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MAPPING AQSHA 1

Senin, 17 JUNI 2019


Tim Jaga : dr. Intan/dr. wandi
Dokter Muda : Hilwa/ Azin

KELAS 1 KELAS 2 KELAS 3 KELAS 4


DR : dr. Taufiq DR : dr.Muna DR : dr. Riza
COW : dr. Arie S COW : dr.Indra COW : dr. Aziz
DM : DPJP PULMO DM : DM :
Raber : HOM Raber : HOM Raber :
DPJP : dr. M. Diah, Sp.PD, KKV DPJP : Dr.dr.Fauzi Yusuf Sp.PD DPJP : dr. Masralena, Sp.PD
Nama : Rusniar Abd Wahab Nama : Sirathallah Nama : Elidar Ahmad
TTL : 03-04-1967 (52th) TTL : 07-0301957 TTL : 01/07/1968
Alamat : Aceh Besar Alamat : Aceh Besar Alamat : banda aceh
CM : 1210657 CM : 1147397 CM : 0628518
Hari rawatan : 13 Harirawatan : 3 Harirawatan : 4

A/ A/ A/
1. Efusi pleura (S) ec dd/ 1.Gangren diabetik pedis dextra 1. selulitis dd dvt
- pleuropneumoni 2. DM Tipe 2 NW 2. HHD
- CHF 3. Hipertensi stage 2
- Pleuritis TB 4. gastropati diabetik Th/
- Meigh syndrome 5. Charot disease pedis sinistra - Bedrest
2. Pneumonia (CAD) dd infeksi - Diet MB rendah garam
Paru spesifik Th/ 1800kkal/hari
3. ISK - Iv ceftriaxone 2gr/12j
4. DM tipe 2 Normoweight - Tirah baring - Clindmicin 3x30mg
5. Ulkus decubitus grade I - Diet sonde 6x200cc /hari via - Paracetamol 3x500mg
6. Hipoalbuminemia NGT - Herbesser 100mg/24j
7. sepsis (perbaikan) - IVFD NaCl 0,9% 20 tpm - Clopidogrel 1x75mg
- Transfusi PRC 1 kolf - Valsartan 1x80 mg
Th/ - IV Ceftriaxone 2gr/24j
- Bedrest - Clindamisin 3x300mg Lab 14-06-2019
- Diet DM 1700 kkal/hari - SC novorapid 8-8-8 PT/APTT: 12,5/ 31,50
- O2 2 l/i Nasal kanul - Sc lantus 0-0-0-14 D dimer: 405,92
- Three way - Albuminar 24%100cc/hr Kolesterol total: 153
- Sc novorapid 10-10-10 unit - Paracetamol 3x500mg LDL: 135
- Sc lantus 0-0-0-12 unit - Domperidone 3x10mg HDL: 35
- Paracetamol 3x500 mg Trigliserida: 120
- KSR 1x600 mg GDP: 127
- Rawat luka dengan NaCl Lab 14-06-2019 G2PP: 102
0,9% Hb/Ht/E/T/L:9,6/28/3,6/290/16,3 HbA1C: 6,30
- Albumin 25% 100cc /24j MCV/MCH/MCHC: 76/26/35
- Furosemid 40 mg/6jam Diftell: 0/1/0/86/10/3 Urinalisa
- Iv ampicilin sulbactam 1,5 PT/APTT: 16,10/38,80 Warna: kuning
gr/6 jam Albumin: 2,52 Kejernihan: jernih
- Sucralfat syr 3xCI Ur/Cr : -/0,83 pH: 5
Na/K/Cl : 134/3,7/103 berat jenis: 1,030
GDS: 434 leu/prot/gluko: (-)
Lab 13-06-2019 keton: (+)
Hb/Ht/E/T/L: 10,1/30/3,7/301/15,1 urobilinogen/bilirubin/darah: (-)
MCV/MCH/MCHC: 81/27/34
Difftel: 0/0/0/87/7/6 Lab 13-06-2019
HDL: 19 Hb/Ht/E/T/L: 10,9/32/3,8/269/7,7
Asamurat: 5,7 MCV/MCH/MCHC: 85/29/34
Na/K/Cl: 132/3,5/93 Diftell: 3/1/0/62/24/10
GDS: 125
Ur/Cr : 25/0,63
Lab 11-06-2019
Albumin:2,34
Kol Tot/HDL/LDL: 83/21/54
Trigliserida 113
Ferritin: 867,38
Fe:25

Lab 10-06-2019
HbA1c : 7,6

Lab 07-06-2019
Hb/Ht/E/T/L: 11,1/33/4,1/469/13,3
MCV/MCH/MCHC: 79/27/34
Alb: 2,63
Ca: 6,4
Na/K/Cl: 135/3,7/98
KELAS 5 KELAS 6 KELAS 7 KELAS 8
DPJP BEDAH ORTHOPEDI DR : dr. Taufik DR : dr.Muna
COW : dr.Fahril COW : dr.Indra
DM : DM :
DPJP BEDAH ORTHO
Raber : Raber :HOM
DPJP : dr. M. RiswanSp.PD DPJP : Dr.dr.Fauzi Yusuf Sp.PD
KHOM
Nama : Lasminah Abdullah Nama : Asmiati M Panaidi
TTL :01-051950 TTL :11/03/1967
Alamat : Aceh Besar Alamat : Banda Aceh
CM :1107484 CM :0134844
Hari rawatan : 7 Hari rawatan : 5

A/ A/
1. selultis (perbaikan) 1. Gout artritis akut
2. Anemia sedang hipokrom mikrositer
Th/ ec dd/
-Bedrest -occult bleeding
-Diet MB 1700 kkal/hari -def.besi
-IVFD tutofusin 20 tpm -penyakit kronik
-IV cefoperazone sodium /12jam 3.Dispepsia tipe like ulcer
-PCT 500mg /8j
-pradaxa 1x75mg Th/
-MST 2x1 -Bedrest
- iv omeprazole 40mg/12 jam -Diet MB 1700 kkal/hari
-ondancetron 4mg/12 jam -Threeway
- sucralfat syr 3xCI -Transfusi PRC sdHb>10gr/dl
-Premed IV dexa 1 amp (extra)
Lab 13-06-2019 -Ceftriaxone 2g/24j IV
Hb/Ht/E/L/T : 11,4/33/3,9/14,2/320 -Lansopo[razole 30mg/12j IV
MCV/MCH/MCHC : 85/30/35 -Dipenhidramine 1 amp extra
Diftel : 1/0/0/79/13/7 -Sukralfat 3x CII
-Recofar 0,5mg/8j
Lab 11-06-2019 -PCT 500mg /8j
Hb/Ht/E/L/T : 13/37/4,5/220/20 -allopurinol 1x100mg
MCV/MCH/MCHC : 83/29/35
Diftel : 0/0/0/87/7/6 Lab (14/06/19)
apTT pasien: 34,10 LED: 114
INR : 1,00 Ferritin: 1801,83
Ur/Cr: 43/0,91 CRP kual: +
Na/K/Cl: 137/3,4/103 As. Urat: 12,7

Lab 11-06-2019
Hb/Ht/E/L/T : 7,9/24/4,1/360/9,8
MCV/MCH/MCHC : 58/19/33
Diftel : 0/0/1/79/18/2
Ur/Cr: 34/1,14
Na/K/Cl: 138/5,0/109
KELAS 9 KELAS 10 KELAS 11 KELAS 12

DR : dr. Reyza DR : dr. Taufiq


COW : dr. Nadi COW : dr. Fahril
DPJP BEDAH ORTHO DPJP PULMO DM : DM :
Raber: bedah urologi Raber:
DPJP : dr. Abdullah, Sp.PD DPJP : dr.Riswan, Sp.PD KHOM
Nama : Nikma Meuraksa Nama :Nuriah
TTL :01-01-1973 (46th) TTL :07-08-1937
Alamat : Aceh Utara Alamat :Banda Aceh
CM : 1208492 CM : 1117791
HariRawatan : 10 HariRawatan : 5

A/ A/
1. CKD stage 5 dengan 1.PPOK
uremic syndrome 2. Geriatric problem
(perbakan) ec HN 3. Anemia sedang hipokrom
2. Malposisi CAPD mikrositerec dd/
3. HHD -def Fe
4. Hipokalemia ringan -Penyakit kronis
4. HT stage 2
5.PAD dd Buerger Disease
Th/ 6.Hipoalbumin berat
- Bedrest
- Diet ginjal 1700kkal
- Threeway Th/
- Hemodialisa -Bederest
- Paracetamol 1gr/8j -Diet rendah garam + extra putih telur
- Lenal ace 169mg/12j -IVFD tutofusin 20 tpm
- Asam folat 400mg/12j - Albumin 25% 100cc/hari
- Iv Furosemid 20mg/8j -As.Folat 2x400mcg
- Amlodipin 1x10mg -Valsartan 1x80mg
- Iv ondancetron 4mg/8j -IV ceftriaxone 2gr/24j
- Mecobalamin 2x500mg - IV omeprazole 4mg/12j
- Valsartan 1x80mg -gabapentin 1x300mg
- Bicnat 1x50mg - drip heparin 200 unit per jam
- Coditam (k/p) - nebul combiven /8jam
- Ksr 600mg -nebul ventolin /12 jam
- Iv metronidazole
500mg/12j Lab 16-06-2019
Hb/Ht/E/L/T : 10,2/30/4,7/10,6/378
Lab 16-06-2019 MCV/MCH/MCHC : 63/22/35
Hb/Ht/L/T : 9,9/30/12,8/292 Diftel : 1/1/1/79/12/6
MCV/MCH/MCHC : 86/28/33 Ca: 7,4
Diftel : 6/0/0/78/9/7 Na/K/Cl: 135/4,2/102
Ca: 9,1
Ur/Cr: 61/5,50 Lab 13-06-2019
Na/K/Cl: 143/3,4/108 PT/APTT: 13/40,30
D dimer: <50,00
Lab 14-06-2019
Ur/cr: 87/6,44 Lab 13-06-2019
Ferritin 42,69
Lab 12-06-2019 Besi: 11
Hb/Ht/E/L/T : 8,1/23/2,8/23,2/226 Urinalisa: normal
MCV/MCH/MCHC : 82/29/35 fesesrutin:normal
Diftel : 2/0/0/92/3/3
Ca: 10 Lab 12-06-2019
GDS: 114 Hb/Ht/E/L/Tr: 7,0/21/3,8/12,6/384
Ur/Cr: 208/10,56 MCV/MCH : 56/18
Na/K/Cl: 141/3,1/103
PT/APTT: 14,01/38,40
ISO 1 ISO 2 ISO 3 ISO 4
DR : dr. Taufiq DR : dr. Muna DR : dr. Riza
COW : dr. Arie COW : dr. Indra COW : dr. Aziz
DM : DPJP NEURO DM : DM :
Raber : Raber :HOM, GH Raber :
DPJP : dr. M. Diah, Sp.PD-KKV DPJP : dr. Fauzi Yusuf Sp.PD DPJP : dr. M Darma Sp.PD
Nama : katijah ibrahim Nama : Basri Abdul Wahab Nama :Nurhakimah mahmud
TTL : 15-03-1962 (57th) TTL :07-11-1977 TTL :20-11-1953 (65th)
Alamat : Aceh Besar Alamat : Banda Aceh Alamat : Lhokseumawe
CM : 0-88-65-79 CM : 1-08-78-64 CM : 0873253
Hari Rawatan : 2 Hari Rawatan : 9 Hari Rawatan : 5

A/ A/ A/
1. CKD stg V dengan uremic 1.NHL pro kemoterapi siklus I dgn 1.abses ar cruris dextra dd/ DVT
syndrom ec dd/ regimen ICE MESNA 2.DM tipe 2 OW
- HN 2.AKI stg III dd acute on CKD 3.Hipokalemia
- PNC
2. CHF FC NYHA I-II ec dd Th/ Th/
- IHD - Bedrest - Bedrest
- HHD - Diet MII 1700kkal/hr - Diet DM 1700 kkal/hr
3. DM tipe 2 NW - IVFD NaCl 0,9% 20tpm - IVFD NaCl 0.9% 20 tpm
4. Ulkus diabetik ar pedis Sin - Transfusi PRC 1 kolf - Iv. Cefepime 1 g/12 jam( H1)
5. Sepsis ec dd - IV ciprofloxacin 200mg/12j - Paracetamol 3x500 mg
- Pneumonia - MST 2x15mg - Cliodomisin 300 mg 3x1
- urosepsis - Flumucyl 3x200mg - KSR600 mg !x600mg
6. pneumonia - Tracetat 1x160mg
7. hipokalemia sedang - Kalitake 3x1 Lab 13/06/19
8. hiponatremia - Lactulac syr 3xCI D-dimer: 1927,67
9. anemia berat ec dd/ - Bicnat 3x500mg Urinalisa
- penyakit kronis - IV Ondansetron 8 mg/8 jam Ca oxalat : +
- perdarahan - Omeprazole 40 mg/12 jam
Lab 12/06/19
TH/ Lab 16-06-2019 -Hb/Ht/E/L/T: 9,6/28/2,9/90/6,7
- bedrest Hb/ht/E/Tr/L: 8,7/25/3,1/143/4,6 -MCV/MCH/MCHC: 96/33/35
- O2 2-4 liter/menit (NS) MCV/MCH: 83/29 -Diftel: 1/1/0/70/19/9
- Asam folat 2x1 Diftel: 0/0/0/37/43/20 -GDS: 150
- Lenal ace 2x169mg Ca: 8,1 -Ur/Cr: 12/0,65
- Ceftriaxone 2gr/24 jam Ur/cr: 182/4,95 -Na/K/Cl: 140/3,2 D-dimer: 1927,67
- ISDN 2x1 Na/K/Cl: 143/5,2/114 /109
- Kalitake 3x1sch -HbsAg: negatif
- Atorvastatin2x20mg Lab 15-06-2019
- Apidra 6-6-6 Hb/ht/E/Tr/L: 8,1/22/2,7/259/5,5
- IV Furosemid 20mg/24jam MCV/MCH: 83/30
Diftel: 0/0/0/42/44/14
Lab 16/06/19
Na/K/Cl: 111/7,1/90 Lab 13-06-2019
Hb/ht/E/Tr/L: 6,5/20/2,4/26/4,8
Lab 15/06/19 MCV/MCH: 84/27
-Hb/Ht/E/L/T:6,3/17/2,2/33,5/431 Diftel: 0/0/1/64/23/8
-MCV/MCH/MCHC: 78/29/37
-Diftel: 1/0/0/90/4/5 Lab 10/06/19
- Anti HCV/HbsAg : -/- Protein +1
-GDS: 214 Darah +
-Ur/Cr: 223/8,49
-Na/K/Cl: 116/6,7/93 Lab 12-06-2019
Hb/ht/E/Tr/L: 7,7/24/2,7/21/3,8
MCV/MCH: 86/28
Diftel: 0/0/0/70/25/5
Ur/Cr: 136/5,89
Na/K/Cl: 142/6,0/114

Lab 12-06-2019
Protein (+)

Lab (08/06/19)
Hb/ht/E/Tr/L: 8,4/26/3,1/20/6
MCV/MCH: 84/28
Diftel: 0/1/0/53/37/9
GDS: 89
Ur/Cr: 102/6,15
Na/K/Cl: 142/5,9/116
ISO 5 ISO 6 ISO 7 ISO 8
DR : dr. Taufiq DR : dr. Okdimur DR :
COW : dr. Fahril COW : dr. TM Reza COW :
BEDAH ORTHOPEDI DM : DM : DM :
Raber : Raber : neurologi Raber :
DPJP : dr. M. Riswan Sp.PD DPJP : dr. Hendra Zufry Sp.PD DPJP :
Nama : Latifah Sarong Nama : Hamdani HS Nama :
TTL : 1/1/1949(70 th) TTL : 12/08/1951 (67th) TTL :
Alamat : sigli Alamat : Banda Aceh Alamat :
CM : 1210427 CM : 1158923 CM :
HariRawatan : 7 HariRawatan : 4 HariRawatan :

A/ A/ A/
1. AML dd CML 1. DM tipe 2 NW poorly
2. Hiperurisemia controlled
2. Pneumonia Th/
Th/ 3. Pain neuropathy
- Bedrest
-Diet MB 1700 kkal/hari Th/
IVFD RL 20 tpm - Diet MB 1700 kkal/hari
-MST 2x15mg - IVFD NaCl 0,9% 20tpm
- Cs lantus 0-0-0-8 unit
Lab 11/06/19 - Iv cefoperazone 1gr/12j
Hb/Ht/E/L/T: 8,1/23/2,9/139,0/30 - IV mecobalamin 500mg/12 jam
MCV/MCH : 81/28 - Alpentin 3x100mg
Diftel : 0/0/0/1/65/34 - Atorvastatin 1x40mg
Ur/Cr: 35/1,16
Asam urat :11,6 Lab 13/06/19
Hb/Ht/E/L/T: 13,2/38/4,7/8,2/312
Urinalisa MCV/MCH : 81/28/35
Protein +1 Diftel : 3/0/0/41/45/11
Darah + Ca: 9,6
Sedimen urine: Ur/cr: 85/2,98
leuko: 20-25 Na/K/Cl: 135/4,5/104
eritrosit: 90-100
epitel: 3-5

Lab10/06/19
-Hbt /T: 8,2/160.700/35.000
ISO 9 ISO 10 ISO 11 ISO 12
DR : dr. Taufiq
DR : dr. Taufiq DR : dr. Muna
COW : dr. Fahril
COW : dr. Fahril COW : dr. Indra
DM :
DM : DM : DPJP NEURO
Raber : Neurologi
Raber : HOM Raber : PTI
DPJP: dr. M. Riswan, Sp.PD-
DPJP : dr.M. Diah,Sp.PD DPJP : dr. Fauzi Yusuf, Sp.PD
KHOM
Nama : Zairah Ilyas Nama : Syafriadi Nama : Musnaini Abu Bakar
TTL : 16/01/1997 (22th) TTL : 02/04/1991 (28th) TTL : 31/01/1970 (49th)
Alamat : Lhokseumawe Alamat : Aceh selatan Alamat : Aceh Timur
CM : 1211253 CM : 1199294 CM : 1203312
HariRawatan : 4 HariRawatan : 4 HariRawatan : 10

A/ A/ A/
1. Varicella zooster 1.SIDA stadium IV 1. Ca paru std IV post radioterapi
2. Trombositopenia ec ITP 2. pneumonia dd tb paru dengan metastase tulang, otak dan
3. candidiasis oral hepar
Th/ 4.cephalgia 2. Cancer pain
- Bedrest 3. Sirosis hepatis std DC
- Diet Lunak 1700 kkal/hr Th/
- IVFD Nacl 0,9 % 20 tpm - Bedrest Th/
- IV transamin 500mg/8 jam - Kateter urin - Bedrest
- IV metil prednisolon 125mg/12 - Diet sonde 6x200cc/hr - Diet hati II 1700 kkal/hr
jam - IVFD Nacl0,9 % 20 tpm - IVFD aminofusin hepar 1 fls/hr
- Azatioprin 50 mg 2x1 - cotrimoxazole 1x960 mg - IV citicolin 500mg/12j
- Valacyclonir 3x1000mg - nystatin oral drip 4x 2cc - IV mecobalamin 500mg/12j
- Cetirizine 1x10mg - synbio 3x1 - IV ranitidin 50mg/12j
- Protop cr 3x1 - endostein 2x300mg - Propanolol 1x10mg
- Eltrombopag ( rebozet) 25mg - paracetamol 3x500mg - MST 2x10mg
Lab (14/06/19) - KCl 25 mEq dalam 200cc NaCl - Levofloxacin 1x500mg
Hb/Ht/E/L/Tr: 9,4/29/3,7/9,3/4 0,9% 600mg/8jam - Laxadine syr 3x1
MCV/MCH: 79/25 - KSR 3x2 - Cetirizine 1x1
Diftel: 0/0/0/64/27/9 - Attapulgit 2 tab. Selanjutnya 1 tab - Depakote 1x250mg
tiap muntah. - Dexamethasone 1x2mg
Lab (13/06/19) - Ranitidin 2X50 mg
Hb/Ht/E/L/Tr: 9,5/29/3,7/7,5/6,6 Lab (15/06/19) - Curcuma 2x1
MCV/MCH: 77/26 Na/K/Cl: 135/3,9/111 - Borevru 1 fls/ 24 jam
Diftel: 0/1/0/72/23/4 Ca: 7,1
PT/APTT : 13,40/30,40 Lab (13/06/19)
Anti HCV :- Lab (15/06/19) Hb/Ht/E/L/Tr: 14,3/40/4,7/34,5/252
HbsAg:- Albumin: 2,64 MCV/MCH: 85/30
Ur/Cr: 14/0,61 Na/Cl: 137/112 Diftel: 0/0/0/83/6/11
Ca: 7,1 PT/APTT : 12,70/28,10
D.dimer: 4012,43
Lab (14/06/19) Anti HCV :-
Na/K/Cl: 134/2,1/108 HbsAg:-
SGOT/SGPT: 279/200
Lab (13/06/19) Ur/Cr: 80/0,74
Hb/Ht/E/L/Tr: 10,6/30/3,9/3,5/180 Asam urat : 4,2
MCV/MCH: 77/27/36 Ca: 7,9
Diftel: 0/0/0/79/3,2/7 Na/K/Cl: 126/3,6/96
SGOT/SGPT: 39/37
Ur/Cr: 26/0,54 Lab (07/06/19)
Na/K/Cl: 138/1,7/105 PT/APTT: 13,20/31,40
D-dimer: 1621,22

Lab (07/06/19)
Hb/Ht/E/L/Tr: 14,7/42/5/21,3/485
MCV/MCH: 83/29
Diftel: 0/0/1/87/5/7
Bil.total/diret/indirect:
17,35/11,85/5,5
SGOT/SGPT: 420/256
Protein total/Alb/Glo: 4,51/2,60/1,91
GDS: 70
Ur/Cr: 36/0,59
Na/K/Cl: 134/3,8/96