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MAPPING RUANG OBSTETRI ARAFAH 2

Kamis, 14 November 2019

Dr. dr. Hasanuddin, Sp.OG(K) 2 3B, 6F KETERANGAN


Prof. Dr. dr. Mohd. Andalas, Sp.OG 1 5D HAMIL :5
Dr. dr. Rajuddin, Sp.OG(K) POST SC :5
dr. Tgk. Puspa Dewi, Sp.OG POST PV:1
dr. Sarah Ika Nainggolan, Sp.OG(K) 3 2B, 4A, 4B POST VAKUM :2
dr. Niken Asri Utami, Sp.OG ILO :0
Dr.dr. Cut Meurah Yeni, Sp.OG(K) POST HT: 1
POST MANUAL PLASENTA: 0
dr. Munawar, Sp.OG 1 5A
PASIEN GINEKOLOGI : 2
dr. Munizar, Sp.OG
dr. Roziana, Sp.OG
dr. Yusra Septivera, Sp.OG 5 4D, 5B, 5C, 6E, ISO 1
dr. Cut Rika Maharani, Sp.OG 2 3A, 6D
dr. Hilwah Nora, Sp.OG(K) 2 7B, 7F
dr.Ima Indirayani, Sp.OG
TOTAL 16

No Ruang Nama CM Diagnosis Terapi Penunjang Bayi DPJP Rencana


1 1A DPJP ANAK -
2 1B DPJP ANAK -
3 2A DPJP IPD
4 2B Maulidawati 1227138 NH3 P1A1 post vakum ekstraksi Cefixime 2x100 mg Lab 08/11/2019 Bayi laki- SIK - Obs KU,
Zainon, 22 thn a/i distosia PK II, post Asam mefenamat 3x500mg Hb/Ht/E/L/TL laki TTV,
Aceh Jaya perineoraphy a/i ruptur perneum Sohobion 2x360mg 12,7/39/4,9/11,8/292 BBL 3300 kontraksi,
grade II HBsAg: Non Reaktif gr perdarahan
GDs: 127 A/S 7/8 - PBJ
Ur/cr: 17/0,40
NA/K/Cl : 143/4,3/112
5 3A Depi Julita Sari, 31 1227242 POD 2 P2 post histerektomi, a/I Viccilin 1,5 gr/6 jam Lab 12/11/2019 CRM -Obs KU, TTV,
thn, Aceh Besar KPD, BSC 1x Ketorolac 1 amp/8 jam Hb/Ht/E/L/T: kontraksi, DJJ
11,4/33/3,8/18,4/340 -terapi sesuai
FDO

Lab 11/11/2019
Hb/Ht/E/L/T:
11,4/33/3,8/14,9/355
Prot keton negatif

6 3B Siti machfiratul 1227451 G1 hamil 29-30 minggu, JTHIU Adalat oros 30mg/12jam Lab 12/11/2019 HSD - Obs. Ku,
zahwa, 23thn, Banda KPD 3 hari (ICA 9), belum Uterogestan 100mg/12jam Hb/Ht/E/L/T: TTV, HIS,
Aceh inpartu ibu dengan flour albus ec Kaltropen 200mg (k/p) 11,1/32/3,6/11,0/255 DJJ
susp. BV post pematangan paru Nifedipin 20mg (k/p) Ct/bt: 7/2 - Terapi sesuai
16 jam Cefixim 100mg/12jam HBsAg: Non Reaktif FDO
Vitamin C: 1000mg/24jam GDS: 72 - Titrasi
Ur/Cr: 18/0,30 nifedipin 10
Na/K/Cl: 141/3,6/109 tiap 20menit
(max 4x
Urinalisa pemberian)
Warna: kuning - Kaltropen
Kejerniham: keruh 200mg sup
Berat jenis: 1,013 extra
pH: 7
Lekosit: positif
Pro/glu/ket/ nit/uro/bil/dar:
negative

Sedimen urine
Leukosit: 6-8
Eritrosit: 1-2
Eoitel:3-5

Imunoserologi
CRP: negatif

7 4A Yeni Fitriani,37th, 1226306 POD 3 P2A0 post SC ai KPD 6 Cefixime 100mg/12jam Lab 12/11/2019 Bayi laki- SIK -Obs KU, TTV,
Sabanng jam (ICA 5,3) BSC 1x Belum Omeprazole 20mg/12jam Hb/Ht/E/L/TL laki kontraksi,
inpartu As. Mefenamat 500mg/8jam 10,8/31/3,4/12,2/228 BBL 3200 perdarahan
Sohobion 260mg/24jam gr -terapi sesuai
Lab 11/11/2019 A/S 8/9 FDO
Hb/Ht/E/L/TL - Mobilisasi
11,3/32/3,6/15/243 bertahap
HBsAg: Non Reaktif
GDs: 82
Ur/cr: 11/0,30
NA/K/Cl : 142/3,9/111
8 4B Rosalina, 35 th, 1227253 G4p3 hamil 31-32 minggu, Metronidazole 500 mg/8 jam Lab 12/11/2019 SIK -Obs KU, TTV
Simeuleu JPKTH, riwayat ancaman partus Ceftriaxone 2 gr/24 jam TPHA: positif -terapi sesuai
prematurus (ST 3) bebas Kaltropen 2 supp/8 jam FDO
kontraksi 1 hari, post pematangan Lab 11/11/2019
paru 7 jam ibu dengan: Hb/Ht/E/T/L
-hepatosplenomegali ec susp. 9,8/28/3,3/763/237,3
Keganasan MDT: Anemia HM,
- hepatomegaly ec susp. Viral leukositosis, trombositosis
infection ec reaksi leukomoid
-Leukositosis (237) VDRL: non reaktif
-Sifilis lesi aktif (TPHA positif) ALP: 128
TPHA: positif
HBsAg: Non Reaktif
CT/BT:7/3
Bil tot: 0,30
Bil.dir/indirect:0,09/0,21
SGOT/SGPT: 19/15
GDs: 57
Ur/cr: 16/0,40
NA/K/Cl : 142/4,0/110
9 4C DPJP BEDAH
10 4D Nuraini Binti M. 0959390 POD 1 post sc a/I janin letak Oksitosin 20ui Lab 12/11/2019 Bayi laki – YS - Obs.
daud, 35thn, aceh lintang, inpartu, janin dengan Ceftriaxone (skintest) Hb/Ht/E/L/T: laki BBL: Hemodinami
Besar Ketorolac amp/8jam 11,3/34/4,2/10,7/215 1400gr, k
Kaltropen sup II/8ajm Ct/Bt: 8/3 A/S: 6/7 - Terapi sesuai
As. Traneksamat 500mg/8jam HBsAg: Non Reaktif FDO
Omeprazole 40mg/12jam GDS: 84
Ur/Cr: 8/0,40
Na/K/Cl: 143/3,0//112
11 5A Erlina sari, 26 thn, 1115114 G1 hamil 24-25 minggu JTHIU Antasida 3x CII Lab 11/11/2019 MN -Obs. KU, TTV,
Aceh Pidie ibu dengan Sohobion /12 jam Hb/Ht/E/L/TL DJJ
- HEpEF As. Folat /12 jam 9,6/29/3,3/14,8/373 -Terapi sesuai
- efusi pericard Drip Paracetamol 1 gr/8 jam Malaria negative FDO
- hipokalemia Lactulac 3x1 Anti HCV negative
- ISK Ambroxol 3x1 S.paratyphi AH 1/160
Viccilin 1,5gr/8ajm S. Paratyphi CH 1/80

08-11-2019
Albumin : 2,70
Ca/Mg : 7,3/1,7
Na/K/Cl : 141/3,4/103

08-11-2019 (echo)
Kesimpulan :
Global LV fungsi baik, EF
75% Global Normokinetik,
Pericard effusi di posterior
minimal, RV fungsi baik

07-11-2019
Hb/Ht/E/L/T
10,4/29/3,3/7,7/235
Ct/Bt : 8/2
HbsAg: non reaktif
GDS : 112
Ur/Cr : 11/0,60
Na/K/Cl : 137/3,2/107
12 5B Maina Maulidar, 1227528 POD 1 P3A0 post sc a/I BSC 3x, Oksitosin 20ui Lab 12/11/2019 bayi YS - OBS. KU,
34 thn Aceh Besar post B-lynch a/I hipotoania post Ceftriaxone 2gr/24jam Hb/Ht/E/L/T: TTV,
tubektomi Ketorolac amp/8jam 11,2/31/3,6/166 - Terapi sesuai
Kaltropen II/8jam sup Ct/bt: 8/3 FDO
As. traneksamat HBsAg: Non reaktif - Susul hasil
1000mg/8jam SGOT/SGPT: 14/8 lab post op
GDS: 92
Omeprazole 40mg/12jam
Ur/Cr: 12/0,50
Na/K/Cl: 142/3,4/110

Pro/ket: negative
13 5C Hariani Cikani, 27 1227458 NF1 P1 post ekstraksi vakum ai Cefadroxil 2x500 mg 12-11-2019 Bayi YS Obs KU, TTV
tahun, Aceh jaya distosia PK II post perineuraphy Metronidazole 3x500mg Hb/Ht/E/L/T perempuan Terapi sesuai
a/I rupture perineum grade Na.diklofenak 3x50 mg 10,2/31/3,9/16,6/280 BBL FDO
Sohobion 2x360 mg Ct/Bt : 7/2 2900gram
HBsAg : Non Reaktif A/S 8/9
GDS : 69
Ur/Cr : 11/0,40
Na/K/Cl : 139/4,2/108

14 5D Novi Safitri, 27 th, 1220931 POD 5 P2A0 post Sc ai Noncort 4xgtt1 12-11-2019 Bayi laki- MA - Obs Vital
Banda Aceh impending eklampsia , akseptor Adalat oros 30mg/24jam Hb/Ht/E/L/T laki BBL sign,
IUD, ibu dengan : Metildopa250mg/12jam 9,2/26/3,4/11,1/357 2200gram perdarahan,
- hipoalbumin Albumin/24jam A/S 8/9 KGD
-diabetes gestasional Cefixime 100mg/12jam Lab (11/11/2019) - Mobilisasi
-hipokalsemia ringan (8,4) Omeprazole 20mg/12jam Protein total 3,76 bertahap
-retinopati hipertensi grade 4 Albumin 1,98 - Cek KGDP
-edema Globulin 1,78 - Balance
LDH 342 cairan
Ca/Mg : 8,4/1,8 - TW
Na/K/Cl : 136/3,7/110

15 6A DPJP ANAK
16 6B DPJP IPD
17 6C DPJP ANAK
18 6D Irma Firman, 1227227 G1 hamil 28-29 minggu JTHIU Metildopa 3x500mg Lab 12/11/2019 CRK - Obs. DJJ,
30thn, Aceh Barat ibu dengan sukrlfat 3x1 Hb/HT/E/L/T: tanda
Daya - PEB Nifedipin 3x10mg 16,0/47/6,1/12,6/233 perburukan
- Hipoalbumin Albumin fls/24jam PEB
- Hipermagnesium Urinalisa - Ba;ance
- ISK Warna: kuning cairan
Kejernihan: keruh
pH: 6,5
le: +
protein: (+3)
glu/ket/nit/uro/bil:
negative
darah: postif
sedimen urine:
leu: 100-140
eitrosit 6-8
epitel: 3-5

hyaline cast: positif


bakteri: positif
19 6E Humaira Razali 1227675 P3 post partus spontan Sohobion 2x360mg Lab 13/11/2019 YS - Obs. Ku,
Djhohan, 29thn, Na. diklofenat 3x50mg Hb/Ht/E/L/T: TTV,
banda aceh Cefadroxil 2x500mg 12,2/36/4,7/17,0/199 perdarahan
Oxytosin 2oiu /8jam Ct/bt: 7/2
HBsAg: Non Reaktif
GDS: 128
Ur/Cr: 9/0,40
Na/K/Cl: 141/3,5/109
20 6F Ida Rosma, 50 thn, 1094305 Ca ovarium residif, anemia post Lab 13/11/2019 HSD - Pro
Aceh Barat kemoterapi siklus 2 Hb/Ht/E/L/T: kemoterapi
10,3/32/3,9/6,6/303 siklus 3
setelah
Lab 11-11-2019 perbaikan
Hb/Ht/E/L/T KU
9,5/29/3,5/7,4/321 - Transfusi
Ct/Bt : 8/2 PRC 2 kolf
HBsAg : Non Reaktif
GDS : 117
SGOT/SGPT: 23/21
ALB: 3,80
Ur/Cr : 20/0,70
Na/K/Cl : 142/4,8/106

21 7A DPJP ANAK
22 7B Yusni Budiman, 1116127 POD 1 P3post sc a/I KPD 12jam Transamin 500mg/8jam Lab 13/11/2019 Bayi laki- HN - Obs. KU,
38thn, Aceh Besar (ICA3) PEB belum inpartu. BSC Ceftriaxone 2gr/24jam HB/Ht/E/L/T: laki BBL: TTV,
1x (IDT 2 thn), akseptop Ketorolac 30mg/8jam 14,0/38/4,6/11.1/314 300gr, perdarahan
tubektomi Omeprazole /12jam Ct/bt: 7/2 A/S: 8/9 - Mobilisasi
Kaltropen supp II/8jam HbaAg: Non Reaktif bertahap
Paracetamol 1000mg/8jam SGOT/SGPT: 14/10
Vitamin K amp/24jam Alb: 3,70
GDS: 107
Ur/Cr: 11.0/50
Na/K/Cl: 142/3,3/110

Urinalisa
Pro: (+1)
Keton: negatif
23 7C DPJP BEDAH
24 7D DPJP BEDAH
25 7E DPJP ANAK
26 7F Misrawani Jufri, 1227305 POD 2 Post laparotomi Cefixime 100mg/12jam Lab 13/11/2019 HN -Cek DR post op
35 thn, A.Besar salfingektomi ai KET As. Traneksamat 500mg/8jam Hb/Ht/E/L/T: 2 jam
Omeprazole 20mg/12jam 9,9/29/3,5/11,5/251 -Mobilisasi
Sf/12jam bertahap
12-11-2019
Hb/Ht/E/L/T
8,7/25/3,0/12,1/273

27 ISO 1 Suryanti 1226677 G7P6 hamil 23-24 minggu, Aspilet 1x1 tab Lab 13/11/2019 YS -Obs. KU, TTV,
Baharuddin, 36 JTHIU, BSC 1 x (IDT 4 tahun), Methyl prednisolone 2x4mg Hb/Ht/E/L/T: His, DJJ
thn, ibu dengan poliartritis ec dd. Ostriol 1x0,25mg 9,5/30/3,8/17,8/498 -Terapi sesuai
Aceh Pidie 1. Susp. SLE Lenal ace 2x1 tab FDO
2. Pneumonia CAP Asam folat 1x400mg Lab 11-11-2019 -ECHO (+)
3. Anemia Ambroxol 3x1 tab Urinalisis - ANA test
4. Leukositosis Salep kulit 2x1ue Protein : +1 terlampir
5. Dermatitis ec lichen simplex Keton : positif -USG poli
kronis kutaneus Darah : positif 12/11/19
erithematosus Leukosit : 8-10
Eritrosit 4-6
Epitel 3-5
Bakteri : positif

08-11-2019
Hb/Ht/E/L/T
8,5/ 26/ 3,3/16.3/322

Lab 06-11-2019
LED/Retikulosit : 109/0,6
ASTO: 400
RF : Negatif
Widal :
S.Paratyphi AH 1/320
S.Paratyphi CH : 1/80

05-11-2019
Hb/Ht/E/L/T
9,4/29/3,6/15,6/222
Ct/Bt : 7/3
Gds : 142
HbsAg: non reaktif
Ur/Cr : 12/0,30
Na/K/Cl : 133/3,9/105
IgG/IgM anti dengue:
(+)/(-)
28 ISO 2 DPJP ANAK -

Pasien Obstetri di Arafah 3 (14/11/2019)

1 ISO1 Ny. Nurmalina 1227304 G4P2A1 hamil 13-14 Uterogestan 2x1 Lab 12/11/2019 SIK - Obs KU TTV
Mahmud, 35 th, minggu, JTHIU abortus As folat 1x1 Alb: 2,70 - Cek GDS
G4P2A1, Aceh iminens dengna Metronidazol 500mg 2x1 - GV rawat luka 2
Besar permasalahan gangrene Levemir 0-0-0-14 IU Lab 11/11/2019 x/hari
diabetikum, DM tipe II Novorapid 8-8-8 Hb/Ht/E/L/T: - Cek albumin
8,5/25/3,0/23,5/460 - Diet DM 1900
HbsAg non reaktif kkal
CT/BT 7/2
SGOT/SGPT 17/16
GDS: 300
Ur/Cr: 14/0,30
Na/K/Cl: 134/5,3/100