Mapping R5B

Bed 1.1/ Bed 1.2 / Bed 1.3

Bed 1.6 / machnunah / dr. EWA Bed 1.5/Marinah/59th/ dr EWA/ 18-12-19 Bed 1.4/ Karmini/67 tahun/23-12-19/dr EWA

A/ P4A1 60th A/ P5A0 59th A/

Susp Ca ovarii dd/ Ca endometrium Susp Ca ovari dd/ peritoneal carcinomatosis P5A0 67 th
Abd pain Susp ca ovarii.
P/ pro kuretase bertingkat Metastasis malignant epitelial tumor Ascites
Diaiapkan jam 11. Ascites Efusi pleura duplex
Azotemia (Ur/Cr : 88/1.4) Pasca pungsi efusi pleura kanan.
Lab(1/1/20) Hipoalbuminemia ( 2.6)
Hb/L/Tr : 11.8/6.9/331 Hipokalemia (3.1) P/
Ur/Cr : 21/0.8 Pap smear
Na/K/Cl : 140/3.8/104 P/ pro BSO + FS (3/1/20) USG gin bila memungkinkan
GDS/OT/PT : 149/24/18 Izin MSCT scan dan echo bila mungkin
Konsul TS anes
Konsul TS bedah digest TS interna
Inf RL 10tpm Levofloxacim 500 mg/24 jam
O2 3lpm Ranitidin 50g/12jam
Inj Ketorolac 30mg/12jam N asetil sistein 200 gr/8 jam
Inj omz 1amp/12jam Inj furosemid 200 gr/12 jam
Inj metoklopramid 10mg/8jam
Po : cesr 600mg/8jam TS cardio
Sucralfat /8jam Echo
Digoxin 1x 0.25 gr
Konsul TS gizi Spironolakton 1x100 mg
Konsul ts rehab medik u breathing exercise
Cek DR Lab 22/12/19
Konsul Ts ICU Hb 11,3
Ht 35,7
Lab (1/1/20) L 6,9

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Hb/L/Tr : 12.8/7.8/388 Tr 696.000

Alb 2.6 Gds 92
Sgot sgpt 28 20
Lab (31/12/19) Alb 3,5
OT/PT : 44/17 Ur/cr 34/0,8
Ur/Cr : 88/1.4 Na/K/Cl 144/3,7/100
Na/K/Cl : 139/3.1/91
Bed 2.2 / Sukinah/58th/dr Endy/ 15-12-19 Bed 2.3/ pasien bedah
Bed 2.1 Sri Riyati/47th/drEWA/
30/12/19/Andhika
S/lemas berkurang
O/TD 140/80
A/ P3A1 47 th
A/ P3A0 58th
Adeno ca cervix uteri IIB
Susp Ca cervix uteri std IIIB
PRL (4/2018)
Azotemia (Ur/Cr : 43/1.5)
Remisi (12/2018)
Moderate HN + HU duplex
Residif (2/2019)
Ascites gr II
Pasca paxus carbo adj III 29/4/19
CKD stg 4 on HD
Pasca ER tambahan 20x 7/11/19
Pasca nefrostomi sinistra + sistoskopi (27/12/19)
Pasca AL I 12/12/19
P/ perbaikan KU
Pasca trf PRC 2 kolf saat HD
Daftar masalah
Inf NaCl 0,9% 20tpm
Ca cervix IIB pro AL II Acc dpjp
Inj Ranitidin 50mg/12jam
Inj Metoclopramide 10mg/8 jam
P/
Po : CaCO3 500mg/8jam
Pro AL II acc dpjp
As folat 1mg/24jam
Izin tindakan
Amlodipin 5mg/24jam
Konsul ts radioterapi
Biopsi diambil seminggu yang lalu
Tunggu jawaban
Pengawasan kU, TV, ppv
TS interna HD senin kamis
Rencana sinar tambahan 3x
Biopsi cervix —> tunggu hasil
Lab 23/12/19
Hb 11,9
Lab (31/12)
Ht 35,5
Hb/L/Tr : 10.8/14.4/179
L 5,1
Ur/Cr : 43/1.5

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Na/K/Cl : 139/3.0/100
Tr 218.000
Gds 142
Sgot 17
Sgpt 29
Ur/Cr 25/0,6
Na 136
K 3,1
Cl 99
Waktu prothrombin 13,4
Ppt kontrol 16,1
Waktu thromboplastin 31
Aptt kontrol 30,9
Bed 2.6 Suyatmi/ 44 th/Dr.Edi w/ 10/12/2019 Bed 2.4 pasien lain
Bed 2.5 pasien lain

A/ P2A0 44tahun
Ca cervix uteri std III B
Pasca platosin 3 weekly I (31/12/19)
HIV on treatment
Moderate HN + HU sinistra
Hipoalbumin (1.7)
Anemia ringan (9.9)

P/ pro ER I (8/1/20)
Inf RL 20tpm
Pasca transfusi 5 PRC
Ts interna
FDC ARV 1tab/24jam
Ts urologi
Pasang DC menetap 3 bln (27/3/20)
Usul tunda rawat jalan
Transfusi PRC 1 kolf premed dexa
Usaha albumin 20% 100 cc

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Lab (31/12/19)
Hb/L/Tr : 9.9/15.1/353
Alb : 1.7
Ur/Cr : 26/1.4
GDS/OT/PT : 83/41/32
Na/K/Cl : 135/2.8/102

Bed 3.1/ Nursiah/51th/dr. EWA/ 27-12-19 Bed 3.2 Bed 3.3/Supriyati/33th/31/12/2019/dr Lubena

A/
P0A0 51 th A/
Ca endometrii std 3A klinis P2A0, 32 tahun
Kista ovarii Non keratinizing squamous cell ca servix uteri
Obs dispneu perbaikan Anemia sedang (6.4)
Abdominal Pain P/
Retensio urin Usaha transfusi PRC 4 kolf
Trombositosis (516000) Inf RL 20 tpm
Hipoglikemi (51) Inj ca Glukonas paska 4 PRC
Hipokalemi (2.9) X foto thorax (-).
Hipoklorida (91) USG abdomen (-).
Azotemia (CCT 23) Pengawasan ku, TTV, PPV
Moderate HN + HU sinistra
Ascites Lab (31/12/19)
Efusi pleura duplex Hb/L/Tr : 6.4/17.1/389
Pernah kuretase di rs ken saras 2 bln lalu Ur/Cr : 17/1.1
OT/PT : 18/20
P/ Ur/Cr : 17/1.1
Perbaikan KU Na/K/Cl : 144/3.8/113
O2 3 LPM
Inf NaCl 20 tpm
Inj ketorolac 30 mg/8jam
Inj ranitidin 2 amp/12 jam
Verifikasi CT simulator 7/1/20
Konsul TS urologi
Diet biasa.

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Lab 27/12/19
Hb/Er/Tr/Leu : 10.5/3.61/10.8/516
Sisanya terlampir diatas
Ca 125 (>600.000)

bed 3.6/pulang 3.5 pasien lain Bed 3.4/ Purjiyem/32th/ dr. Endy / 26-12-19

A/P1A0 32th
AUB
Trombositopeni (109.000)
HIV on treatment

P/ pro kuretase bertingkat

Inf NaCl 20tpm
Inj Kalnex 500mg/8jam
Prednison 2 tab/8jam
As folat 1tab/24jam
Usul TC 2 kolf
Raber TS interna
FDC ARV/24 jam
Pengawasan KU, TTV,PPV

Lab(30/12/18)
CD4 368

29/12
Hb/L/Tr : 8,4/4.3/167

31/12/19
Hb/L/Tr : 11,2 / 5,2 / 109

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Bed 4.1/ Wastum/ 47th/ dr. EWA/ 4.2/ Bed 4.3/

27-12-19/Andhika

A/
P6A0 46 tahun
Epidermoid ca cervix uteri std IIA2
Paska NAC (19/11/19)
HT std I
DM tipe II
Leukositosis (15.800)
Hiponatremi (130)

P/
Perbaikan KU
Pro NAC 2 setelah perbaikan KU
Po
NaCl cap 500 cc/8 jam
Amlodipin 10 mg/24 jam

lab (30/12/19)
Hb 9.2
Eritrosis 3.53
Leukosit 17.8
Trombosit 349

Lab (28/12/20)
Ur/Cr : 75/2
Na : 125

Lab (1/1/20)
Hb/L/Tr : 10.2/15.8/354
Ur/Cr : 30/1.1
Na/K/Cl : 130/3.5/99

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Bed 4.6 / Bed 4.5 Bed 4.4

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5.1/ Bed 5.2/ Suriyati/ 59 th /Dr.MZ/ 27/12/19 Bed 5.3/

A/
P3A0 59 th
Ca cervix uteri std IIIB
PRL 10/9/19
Proktitis radiasi
Susp fistula rectovagina
Efusi pleura kanan
Susp metastasis pulmo
Ascites
DVT

P/
Perbaikan ku
Inf Nacl 20tpm
O2 3lpm nc
Dunogesic patch/3hari
Po : sukralfat 3x1

TS interna sub gastronomi

Po lansoprazol 1tab/12jam

TS pulmo
Pro pungsi guide USG bila dpt duduk

TS bedah
Pro kolon in loop →tunggu

Pengawasan KU TTV PPV

Lab29/12/19
Hb/L/Tr: 11.6/5.6/368

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Thorax 11/12 Efusi pleura kanan
Abd 6/12 Ascites

Bed 5.6/ Bed 5.5/ Bed 5.4

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Bed 6.1 / Wiji Lestari/39th/dr.Endy Bed 6.2/ Bed 6.3 /

Cahyono/27/12/19

A/ P1A0 39th
Pasca radikal histerektomi + BSO + Limfadenektomi
Pelvis Bilateral a.i squamous cell Ca cervix IB3
(31/12/19)

P/ Inf RL:D5%:NaCl 0,9% 20tpm

Inj Cefotaxime 1g/12jam
Ini Ketorolac 30mg/8jam
Profenid supp/12jam
Insepsa IC/8jam
Terpasang DC
Diet bertahap (bubur sumsum)
Mobilisasi bertahap (mulai miring)

Lab (1/1/20)
Hb/L/Tr : 11.3/16.6/303

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Bed 6.6/ Bed 6.5/Indasah/48th/ dr Nurvita / 24-12-19 Bed 6.4/ Sutikah/55th/ dr.EWA/ 29-12-19

A/ P2A0 48th A/P0A0 55th

NOK dg bagian padat curiga ganas Adenosquamos Ca cervix uteri std IIIB
Ascites Pasca ER 25x (28/10/19)
Azotemia (Ur/Cr : 26/1.6)
Hipoalbuminemia (2.6) P/ pro AL I (acc) hari ini
Hipokalemia (5.2) Izin
Konsul TS radioterapi
P/ perbaikan KU Pengawasan KU,TTV, PPV
Inf RL 20 tpm
Inj Ketorolac 30mg/12jam Lab 23/12
Po : kalitake 1 sach/12jam Hb/L/Tr : 10,9/6,5/347
CaCO3 500mg/12jam OT/PT : 17/33
As folat 1mg/24jam Ur/Cr : 23/0.7
Konsul TS interna Na/K/Cl : 134/3.7/98
Melengkapi pemeriksaan USG abd (+)
Hasil : lesi solid dg bagian kistik bersepta
didalamnya pada cavum pelvis cenderung berasal
dari ovarium
Sludge vesica felea
Ascites disertai debris
Efusi pleura dupleks
Pengawasan KU, TTV, PPV

Lab (31/12)
Alb 2.6
Ur/Cr: 26/1.0

29/12
Ca 125 469.5 (H)

28/12
Na/K/Cl : 140/5.2/103

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Bed 7.1/xxx Bed 7.2/xxx Bed 7.3/xxx

Bed 7.6/xxx Bed 7.5/xxx Bed 7.4/xxx