Profile Pasien

Data Visit

Diagnosa

CPPT

Laboratorium

Radiologi

Obat & BMHP

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Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

CPPT

1. 2025-05-08 14:20

   • SUBJECTIVE :

     os tiba diruang vk pkl 13 : 00 wib dari ruang igd dalam keadaan sadar,

     os mengatakan mules2 (+), keluar lendir darah (+), keluar air2 (+)

   • OBJECTIVE :

     k/u cm

     TD :  120/90 Mmhg

     HR : 84x/i

     RR: 20 x/i

     T :36,6

     DJJ : 160 X/I

   • ANALYST :

     G3P2A0 UK 33-34 MINGGU + KPD + Oligohidromion+ fetal distres

   • PLANNING :

     Therapy

     - ivfd RL 30 GTT/I 

     - Inj ceftriaxon 1 gram/ 12 jam

   • INSTRUKSI :
   Bidan
2. 2025-05-08 13:37

   • SUBJECTIVE :

     mules2 (+), keluar lendir darah (+),

   • OBJECTIVE :

     k/u cm

     TD :  120/90 Mmhg

     HR : 84x/i

     RR: 20 x/i

     T :36,6

     djj : 160 x/i

   • ANALYST :

     G3P2A0 UK 33-34 MINGGU + KPD + Oligohiromion + fetal distres

   • PLANNING :

     Therapy

     - ivfd RL 30 GTT/I 

     - Inj ceftriaxon 1 gram/ 12 jam

   • INSTRUKSI :

     advice dr. hendri sp.og

     operasi sc pukul 14.00

   Dokter Umum
3. 2025-05-08 23:33

   • SUBJECTIVE :

     OS MENGATAKAN NYERI LUKA OPERASI (+),MUAL/MUNTAH(-)

     DEMAM(-)

      

   • OBJECTIVE :

     KU SADAR

     TD:120/80 MMHG

     HR:78 X/I

     RR:22 X/I

   • ANALYST :

     P3A0+POST SC ai KPD+OLIGOHIDRAMION+FETAL DISTERS

   • PLANNING :

     -IVFD RL 20 GTT/I

     -INJ.CEFTRIAXONE 1 GRAM/12 JAM

     -METRIDAZOLE DRIP 1 FLS/8 JAM

     -INJ.KETEROLAC 1 APL/8 JAM

     INJ.RANITIDIN 1 APL/12 JAM

     -INJ METOCOPERAMID 1 APL/8 JAM

     OBAT ORAL

     TTD :2X1

   • INSTRUKSI :
   Bidan
4. 2025-05-09 11:43

   • SUBJECTIVE :

     S :  Nyeri Luka Operasi

   • OBJECTIVE :

     O : TD 110 / 70 mmHg

          Abd : Soepel, Peristaltik (+) N

          P/V : Lochia (+)

   • ANALYST :

     Post Sc 

   • PLANNING :

     Th/ Lanjut sesuai DPJP

   • INSTRUKSI :

     Mobilisasi Bertahap

     Kateter Aff setelah 24 jam post OP

   Dokter Spesialis
5. 2025-05-09 13:20

   • SUBJECTIVE :

     nyeri luka op minimal

     mual (-)

     muntah (-)

     demam (-)

     lapor hasil darut post transfusi

   • OBJECTIVE :

     kes: cm

     TD :  120/90 mmHg

     HR : 84x/i

     RR: 20 x/i

     T :36,6

      

   • ANALYST :

     Post op ai ologohidramnion + Fetal disstres

   • PLANNING :

     Konsul via phone dengan dr. Henry, Sp.OG advice:

     Terapi lanjut

   • INSTRUKSI :

     aff kateter

   Dokter Umum
6. 2025-05-09 14:09

   • SUBJECTIVE :

     os mengatakan nyeri bekas operasi (+), demam (-) mual (-) pusing (-) perdarahan (-)

   • OBJECTIVE :

      TD: 120/80 mmhg

     HR: 82X/i

     RR: 19X/i

     Tem: 36,6 C

   • ANALYST :

     P3A0 POST SC a/i Kpd + Oligohidromion + Fetal Distres hari ke 1

   • PLANNING :

     berikan therapy sesuai dengan advice dokter

     IVFD RL+ OKSITOXIN S/s Dex 5% 20 gtt/i

     INJ CEFRIAXONE 1gr/ 12 jam

     INJ RANITIDIN 1A/12 jam

     INJ Metoclopramid 1A/8 jam

     Metronidazole drip 1 fls/8jam

     TTD 2X1

   • INSTRUKSI :

     ANJURKAN IBU MOBILASI MIRING KANAN DAN MIRING KIRI

   Bidan
7. 2025-05-09 23:44

   • SUBJECTIVE :

     OS MENGATAKAN NYERI BEKAS OPERASI(+)DEMAM(-)

     MUAL(-)PUSING(-),PENDARAHAN(-)

   • OBJECTIVE :

     KU SADAR

     TD :110/80 MMHG

     HR:78 X/I

     RR:22 X/I

     T:37 0C

   • ANALYST :

     P3A0 POST SC ai KPD+OLIGOHIDRAMION+FETAL DISTRES HARI PERTAMA

   • PLANNING :

     -KOLABORASI DENGAN DOKTER OBGYN

     -IVFD DEXTRO 5% 20 GTT/I

     OBAT ORAL

     -IBUBROFEN 3X1

     -CEFADROXIL 2X1

     METRONIDAZOLE 3X1

     -TTD 2X1

   • INSTRUKSI :
   Bidan
8. 2025-05-10 14:49

   • SUBJECTIVE :

     Os mengatakan nyeri bekas operasi (+) demam (-) mual (-) pusing (-)perdarahan (-)

   • OBJECTIVE :

     TD: 100x/70 mmhg

     HR: 80X/i

     RR:22X/i

     Tem:37 c

      

   • ANALYST :

     P3A0 POST SC a/i kpd+ oligohidromion + fetal distres

   • PLANNING :

     obat oral 

     - ibu propen 3x1

     - metronidazole 3x1

      

   • INSTRUKSI :
   Bidan
9. 2025-05-10 10:52

   • SUBJECTIVE :

     nyeri luka op minimal

     mual (-)

     muntah (-)

     demam (-)

      

   • OBJECTIVE :

     kes: cm

     TD :  110/70 mmHg

     HR : 84x/i

     RR: 20 x/i

     T :36,6

      

   • ANALYST :

     Post op ai ologohidramnion + Fetal disstres

   • PLANNING :

     Konsul via phone dengan dr. Hendri, Sp.OG advice:

     Terapi lanjut

   • INSTRUKSI :
   Dokter Umum
10. 2025-05-10 23:25

    • SUBJECTIVE :

      Os mengatakan nyeri bekas luka operasi (+), demam (-), mual (-), perdarahan (-)

    • OBJECTIVE :

      TD: 110/80 mmhg

      HR: 80 x/i

      RR: 19 x/i

      T: 36,5 c

    • ANALYST :

      P3A0 post sc a/i KPD + Oligohidramnion + Fetal Distress

    • PLANNING :

      Therapy:

      -Aam Mefenamat 3x1 tablet

      -Metronidazole 3x1 tablet

      -Cefadroxil 2x1 

      -Tablet Tambah Darah 2x1

    • INSTRUKSI :

      -Anjurkan ibu mobilisasi

      -Anjurkan ibu makan makanan bergizi

    Bidan
11. 2025-05-11 16:00

    • SUBJECTIVE :

      Os mengatakan nyeri luka bekas operasi (-) demam (-) perdarahan (-) mual (-)

    • OBJECTIVE :

      TD: 110/80 mmhg 

      Hr:80x/i

      Rr: 19x/i

      Tem: 36,5 C

    • ANALYST :

      P3A0 POST SC a/i kpd + Oligohidromion +fetal distres

    • PLANNING :

      ANJURAN PBJ

      Asammefenamat 3x500mg

      Metronidazole 3x500 mg

    • INSTRUKSI :
    Bidan
12. 2025-05-11 14:40

    • SUBJECTIVE :

      luka operasi kering

      nyeri luka operasi berkurang

    • OBJECTIVE :

      sen : cm

      TD: 110/80 mmhg 

      Hr:80x/i

      Rr: 19x/i

      Tem: 36,5 C

    • ANALYST :

      P3A0 Post Sc a.i KPD + Oligohidromanion + Fetal Distres

    • PLANNING :

      Konsultasi dr. Hendri, Sp.OG via Telpon Advice :

      PBJ

      Cefadroxil 2x 500 mg

      Metronidazole 3x500 mg

      Asmefenamat 3x 500 mg

      Ranitidin 2x 50 mg

      Etabion 2x1

    • INSTRUKSI :
    Dokter Umum
13. 2025-05-10 11:30

    • SUBJECTIVE :

      KELUHAN (-)

    • OBJECTIVE :

      K/U : CM

      TD : 120/80 mmhg

      HR : 78 x/i

    • ANALYST :

      post sc

    • PLANNING :

      terapi lanjutkan

    • INSTRUKSI :
    Dokter Spesialis
14. 2025-05-11 15:15

    • SUBJECTIVE :

      keluhan (-)

    • OBJECTIVE :

      k/u : CM

      TD :110/80 mmhg

      RR : 80 x/i

    • ANALYST :

      post sc

    • PLANNING :

      pbj

      asam mefenamat 3x 500 mg

      cefadroxil 2x 500 mg

      metronidazole 3x 500 mg

      etabion 2x1

      ranitidin 2x 50 mg

    • INSTRUKSI :

      kontrol ulang 1 minggu 

    Dokter Spesialis

Laboratorium

1. DARAH LENGKAP

   2025-05-09 08:58:30
   Lihat Hasil

Radiologi

Obat & BMHP 2025-05-08 14:27:45 | Vitamin k | - (1Tablet) 2025-05-08 14:27:45 | HB 0 Vaksin | - (1Pcs) 2025-05-08 14:27:45 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-05-08 14:27:45 | Dextrose 5% 500 ml | 20 gtt/i (1fls) 2025-05-08 14:27:45 | Ketorolac inj | 1amp/8jam (1Ampul) 2025-05-08 14:27:45 | Ranitidin inj | 2 X 1 (1Ampul) 2025-05-08 14:27:45 | Metronidazole infus | 1fls/8jam (1botol) 2025-05-08 14:27:45 | Metoclopramide injeksi 5 mg | 1amp/8jam (1ampul) 2025-05-08 14:27:45 | Oxytosin inj / oksitosin / oxitosin | - (1Ampul) 2025-05-09 10:58:48 | Ringer Lactat / RL | 20 gtt/i (1fls) 2025-05-09 10:58:48 | Dextrose 5% 500 ml | 20 gtt/i (1fls) 2025-05-09 10:58:48 | Metronidazole infus | 1 fls/8 jam (1botol) 2025-05-09 10:58:48 | Ceftiaxiason inj | 1gr/12jam (1Vial) 2025-05-08 06:35:59 | Ringer Lactat / RL | 1 (1fls) 2025-05-08 06:35:59 | Ceftiaxiason inj | 1x12 jam (1Vial) 2025-05-08 06:35:59 | Aqua pro injection | 1 (1Vial) 2025-05-08 06:35:59 | Ketorolac inj | TIAP 8 JAM (2Ampul) 2025-05-08 06:35:59 | Metronidazole infus | TIAP 8 JAM (2botol) 2025-05-08 06:35:59 | Ranitidin inj | tiap 12 jam (1Ampul) 2025-05-08 06:35:59 | Metoclopramide injeksi 5 mg | 8 jam (2ampul) 2025-05-09 06:43:46 | Ringer Lactat / RL | 1 (1fls) 2025-05-09 06:43:46 | Ceftiaxiason inj | 1 (1Vial) 2025-05-09 06:43:46 | Tablet tambah darah | 2x1 (2Tablet) 2025-05-09 06:43:46 | Dextrose 5% 500 ml | 1 (1fls) 2025-05-09 06:43:46 | Ibuprofen suspensi 200mg/5ml | 1 (1botol) 2025-05-09 06:43:46 | Cefadroxil Monohydrate 500mg | 2x1 (1tablet) 2025-05-09 06:43:46 | Metronidazole 500 mg | 3x1 (1tablet) 2025-05-10 11:32:41 | Asering | . (1fls) 2025-05-10 11:32:41 | Metronidazole 500 mg | 3x1 (1tablet) 2025-05-10 11:32:41 | Asam Mefenamat 500mg | 3x1 (1Pcs) 2025-05-10 21:49:55 | Cefadroxil Monohydrate 500mg | 2 X 1 (2tablet) 2025-05-10 21:49:55 | Metronidazole 500 mg | 3x1 (2tablet) 2025-05-10 21:49:55 | Asam Mefenamat 500mg | 3x1 (2Pcs) 2025-05-10 21:49:55 | Tablet tambah darah | 2 X 1 (2Tablet) 2025-05-11 15:11:35 | Cefadroxil Monohydrate 500mg | 3x1 (10tablet) 2025-05-11 15:11:35 | Metronidazole 500 mg | 3X1 (10tablet) 2025-05-11 15:11:35 | Asam Mefenamat 500mg | 3X1 (10Pcs) 2025-05-11 15:11:35 | Ranitidine 50 mg/2 ml | 2X1 (10ampul) 2025-05-11 15:11:35 | Etabion | 2 X 1 (10tablet) 2025-05-11 15:11:35 | Gentamicin salep | 1 (1tube)

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2025-05-08 14:29:10 | Alat suntik sekali pakai spuit 1 cc | - (1pcs) 2025-05-08 14:29:10 | Suction Cateter No.8 | - (1pcs) 2025-05-08 14:29:10 | Alat suntik sekali pakai spuit 3 cc | - (3pcs) 2025-05-09 11:00:07 | Alat suntik sekali pakai spuit 3 cc | - (2pcs) 2025-05-09 11:19:50 | Alat suntik sekali pakai spuit 3 cc | 3X1 (2pcs) 2025-05-08 06:40:57 | Alat suntik sekali pakai spuit 3 cc | 1 (3pcs) 2025-05-09 06:42:16 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-09 06:42:16 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-09 06:42:16 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-09 06:42:16 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-09 06:42:16 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-11 15:20:50 | Kasa Hydrophil Steril Uk 16 cm x 16 cm | 1 (1box) 2025-05-11 15:20:50 | Handscoen Steril (size 7) | 1 (1pcs)

Tindakan

Alat Kesehatan

USG

Profile Pasien

Data Visit

Diagnosa

Laboratorium

1. DARAH LENGKAP

   2025-05-08 12:17:32
   Lihat Hasil

1. CTBT (Masa Pembekuan Masa Pendarahan)

   2025-05-08 12:17:38
   Lihat Hasil

1. KGD AD RANDOM

   2025-05-08 12:17:45
   Lihat Hasil

1. GOLONGAN DARAH

   2025-05-08 12:17:50
   Lihat Hasil

1. URINE LENGKAP

   2025-05-08 12:18:31
   Lihat Hasil

Radiologi

Obat & BMHP 2025-05-08 12:18:42 | Ringer Lactat / RL | 20gtt/i (1fls) 2025-05-08 12:18:42 | Ceftiaxiason inj | 1000mg/12jam (1Vial) 2025-05-08 12:18:42 | Dexamethason inj | 2amp/extra (1Ampul)

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2025-05-08 12:19:00 | Handscoen non steril (size M) | 4 (4pcs) 2025-05-08 12:19:00 | Blood Transfusion Set | 1 (1pcs) 2025-05-08 12:19:00 | abocath/ IV Catheter No.20 | 1 (1pcs) 2025-05-08 12:19:00 | Alat suntik sekali pakai spuit 1 cc | 1 (1pcs) 2025-05-08 12:19:00 | Alat suntik sekali pakai spuit 3 cc | 1 (1pcs) 2025-05-08 12:19:00 | Alat suntik sekali pakai spuit 10 cc | 2 (2pcs) 2025-05-08 12:19:00 | Foley Catheter 2 Way No. 16 | 1 (1pcs) 2025-05-08 12:19:00 | Urine Bag | 1 (1pcs)

Tindakan Pasang Infus : dr. Ikhsan Anugerah Honor Dokter IGD : dr. Ikhsan Anugerah

Alat Kesehatan

USG