E Cut ajaniar, 0791345 POD 2 post laporotomy Lab (11-1-2018) Inj.ceftriaxon 2 gr/24 jam HSD Obs ttv, nyeri dan perdarahan
45 th, P4 debulking tumor ai NOK Hb/ht/E/L/T Inj. Ketorolac 1 amp/8 jam
(AH1) susp. Malignancy 10,7/32/3,6/7,0/285 Sohobion 3x1

29 7F

30 ISO 2 -
 DPJP Kode Rekapitulasi Pasien DPJP Bed

Dr. dr. Hasanuddin, Sp.OG(K) HSD 7 1B, 2B, 3A, 3B, 6A, 7E

dr. Yusra Septivera, Sp.OG

Dr. dr. Rajuddin, Sp.OG(K)
dr. Tgk. Puspa Dewi, Sp.OG
dr. Sarah Ika N, Sp.OG(K) SIK 3 6D,6F, 7A

dr. Niken Astri Utami, Sp.OG

Dr. dr. Cut MeurahYeni, Sp.OG CMY

dr. Munawar, Sp.OG MW 3 6B

dr. Munizar.Sp.OG 6C

Dr.dr.Mohd. Andalas, Sp.OG

dr. Dewi Karlina, Sp.OG
dr. Roziana, Sp.OG RZ 3 4C,7D

DR. Cut Rika sp OG

Total 13