LAPORAN MINGGUAN BANGSAL

Selasa, 28 November 2017

07.00-07.00

OBSTETRI :6

Ny. Siti Aminah/18thn/EKA/Putri Iffah

MRS: 26 November 2017 D/ G1P0A0 gravida 36-37minggu+ febris+ anemia + JTH IU Preskep
09.00
TD : 120/80// Nadi : 80x/i // RR : 20x/i // S: 36,5
Lab (27/11) TFU : 30cm// DJJ: 150x// TBJ: 2900gr// HPHT : lupa
HB : 9,4
WBC : 13,04 T/IVFD RL 20tpm
RBC : 3.64 Inj.cefotaxime 2x1gr
PLT : 318 Post transfusi PRC 2 kolf
Tes widal : -
DDR : -

Ny.Nova Eliana/23thn/PNG/ Putri Iffah

MRS: 27 November 2017 D/ G1P0A0 gravida 13-14minggu +varisela
15.00
TD : 90/60// Nadi : 82x/i // RR : 22x/i // S: 36,5
Lab (27/11) TFU : 3 jari di atas simphisis // HPHT : 15 Agustus 2017
HB : 11,2
WBC : 5,81 T/IVFD RL 20tpm
RBC : 3,83 Inj.cefotaxime 2x1gr
PLT : 205 PO acyclovir 5x800mg
Paracetamol 3x500mg
Asam folat 2x1tab

Ny.Rosnaini/32thn/ EKA/ Putri Iffah

MRS: 26 November 2017 D/P3 A0 post op laparatomi salpingektomi sinistra hari ke-1 a/i ruptur
17.00 tuba sinistra

Lab (28/11) TD : 120/80// Nadi : 80x/i // RR : 20x/i // S: 36,5

HB : 10,2 HPHT : 21/8/2017// op: 27/11/2017 16.30-17.15
WBC : 13,29
RBC : 3.34 T/ Inj Ceftriaxone 2x1
PLT : 224 Inf. Metronidazole 3x500mg
Inj. Asam tranexamat 3x500mg
IVFD RL + 2amp ketorolac 20tpm
Inj ca gluconas + furosemide post transfusi 1 kolf
Ny.Marhana/38thn/EKA/ Rahmania
MRS: 26 November 2017 D/ P2A1 Post kuretase hari ke 1 a/i sisa plasenta
11.20
TD : 110/80// Nadi : 82x/i // RR : 22x/i // S: 36,5
Lab (28/11)
HB : 10,5 T/ IVFD RL +1 amp oksitosin 20 tpm
WBC : 13,31 PO : Cefixime 2x100mg
RBC : 3,32 Methergin 3x1
PLT : 309 Asam mefenamat 3x500mg

Ny. Aini/36thn/EKA/ Rahmania

MRS: 27 November 2017 D/ G3P2A0H1 gravida 33-34minggu HAP e.c plasenta previa marginalis +
03.50 JTH IU Preskep

Lab (27/11) TD : 100/90// Nadi : 80x/i // RR : 22x/i // S: 36,3

HB : 11,9 TFU : 27cm// DJJ: 132x// Presentasi Kepala// Punggung Kanan
WBC : 12,19 HPHT : 3 April 2017
RBC : 4,01
PLT : 241 T/ IVFD RL + 2 amp duvadilan 15 tpm
Inj. Dexamethasone 2x2amp
Inj. Asam tranexamat 3x500mg
Inj.ceftriaxone 2x1gr

Ny.Ratna Sari/21th/EKA/Rahmania
MRS: 27 November 2017 D/ P2A0 Post Kuretase hari ke-1 a/i sisa plasenta
16.53
TD : 90/70// Nadi : 80x/i // RR : 22x/i // S: 36
Lab (27/11)
HB : 9,8 T/ Cefixime 2x100mg
WBC : 11,05 Methergin 3x1
RBC : 3,38 Asam mefenamat 3x500mg
PLT : 232

GYNECOLOGY: 4

Ny. Kalimah/32thn/RUG/Putri Iffah

MRS: 26 November 2017 D/Ca cervix stadium III + anemia berat
13.20
TD : 120/80// Nadi : 86x/i // RR : 20x/i // S: 36
Lab (26/11)
HB : 4,8 T/ IVFD RL 20tpm
WBC : 12,28 Inj. Ranitidine 2x1amp
RBC : 2,97 Inj. Ceftriaxone 1x2gr
PLT : 362 Inj. Asam tranexamat 3x500mg
PO asam folat 2x1
Paracetamol 3x500mg
Post Transfusi PRC kolf 3

Ny. Saskia/43thn/RUG/ Putri Iffah

MRS : 23 November 2017 D/ Post kemoterapi seri ke-1 ca cervix stadium IIIB
13.20
TD : 120/80// Nadi : 84x/i // RR : 21x/i // S: 36,2
Lab (26/11)
HB : 11,8 T/ IVFD RL 20tpm
WBC : 15,62 PO Ondansentron 3x1
RBC : 4,41 Ranitidine 2x1
PLT : 506
Ny.Samiyah/37thn/RUG/Rahmania
MRS : 26 November 2017 D/ Post op trahelektomi totalis hari ke-1
16.20
TD : 110/80// Nadi : 84x/i // RR : 22x/i // S: 36,2
Lab (27/11)
HB : 11,7 T/ IVFD Dex5% : RL (3:1) 30tpm
WBC : 16,62 Inj . ceftriaxone 3x1gr
RBC : 4,16 Inj Metronidazole 3x500mg
PLT : 321 Inj Ranitidine 3x1amp
Inj. Asam tranexamat 3x500mg
Pronalges supp 3x1

Ny. Hapsah/55thn/ RUG/Rahmania

MRS : 23 November 2017 D/ ca cervix stadium III + anemia berat
19.00 WIB
TD : 110/80// Nadi : 86x/i // RR : 22x/i // S: 36,5
Lab (27/11) post trf kolf 6
HB : 10,5 T/ IVFD RL 20tpm
WBC : 9.08 Inj. Ondansentron 3x1 amp
RBC : 1,42 Inj. Asam Tranexamat 3x1 amp
PLT : 107 PO : Sucralfat syr 3x1
SF 2x1
Asam folat 2x1
Transfusi Kolf ke 6

LAPORAN MINGGUAN BANGSAL

Rabu, 29 November 2017

07.00-07.00

OBSTETRI :6

Ny. Siti Aminah/18thn/EKA/Putri Iffah

MRS: 26 November 2017 D/ G1P0A0 gravida 36-37minggu+ febris+ anemia + JTH IU Preskep
09.00
TD : 120/80// Nadi : 80x/i // RR : 20x/i // S: 36,5
Lab (28/11) TFU : 30cm// DJJ: 141x// TBJ: 2900gr// HPHT : lupa
HB : 8,9
WBC : 13,38 T/IVFD RL 20tpm
RBC : 3.63 Inj.cefotaxime 2x1gr
PLT : 324 Post transfusi PRC 2 kolf
Tes widal : -
DDR : -

Ny.Nova Eliana/23thn/PNG/ Putri Iffah

MRS: 27 November 2017 D/ G1P0A0 gravida 13-14minggu +varisela
15.00
TD : 120/80// Nadi : 80x/i // RR : 22x/i // S: 36,5
Lab (27/11) TFU : 3 jari di atas simphisis // HPHT : 15 Agustus 2017
HB : 11,2
WBC : 5,81 T/IVFD RL 20tpm
RBC : 3,83 Inj.cefotaxime 2x1gr
PLT : 205 PO acyclovir 5x800mg
Paracetamol 3x500mg
Asam folat 2x1tab

Ny.Rosnaini/32thn/ EKA/ Putri Iffah

MRS: 26 November 2017 D/P3 A0 post op laparatomi salpingektomi sinistra hari ke-2 a/i ruptur
17.00 tuba sinistra

Lab (28/11) TD : 110/80// Nadi : 85x/i // RR : 20x/i // S: 36,5

HB : 10,2 HPHT : 21/8/2017// op: 27/11/2017 16.30-17.15
WBC : 13,29
RBC : 3.34 T/ Inj Ceftriaxone 2x1
PLT : 224 Inf. Metronidazole 3x500mg
Inj. Asam tranexamat 3x500mg
IVFD RL + 2amp ketorolac 20tpm
Inj ca gluconas + furosemide post transfusi 1 kolf
Ny. Khasibah/37thn/EKA/ Putri Iffah
MRS: 28 November 2017 D/ G3P1A1 gravida 34-35 minggu belum inpartu + HAP e.c plasenta
16.45 previa totalis +anemia + JTH IU Preskep

Lab (28/11) TD : 100/70// Nadi : 80x/i // RR : 20x/i // S: 36,5

HB : 6,8 HPHT : 22/2/2017//KONUT : + jarang// TFU : 30cm// DJJ : 145x/i//
WBC : 20,18 Punggung Kanan// Presentasi Kepala// Perdarahan : + flek
RBC : 2,44
PLT : 208 T/ / IVFD RL + 2 amp duvadilan 20 tpm
Inj. Dexamethasone 2x2amp
Inj.ceftriaxone 2x1gr

Ny.Martini/31thn/ EKA/ Putri IFFah

MRS: 28 November 2017 D/ P3A1 post op sc hari ke 1 a/i KPD 2 hari +bekas SC1x
00.45
TD : 110/70// Nadi : 89x/i // RR : 20x/i // S: 36,2
Lab (28/11) post trf kolf 1
HB : 10,9 T/ IVFD RL 20 tpm
WBC : 15,27 Inj . ceftriaxone 2x1gr
RBC : 4,05 Inj Metronidazole 3x500mg
PLT : 238 Inj Ranitidine 3x1amp
Inj. Asam tranexamat 3x500mg
Pronalges supp 3x1
Post transfusi kolf I (28/11)

Ny.Aini/36thn/ EKA /Rahmania

MRS: 27 November 2017 D/ G3P2A0H1 gravida 33-34minggu HAP e.c plasenta previa marginalis +
03.50 JTH IU Preskep

Lab (27/11) TD : 100/90// Nadi : 80x/i // RR : 22x/i // S: 36,3

HB : 11,9 TFU : 27cm// DJJ: 132x// Presentasi Kepala// Punggung Kanan
WBC : 12,19 HPHT : 3 April 2017
RBC : 4,01
PLT : 241 T/ IVFD RL + 2 amp duvadilan 15 tpm
Inj. Dexamethasone 2x2amp
Inj. Asam tranexamat 3x500mg
Inj.ceftriaxone 2x1gr

Ny.Satira/ 37th/ZUL/Rahmania
MRS: 28 November 2017 D/ P6A0H5 Post op SC a/i KPD+gawat janin+ca mammae post
14.06 kemoterapi 1 bulan yang lalu
Lab (28/11)
HB : 10,7 Kesadaran: apatis// TD : 100/90// Nadi : 80x/i // RR : 22x/i // S: 36,3
WBC : 8,16 TFU : 2 jari di bawah umbilikus//
RBC : 3,76
PLT : 97 T/ IVFD RL 20 tpm
GDS :85 Inj. Cefotaxime 3x1gr
Inf metronidazole 3x500mg
Inj.tramadol 3x1gr
R/ Konsul saraf

Ny. Salbya/ 41th/ZUL/ Rahmania

MRS : 28 November 2017 D/ P4A0 Post manual plasenta a/i retensio plasenta +anemia berat
14.06
TD : 130/80// Nadi : 74x/i // RR : 22x/i // S: 36,3
Lab (28/11) TFU : 2 jari di bawah umbilikus//
HB : 4,7
WBC : 18,24 T/ IVFD RL 20 tpm
RBC : 1,59 Inj. Ceftriaxoe 2x1gr
PLT : 209 Inf metronidazole 3x500mg
Inj.tramadol 3x1gr
Post Transfusi PRC kolf 2

GYNECOLOGY :5

Ny. Kalimah/32thn/RUG/Putri Iffah

MRS: 26 November 2017 D/Ca cervix stadium III + anemia berat
13.20
TD : 120/80// Nadi : 86x/i // RR : 20x/i // S: 36
Lab (26/11)
HB : 4,8 T/ IVFD RL 20tpm
WBC : 12,28 Inj. Ranitidine 2x1amp
RBC : 2,97 Inj. Ceftriaxone 1x2gr
PLT : 362 Inj. Asam tranexamat 3x500mg
PO asam folat 2x1
Paracetamol 3x500mg
Post Transfusi PRC kolf 3

Ny. Pitrianti/33thn/ HER/ Putri Iffah

MRS: 28 November 2017 D/ Kista Ovarium dengan kolik abdomen
18.20
 TD : 110/70// Nadi : 78x/i // RR : 18x/i // S: 36
Lab (28/11) USG : Kista ovarium 9x5cm
HB : 12
WBC : 17,71 T/IVFD RL 2 tpm
RBC : 4,2 Pronalges supp (k/P)
PLT : 252 R/ op

Ny.Samiyah/37thn/RUG/Rahmania
MRS : 26 November 2017 D/ Post op trahelektomi totalis hari ke-1
16.20
TD : 110/80// Nadi : 84x/i // RR : 22x/i // S: 36,2
Lab (27/11)
HB : 11,7 T/ IVFD Dex5% : RL (3:1) 30tpm
WBC : 16,62 Inj . ceftriaxone 3x1gr
RBC : 4,16 Inj Metronidazole 3x500mg
PLT : 321 Inj Ranitidine 3x1amp
Inj. Asam tranexamat 3x500mg
Pronalges supp 3x1

Ny. Hapsah/55thn/ RUG/Rahmania

MRS : 23 November 2017 D/ ca cervix stadium III + anemia berat
19.00 WIB
TD : 110/80// Nadi : 86x/i // RR : 22x/i // S: 36,5
Lab (27/11) post trf kolf 6
HB : 10,5 T/ IVFD RL 20tpm
WBC : 9.08 Inj. Ondansentron 3x1 amp
RBC : 1,42 Inj. Asam Tranexamat 3x1 amp
PLT : 107 PO : Sucralfat syr 3x1
SF 2x1
Asam folat 2x1
Transfusi Kolf ke 6
Ny.Betty/47th/RUG/Rahmania
MRS : 27 November 2017 D/ Ca Cervix Stadium IIIb + dyspepsia
02.30 WIB
TD : 110/70// Nadi : 88x/i // RR : 19x/i // S: 36
Lab (27/11) post trf kolf 6
HB : 10,5 T/ IVFD RL 20tpm
WBC : 9.08 Inj Ketorolac 3x1amp
RBC : 1,42 Inj. Ranitidine 2x1
PLT : 107 Ondasentron 2x1
Post transfusi PRC kolf 2
 LAPORAN MINGGUAN BANGSAL

Kamis, 30 November 2017

07.00-07.00

OBSTETRI :9

Ny.Nova Eliana/23thn/PNG/ Putri Iffah

MRS: 27 November 2017 D/ G1P0A0 gravida 13-14minggu +varisela
15.00
TD : 120/80// Nadi : 80x/i // RR : 22x/i // S: 36,5
Lab (27/11) TFU : 3 jari di atas simphisis // HPHT : 15 Agustus 2017
HB : 11,2
WBC : 5,81 T/IVFD RL 20tpm
RBC : 3,83 Inj.cefotaxime 2x1gr
PLT : 205 PO acyclovir 5x800mg
Paracetamol 3x500mg
Asam folat 2x1tab

Ny. Khasibah/37thn/EKA/ Putri Iffah

MRS: 28 November 2017 D/ G3P1A1 gravida 34-35 minggu belum inpartu + HAP e.c plasenta
16.45 previa totalis +anemia + JTH IU Preskep

Lab (28/11) TD : 100/70// Nadi : 80x/i // RR : 20x/i // S: 36,5

HB : 6,8 HPHT : 22/2/2017//KONUT : + jarang// TFU : 30cm// DJJ : 145x/i//
WBC : 20,18 Punggung Kanan// Presentasi Kepala// Perdarahan : + flek
RBC : 2,44
PLT : 208 T/ / IVFD RL + 2 amp duvadilan 20 tpm
Inj. Dexamethasone 2x2amp
Inj.ceftriaxone 2x1gr

Ny.Martini/31thn/ EKA/ Putri IFFah

MRS: 28 November 2017 D/ P3A1 post op sc hari ke 2 a/i KPD 2 hari +bekas SC1x
00.45
TD : 110/70// Nadi : 89x/i // RR : 20x/i // S: 36,2
Lab (28/11) post trf kolf 1
HB : 10,9 T/ IVFD RL 20 tpm
WBC : 15,27 Inj . ceftriaxone 2x1gr
RBC : 4,05 Inj Metronidazole 3x500mg
PLT : 238 Inj Ranitidine 3x1amp
Inj. Asam tranexamat 3x500mg
Pronalges supp 3x1
Post transfusi kolf I (28/11)

Ny.Nurhayati/34thn/ ZUL/ Putri Iffah

MRS: 29 November 2017 D/P3A0 post partum hari ke1
06.00
TD : 120/80// Nadi : 80x/i // RR : 22x/i // S: 36,5
Lab (29/11) TFU : 1 jari di bawah umbilikus
HB : 11,5
WBC : 16,34 T/ PO amoxicilin 3x500mg
RBC : 3,75 SF 1x1
PLT : 358 Paracetamol3x500mg
Vit.B complex 2x1
Ny. Sarifa Ratna/18thn/ZUL/Putri Iffah
MRS: 30 November 2017 D/ P1A0 post SC hari ke 1 a/i KPD+partus lama+gawat janin
08.00
TD : 120/80// Nadi : 80x/i // RR : 22x/i // S: 36,5
Lab (30/11)
HB : 10,1 T/ IVFD RL 20 tpm
WBC : 22,4 Inj . ceftriaxone 2x1gr
RBC : 5,26 Inj Metronidazole 3x500mg
PLT : 337 Inj Tramadol 3x1amp

Ny. Tina/38th/ PAR/ Putri Iffah

MRS: 30 November 2017 D/ P1A0 post SC hari ke 1 a/i PEB
02.00
TD : 150/90// Nadi : 96x/i // RR : 22x/i // S: 36,4
Lab (30/11)
HB : 8,8 T/ IVFD RL 20 tpm
WBC : 16,34 Inj . ceftriaxone 2x1gr
RBC : 3,56 Inj Metronidazole 3x500mg
PLT : 256 Kaltropen supp 2x1

Ny.Aini/36thn/ EKA /Rahmania

MRS: 27 November 2017 D/ G3P2A0H1 gravida 33-34minggu HAP e.c plasenta previa marginalis +
03.50 JTH IU Preskep

Lab (27/11) TD : 100/90// Nadi : 80x/i // RR : 22x/i // S: 36,3

HB : 11,9 TFU : 27cm// DJJ: 138x// Presentasi Kepala// Punggung Kanan
WBC : 12,19 HPHT : 3 April 2017
RBC : 4,01
PLT : 241 T/ IVFD RL + 2 amp duvadilan 15 tpm
Inj. Dexamethasone 2x2amp
Inj. Asam tranexamat 3x500mg
Inj.ceftriaxone 2x1gr

Ny.Satira/ 37th/ZUL/Rahmania
MRS: 28 November 2017 D/ P6A0H5 Post op SC hari ke II a/i KPD+gawat janin+ca mammae post
14.06 kemoterapi 1 bulan yang lalu
Lab (29/11)
HB : 9,8 Kesadaran: apatis// TD : 100/90// Nadi : 80x/i // RR : 22x/i // S: 36,3
WBC : 8,3 TFU : 2 jari di bawah umbilikus//
RBC : 3,22
PLT : 105 Konsul Saraf : susp SOL intrakranial e.c ca mammae metastase
GDS :85 R/ Pindah ruang rawat saraf

T/O2 3l/m
IVFD RL 20 tpm
Inj. Cefotaxime 3x1gr
Inf metronidazole 3x500mg
Inj.tramadol 3x1gr
 Diet : NGT 200cc/4jam
Ny. Salbya/ 41th/ZUL/ Rahmania
MRS : 28 November 2017 D/ P4A0 Post manual plasenta a/i retensio plasenta +anemia berat
14.06
TD : 130/80// Nadi : 74x/i // RR : 22x/i // S: 36,3
Lab (30/11) TFU : 2 jari di bawah umbilikus//
HB : 8,5
WBC : 26,24 T/ IVFD RL 20 tpm
RBC : 2,99 Inj. Ceftriaxoe 2x1gr
PLT : 208 Inf metronidazole 3x500mg
Inj.tramadol 3x1gr
Post Transfusi PRC kolf 3
Inj Ca gluconas+furosemide

GYNECOLOGY: 4

Ny. Kalimah/32thn/RUG/Putri Iffah

MRS: 26 November 2017 D/Ca cervix stadium III + anemia berat
13.20
TD : 120/80// Nadi : 86x/i // RR : 20x/i // S: 36
Lab (26/11)
HB : 4,8 T/ IVFD RL 20tpm
WBC : 12,28 Inj. Ranitidine 2x1amp
RBC : 2,97 Inj. Ceftriaxone 1x2gr
PLT : 362 Inj. Asam tranexamat 3x500mg
PO asam folat 2x1
Paracetamol 3x500mg
Post Transfusi PRC kolf 3

Ny. Pitrianti/33thn/ HER/ Putri Iffah

MRS: 28 November 2017 D/ Kista Ovarium dengan kolik abdomen
18.20
TD : 110/70// Nadi : 78x/i // RR : 18x/i // S: 36
Lab (28/11) USG : Kista ovarium 9x5cm
HB : 12
WBC : 17,71 T/IVFD RL 2 tpm
RBC : 4,2 Pronalges supp (k/P)
PLT : 252 R/ op

Ny. Hapsah/55thn/ RUG/Rahmania

MRS : 23 November 2017 D/ ca cervix stadium III + anemia berat
19.00 WIB
TD : 110/80// Nadi : 86x/i // RR : 22x/i // S: 36,5
Lab (27/11) post trf kolf 6
HB : 10,5 T/ IVFD RL 20tpm
WBC : 9.08 Inj. Ondansentron 3x1 amp
RBC : 1,42 Inj. Asam Tranexamat 3x1 amp
PLT : 107 PO : Sucralfat syr 3x1
SF 2x1
 Asam folat 2x1
Transfusi Kolf ke 6
Ny.Betty/47th/RUG/Rahmania
MRS : 27 November 2017 D/ Ca Cervix Stadium IIIb + dyspepsia
02.30 WIB
TD : 110/70// Nadi : 88x/i // RR : 19x/i // S: 36
Lab (27/11) post trf kolf 6
HB : 10,5 T/ IVFD RL 20tpm
WBC : 9.08 Inj Ketorolac 3x1amp
RBC : 1,42 Inj. Ranitidine 2x1
PLT : 107 Ondasentron 2x1
Post transfusi PRC kolf 2