MAPPING RUANG OBSTETRI (ARAFAH 3)

Kamis, 2 November 2017

No Room Name MedRec Diagnosis Laboratorium Treatment DPJP Laporan Bayi Planning KET
1

1A

2 1B

Lab 31/110/7
Hb/Ht/E/L/T
9,2/29/3,8/16,5/406
Kista endometriosis bilateral
MCV/MCH/MCHC/RDW
dengan permasalahan: - Inj. Ketorolac 1 amp/ 8 jam
75/24/32/15,7 - Obs. KU, TTV
3 2A Emilda, 37th 655653 - Nyeri VAS 4 - Drip tramadol 1 amp/ 12 jam HSD
Diftel: 1/0/0/76/17/6 - CA 125 (tunggu hasil)
- HbsAg positif - Inj. Ranitidin 1 amp/ 12 jam
HbsAg: Positif
- Leukositosis (16,5)
GDS: 100
Ur/Cr:18/0,61
NA/K/Cl: 15/3,8/108
4 2B
Ria Mardila, 26th 1148120 POD 2 post laparotomy Lab 31/10/2017 - Inj. Ceftriaxone 2gr/ 24jam DKR - Obs. TTV, KU
eksplorasi, fimbrektomi Hb/Ht/E/L/T - Ketorolac 1 amp/8 jam - Mobilisasi bertahap
sinistra, oforektomi sin, e.c 11,7/34/3,9/12,5/350 - Tramadol drip 1 amp/12jam - Aff FC 1x24 jam
KET Ct/bt : 7/2 - Transamin 1 amp/8jam - GV hari ke 3
5 3A
Hbsag: negatif - Ranitidin 1 amp/ 12 jam
Gds : 104 - Doksisiklin 2x 100mg
Na/K/Cl : 139/3,60/109/9,2

6 3B - -

Rika, 31th 1148630 P2A0 Post SC a/i KPD 12 Lab 1/11/17 - Inj. Ceftriaxone 2gr/ 24jam MZ BY LK, 2750 gr, A/S - Obs. KU, TTV
jam, oligohidramnion, PEB, Hb/Ht/E/L/T - Ketorolac 1 amp/ 8 jam 8/9 - Mobilisasi bertahap
7 4A belum inpartu, akseptor IUD 9,7/28/3,4/21,0/246 - Kaltopren supp II/ 8 jam - FC 1x24 jam
LED: 45 - Drip oksitosin 20 IU dalam - GV hari ke 3
Diftel: 0/0/0/88/7/5 500cc selama 12 jam - Diet TKTP
 Lab 31/10/2017 - Sohobion tab 1x1 - Cek Hb 2 jam post op,
CT/BT: 2/8 - MgSO4 40% maitenance jika Hb<8 g/Dl, TF S/D
HbsAg: Negatif 1gr/jm selama 24 jam Hb>10gr/dL
SGOT/SGPT: 17/5 - Adalat oros 1x30mg
GDS: 78
Ur/Cr: 10/0,42
Na/K/Cl: 135/3,9/112
Sengeda, 31th 1147012 G4P3 (AH2) hamil 35-36 Lab 1/11/2017 -MgSO4 40% 1gr/jam selama 24 CMY - Bed rest
mgg, JPKTH, KEB dengan Hb/Ht/E/L/T: 13,7/39/4,7/9,5/267 jam - Obs. TTV, KU, his, djj
janin hidrochepalus LED: 75 - adalat oros 1x30mg - Obs. tanda impending
Diftel: 1/0/0/73/21/5 - inj. Dexamethason 6mg/ 12jam eklamsia
PT/APTT: 9,1/33,2 selama 2 hari - Balance cairan tiap 3 jam
8 4B
SGOT/SGPT: 11/7 - Rencana SC elektif
Alb: 3,09
LDH: 176
Kolestrol total: 367
LDL/HDL/TGD: 83/220/451
As. Urat: 7,3
- Obs. KU, TTV,
- Inj. Ceftriaxone 2gr/ 24 jam kontraksi, perdarahan
- Inj. Metronidazole 500mg/ - Mobilisasi bertahap
Lab 1/11/2017
8jam - FC 1x 24 jam
Hb/Ht/E/L/T: 10,5/33/5,1/11,0/323
P2 Post SC a/i KPD, BSC 1x, - Inj. Ketorolac 30mg/ 8jam BY LK, 3600 gr, A/S - Cek Hb 2 jam post op,
Nova mutia, 24th 1148740 MCV/MCH/MCHC/RDW: YS
9 4C belum inpartu - Kaltopren supp 3x200mg 8/9 jika Hb < 10g/dL tf PRC
65/21/32/15,7
- Inj. Ranitidin 150mg/ sampai target Hb >
Diftel: 1/0/1/73/18/7
12jam 10g/dL
- Sohobion 1x360mg - Motivasi ASI ekslusif
- Diet MB
Lab 31/10/17
Hb/Ht/E/L/T
14,1/41/4,4/9,9/160
MCV/MCH/MCHC
- Inj. Ceftriaxon 2gr/24 jam
92/32/35
- Inj. Asam tranexamat 500mg/
Diftel: 1/1/0/73/16/9
8 jam
CT/BT: 2/7 - Obs. TTV, KU
- Ij. Ketorolac 3%/ 8 jam
G5 hamil 38-39 mgg, BSC 1x SGOT/SGPT: 40/31 - Mobilisasi bertaap
10 4D Erlina, 43th 1148536 - Kaltopren supp II/ 8 jam HSD BY PR, 2500gr, A/S 8/9
(IDT 11th) belum inpartu Albumin: 3,14 - Aff FC 1x24 jam
- Inj. Ranitidin 1amp/ 8 jam
GDS; 103 - Diet TKTP
- Drip oxitosin 1amp/ 8 jam ke
Ur/Cr: 20/0,81
dalam RL 500cc 20gtt/i
Na/K/Cl: 136/3,6/109
selama 24 jam
Lab 1/11/2017
Hb/Ht/E/L/T: 11,3/33/3,6/12,3/122
MCV/MCH: 91/31
 Diftel: 1/0/0/80/12/7

1148424 POD 2 P1 Post SC a/I KPD 20 Lab 31/10/2017 TPD By LK 3000gr A/S 8/9 - Obsttv, ku, perdarahan
11 5A Ewi Handriani 32 jam, low pelvic score, infertil Hb/ht/e/l/t : 11,1/34/4,7/14,5/268 (RI) - Mobilisasibertahap
th primer 5 bulan, akseptor IUD Diftel : 0/0/1/84/10/5 - Aff kateter
Lab 30/10/2017 - Cefadroxil 2x 500mg
Ct/bt : 7/2 - As.Mefenamat 3x500mg
Hbsag : negative - Sohobion 1x1
Gds : 103
Ur/cr : 15/0,38
Na/K/cl : 133/3,3/110
5B Nuriha, 25th 1148491 P1 Post partus spontas post Lab 31/10/2017 - Cefixime 2x100mg MZ BY PR, 3560 gr, A/S - Obs. KU, TTV
12 perinorafi a/i ruptru perineum Hb/Ht/E/L/T: 11,0/34/4,0/11,0/443 - Na. Diklofenac 3x50mg 8/9
grd 3 HbsAg: Negatif - Sohobion 1x1
Ur/Cr: 15/0,66 - Vit. C 2x1
Na/K/Cl: 136/3,9/109

- Inj ceftriaxone 2gr/ 24jam

POD 2 Post SC a/I P3A1, Lab 31/10/2017 - Kaltropensupp II/8jam
FauziahUsman, 36 KPD 14 jam, Hb/HT/E/L/T - Inj ketorolac 1amp/8jam By. Pr 2700gr, A/S 8/9 - Obs.ttv, ku
13 5C 1148456 DKR
th oligohidramnion (SDP 0,1) 12,6/36/4/19,8/216 - Sohobion1x1 (RI) - FC 1x24 jam
belum inpartu Difftel : 0/0/0/89/6/5 - Cefadroxil 2x1
- Na.diklofenac 3x1

- Obs ttv, ku, kontraksi,

31/10/2017
perdarahan
NH 4 post ekstraksi vacuum Hb/ht/e/l/t : 7,6/21/2,7/28,6/47
- Mobilisasi bertahap
diluar, dg riw solusio plasenta, MCV/MCH/MCHC/RDW
- Motivasi ASI
ibu dgn permasalahan PEB: :80/29/36/14.8 - IVFD Atering 14gtt/i
- Bed rest
- HELLP Syndrome Diftel : 0/0/0/82/11/7 - Inj. Meropenem 1gr/ 12jam
- Balance cairan
- Anemia d-dimer : 9781.11 - Kaltropen supp II/ 8jam
- Tf PRC 1 kolf/ hari
14 5D Yuslinar, 25 th 1148459 - Leukositosis HbsAg: Negatif - Inj. Dexametason 10mg/12 RZ
- Tf Albumin 1 fls/ hari
- Aki st 3 sgot/sgpt 452/249 jam->tapring off
- Diet MB 1700 kkal/
- Hipoalbumin albumin 2,64 - Inj. Furosemid 1amp/ 8jam
hari
- Hiponatremi gds 133 - Nifedipin 3x10mg
- Hindari obat-obatan
- Hipokalsemia ur/cr 136/5,33 - Curcuma 3x1
nefrotoksis
- Susp. GERD na/k/cl 114/5,6/110
- Konsul kulit & mata
Urinalisis protein: +2
- Foto thoraks
 6A Rasyidah, 26th 1148091 Lab 1/11/17
15 Hb/Ht/E/L/T: 9,8/29/3,7/24,7/390 - Inj. Ceftriaxone 2gr/ 24
MCV/MCH/MCHC/MPV: jam
POD 5 P1 Post SC a/i distosia
78/26/34/14,9 - Inj. Gentamicin 80mg/12
PK 1 aktif, riwayat ruptur
Diftel: 1/0/0/89/6/4 jam
uteri imminens, post Blynch.
Alb: 2,35 - Drip Metronidazole
Ibu dengan permasalahan: BY LK, 2800 gr, A/S
Ca/Mg: 7,5/1,8 500gr/ 8 jam CMY - Obs. KU, TTV
- Anemia 8/9
Na/K/Cl: 130/2,7/111 - Kaltopren supp/ 8 jam
- Leukositosis
- Drip parasetamol 1gr/ 8
- Hipoalbumin
Urinalisis jam
- Susp. PSMBB
Leukosit: Positif - Inj. Omeprazole/ 12 jam
Protein: +1 - Inbumin 2x1
Darah: positif
Maria Ulfa, 29 th 1129465 G4p3 hamil 34-35 mgg. Janin Lab 30-10-2017 - Adalatoros 2x30mg DKR Obs. KU, TTV
16 6B gemeli kepala-kepala, hidup Hb/ht/e/l/t : 9,2/30/4,1/11,6/201 - Kaltrofen sup 2x
keduanya, riwayat ancaman Hbsg negative - Cefadroksil 2x500mg
partus prematurus (ec. Flour Na/K/cl/ca : 133/3,3/107/8,3 - Uterogestan 2x1
albous susp. BV, post Gds 143 - Cygestovula 1x1 malamhari
pematangan paru 11 hari Ur/cr : 13/0,66 - SF 2x1

17 6C Rahma sri nanda, 1148505 P1 POD 2 post SC a/I KPD Lab 31/10/2017 - Ceftriakson 2 gr/24 jam YS By PR 2700gr A/S 8/9 - Obs TTV, KU,
27 thn 3 hari, infertil primer 2 thn Hb/Ht/e/l/t : 12,1/35/4,2/11,7/321 - Ketorolac 3% amp/8 jam (RI) - Mobilisasi
Gds : 99 - Omeprazole 40m/12 jam - Motivasi ASI
Ur/cr : 17/0.71 - Sohobion 1x1 - Diet TKTP
Na/k/cl : 137/3,8/110 - Fc 1x24 jam

6D Juariah, 37 th 1148580 P2A1 POD2 Post SC a/i Lab 1/11/2017 - Inj ceftriaxone 2gr/ 24jam SI BY LK, 3800 gr A/S 8/9 - Obs. KU, TTV
18 KPD 12 jam, Hb/ Ht/E/L/T - Kaltropen supp II/8jam - Motivasi ASI
Oligohidramnion, post 10,0/30/,9/15,3/243 - Inj ketorolac 1amp/8jam - Mobilisasi
laparotomi 11 bulan yang MCV/MCH/MCHC/RDW/MPV - Sohobion1x1 - FC 1x24 jam
lalu, infertilitas sekunder 9 79/26/33/18,6/10,6/12,3 - Vit C 1x1 - GV hari ke 3
tahun Diftel: 0/0/0/88/8/4 - SF 1x1 - Diet TKTP

Lab 31/10/2017
CT/BT: 3/8
HbsAg: Negatif
GDS: 89
Na/K/Cl: 134/4,0/106
 1148436 P1 POD 2 post SC a/I KPD Lab 31/10/2017 - Inj ceftriaxone 2gr/ 24jam TPD BY LK, 3100 A/S 8/9 - Mobilisasi bertahap
19 6E 22 jam, infertil primer 3 tahun Hb/ht/E/L/T : 13,4/40/4,5/18,3/283 - Drip metronidazole (RI) - Diet TKTP
Ruwaida, 31 tahun Diftel : 0/0/0/84/9/7 500mg/8jam - Fc 1x24 jam
Lab 30/10/17 - Inj. Tramadol 1amp/ 8jam
CT/BT: 3/8 dalam 500cc RL
HbsAg: Negatif - Omeprazole 40mg/12 jam
Ur/Cr:1/0,73
Na/K/Cl: 136/3,6/112
1147066 G2P0A1 hamil 37-38 mgg 31/10/2017 - Inj. Dexamethason 6mg/ - Obs TTV, KU,
20 6F Rita noviani 34 th jpkth susp.iugr, infertil primer Hb/ht/e/l/t : 11,6/34/3,6/10,6/312 12jam YS - Obs. tanda fetal distres
>7th, dm tipe 2, post PT/APTT : 8.9/31,9 - 5cc insulin lispro mulai 8
pengobatan tb d-dimer : 1853,55 unit (8-8-8 unit 10 AC)
GDS: 88 - As. Folat 800mcg/hari

lab 1/11/2017
Kolestrol total: 235
HDL/LDL/TGD: 59/140/212
Alb/ LDH: 2,77/392
As.Urat: 6,3
GDS: 339
7A 1148620 G1 hamil 17 mgg, JTHIU, Lab 1/11/2017 - Clindamisin tab 3x300mg CMY - Bed rest
21 abortus iminens, Hb/Ht/E/L/T: 10,2/32/4,8/15,6/175 - Flagistatin ovula 1x1 - Diet TKTP
oligohidramnion, flour albus MCV/MCH/MCHC/RDW: - Omeprazole 2x20mg - Rencana
Cut Lindawana, ec candidiasis 68/21/32/21,2 - Utrogestan 2x100mg amniofision
34th Diftel: 5/1/0/76/12/6 - As. Folat 1x400mg
HbsAg: Negatif
SGOT/SGPT: 133/99
GDS: 124
Ur/Cr: 16/0,61
Na/K/Cl: 137/3,8/108
7B
22

11477541 POD 2 post kuretase bertingkat Lab 31/10/17 - Cefadroxil 2x 500mg

7C a/i hiperplasia endometrium Hb/Ht/E/L/T - As.Mefenamat - Obs. KU, TTV,
Juita, 52 th 12,7/37/4,2/7,6/120 3x500mg Perdarahan
23 RDW/MPV: 21,2/11,3 - Sohobion 1x1 CMY - Mobilisasi bertahap
Diftel: 12/1/0/36/38/10 - Diet MB 2500 kkal
PT/APTT: 14,4/42,5 - Aff kateter
 Lab 1/11/2017 - Cefadroxil 2x 500mg BY PR, 3300 gr - Obs. KU, TTV,
Hb/Ht/E/L/T: 12,3/38/4,7/17,4/151 - Na. Diklofenak 2x50mg kontraksi,
MCH/MPV: 26/12,0 - Sohobion 2x1 YS perdarahan
Eva Walanda, 29th CT/BT: 2/8 - Motivasi KB
24 7D 1121504 P2P1 Post partus normal
HbsAg: Negatif - Motivasi ASI
GDS: 121
Ur/Cr: 15/ 0,49
Na/K/Cl: 133/3,7/108

25 7E

26
7F

-
27 ISO 1

28 ISO 2 -
 Jumlah Rekapitulasi Pasien DPJP

Dr.dr.Hasanuddin,Sp.OG(K) 2 2A, 4D
dr. Yusra Septivera, Sp.OG 4 4C, 6C, 6F, 7D
Dr.dr. Rajuddin, Sp.OG(K) - -
dr. Tgk. Puspa Dewi, Sp.OG 2 5A,6E
dr.
DPJPSarah Ika N, Sp.OG(K) 1 6D
dr. Niken Astri Utami, Sp.OG - -
dr. Cut MeurahYeni, Sp.OG 4 4B, 6A, 7A, 7C
dr. Munawar, Sp.OG - -
dr. Munizar.Sp.OG 2 4A, 5B
Dr.dr.Mohd.Andalas, Sp.OG - -
dr. Roziana, Sp.OG 1 5D
dr. Dewi Karlina R,Sp.OG 3 3A, 5C, 6B
Total Pasien 19