MAPPING AQSHA 1

Jumat, 12 April 2019

Tim Jaga : dr. Munawar/ dr. Taufik
Dokter Muda : Cita, S.Ked/ Raihan, S.Ked

KELAS 1 KELAS 2 KELAS 3 KELAS 4

DR : DR : dr. Riza DR : dr. Riza
COW : COW : dr. T. Fahril COW : dr. T. Fahril
DPJP BEDAH ORTHOPEDI
DM : DM : DM :
Raber : Raber :EMD Raber : EMD
DPJP: dr. M. Diah, Sp. PD DPJP: dr. M. Riswan, Sp. PD DPJP : dr. M. Riswan, Sp.PD.
Nama : Yusuf Gade Nama : Marzuki Nama : Jufri Hasbi
TTL : 21-09-1940 (78 th) TTL : 10-09-1971 (47 th) TTL : 9/05/1972
Alamat : Banda aceh Alamat : Aceh Besar Alamat : Aceh Besar
CM : 0-99-66-30 CM : 1009471 CM : 1174440
Hari Rawatan : 1 Hari Rawatan : 16 Hari Rawatan : 4

A/ A/ A/
1. Geriatri Problem 1. Ulkus diabetikum a/r pedis sinistra 1.Adenocarsinoma tiroid post
- inanisi dengan osteomyelitis kronik radioiodine T4b N1M1
- infeksi 2. DM tipe 2 NW 2. Post Traceostomy urgency
- immobilisasi 3. Anemia sedang hipokrom mikrositer 3. Hipotiroid
- impairment of hearing and visual ec DD/ 4. impending OSNA
2. Ulkus decubitus grade II ar. Sacrum - Penya. Kronis 5. hiponatremia hipoosmolar
3.Hipoalbuminemia berat - Perdarahan euvolemik
4. Pneumonia geriatric 4. Hipoalbuminemia
5. Hipocalcemia ringan Th/
Th/ 6. Hipokalemi ringan - bedrest
-bedrest 7. Hiponatremia hipoosmolar euvolemik - Diet sonde 6x200 kkal/hari
-O2 2-4 L/i 8. Konstipasi - euthyrax 1x100mg
-diet sonde 6x200 kkal/hari 9. Pneumonia ec DD - ostriol 2x1
-IVFD Nacl 0,9% 20 tpm - TB paru - ca laktat 2x1
-IVFD Clinimix 1 flsh/hari - Penyakit Kronik - alprazolam 1x0,5mg
-Drip albumin 25% 100 cc/hari 10. Post debridement ulkus diabetikum - erdostein 3x1
-IV. Ceftriaxone 2 gr/24 jm - nebule pulmicort /12 jam
-Clindamicyn 3x300 mg Th/ - metil prednisolone 3x4mg
-burrnazin zalf untuk luka decubitus - Bedrest - salbutamol 2x2 mg
- diet DM 1700 kkal/hari - iv ceftriaxone 1 gr/12 jam
Lab 09/04/19 - IVFD futrolit 20 tpm
Alb : 2,31 - SC lantus 0-0-0-10 unit Lab 09-04-2019
- Clindamisin 3x300mg (H9) Ca: 9,4
Lab 08/04/19 - Paracetamol 3x500mg Na/K/Cl: 144/4,3/88
Hb/L/T: 12,2/9/245 - IV Ca Gluconas 1 amp/ 8 jam Free T3 1,16
MCV/MCH/MCHC : 82/29/35 - Drip Albumin 25 % 100 cc/ hari Free T4 5,94
Diftell: 0/0/0/85/12/3 - IV Vancomisin 1gr/8jam (H4) TSH >60,00
GDS : 236 - Domperidone tab 3x10mg
Ur/Cr : 26/0,27 - Sucralfat syr 3xCI Lab 06/04/19
Na/K/Cl : 133/4/92 - KSR 1x600mg Hb/L/T: 11,9/5,9/236
- Dulcolax tab 2x1 MCV/MCH: 84/30
- Transfusi PRC 1 kolf dengan premed 1 PT/APTT : 0,92/1,03
amp furosemide Alb : 4,25
Ur/Cr : 9/0,61
Lab 11/04/19 Na/K/Cl/Ca : 128/4,1/85/8,8
Hb/L/T: 8,4/13,4/188
MCV/MCH/MCHC : 74/26/35
Diftell: 1/0/0/83/11/5
Ca : 8,2
Ur/Cr : 31/0,52
Na/K/Cl : 136/3,1/90

Lab 10/04/19
Alb: 2,47

Lab 07/04/19
Hb/L/T: 11,2/12,0/237
MCV/MCH: 74/26
Diftell: 0/0/0/88/8/4
Alb: 2,22

Lab 05-04-2019
Hb/Ht/E/L/T: 9,1/27/3,6/14,2/311
MCV/MCH:74/25
Diftel: 0/0/0/91/5/4
PT/APTT: 14,0/49,1
Alb: 2,53 Ca: 8,4 GDS : 140
Na/K/Cl:131/3,5/99
 KELAS 5 KELAS 6 KELAS 7 KELAS 8
DR : DR : dr. Riza
COW : COW : dr. T Fahril
DPJP NEUROLOGI DM : DM : DPJP ORTHOPEDI
Raber : Raber : Geriatri, kardiologi
DPJP : dr. Azzaki Abubakar, Sp.PD DPJP : dr. M Riswan, Sp.PD
Nama : Makawiyah Nama : syarifah Fatimah
TTL : 31-12-1960 (58 th) TTL : 31/12/1928 (90 th)
Alamat : Aceh Timur Alamat : Banda Aceh
CM : 1-20-60-73 CM : 0-96-04-41
Hari Rawatan : 1 Hari Rawatan : 11

A/
1. PSMBA ec DD :
-Ulkus Gaster
-Ulkus Duodenum
-Gastritis erosive
-Ca Gaster
Th/
-Bedrest
-O2 2-4 L/I vial Nasal kanul
-NGT
-Diet sonde 6x50 cc
-IVFD Nacl 0,9 % 10 gtt,i
-IV. Lansoprazole 30 mg/12 jam
-Sucralfat syr 3xCI
-Flumucyl 3x1
-IV. Ceftriaxone 2 gr/24 jam
-Paracetamol 3x500 mg
-Transfusi PRC sd HB >10 gr/dL
Lab 11-04-2019
Hb/Ht/E/L/T: 1,1/36/5,6/12,2/254
MCV/MCH/ MCHC : 63/20/31
Diftel: 1/0/0/78/13/8
Ur/Cr: 92/0,84
Na/K/Cl : 172/3,7/15
GDS : 144
PT/kontrol/INR : 14,9/13,1/1,12
APTT/Kontrol : 29,5/31
HBsAg/ Anti HCV : negatif/negatif
A/
1. Penurunan kesadaran ec dd
1) SDA
2) Sepsis
3) Imbalance elektrolit
2. Sepsis ec dd
1) CAP
2) Ulcus decubitus
3. Pneumonia CAP
4. DM Tipe 2 Normoweight
5. Ulcus decubitus gr III ar sacrum
6. Anemia NN ec dd
1) Penyakit kronis
2) Perdarahan
7. Geriatric problem
8. Hipoalbuminemia
9. Hipertensi urgensi
10. ISK
Th/
- Bedrest
- O2 2-4 l/I Nasal canul
- Diet sonde 6x200 kkal/hari
- IV cefepime 1 gr/8 jam
- drip albumin 25% 100 cc/hari
- valsartan tab 1x80 mg
- amlodipine tab 1x5 mg
- fosen enema (k/p)
- drip pct (k/p)
- IVFD futrolit 20 tpm
- Drip hidronac 1000 mg + 100 cc Dex
5% habiskan selama 2 jam dalam 5
hari
-cetirizine 1x10 mg
-inerson ointment 4x1
-Colostazole1x100 Mg
- Amikasin 500 mg/12 jam

Lab 09-04-2019
Hb/Ht/E/L/T: 8,1/25
MCV/MCH: 91/29
Diftel: 0/0/0/91/5/4
Ca 10,0
Ur/Cr: 82/0,73
Na/K/Cl : 138/5,0/115

Lab 08-04-2019
AGD : pH (7,5) pCO2 (35,90) pO2
(161) HCO3 (28,3) total CO2 (29,3)
BE (5,4) sat O2 (97,1)

Lab 05-04-2019
Hb/Ht/E/L/T: 7,9/24/2,7/16,3/188
MCV/MCH: 91/30
Diftel: 0/0/0/86/9/5
 KELAS 9 KELAS 10 KELAS 11 KELAS 12
DR : dr. Taufiq DR : dr. Riza
DR : dr. Riza
COW : dr. Ade COW : dr. Indra
COW : dr. Indra
DM : DM : DPJP BEDAH ORTHOPEDI
DM :
Raber: GH, EMD Raber : HOM
Raber : GH, Geriatri
DPJP : dr. Azhari Gani, Sp.PD DPJP: dr. Fauzi Yusuf, Sp.PD
DPJP: dr. Fauzi Yusuf, Sp.PD
Nama : Mustafa Nama : Ismadi Nama : Chairuddin
TTL : 31/12/1968 TTL : 31-01-1957 (62 th) TTL : 11/6/1961
Alamat : Aceh Selatan Alamat : Aceh besar Alamat : Aceh Besar
CM : 1204869 CM : 0-99-18-59 CM : 1201802
Hari Rawatan : 13 Hari Rawatan : 22 Hari Rawatan: 4

A/ A/ A/
1. Penurunan kesadaran perbaikan 1. CKD stage V ec DN on HD reg 1. Limfadenopati colli dex et sin ec
ec DD/-uremic ensefalopati – 2. DM tipe 2 normoweight DD/metastase, Ca nasofaring
stroke iskemik – sepsis 3. Anemia sedang Hipokrom 2. Anemia sedang NN ec penyakit
2. Sepsis ec DD/-pneumonia – mikrositer ec. Penyakit ginjal kronik kronik
urosepsis 4. Konstipasi (perbaikan) 3. Hipoalbuminemia
3. Hemiparese sinistra ec stroke 5. Hipokalsemia (perbaikan) 4. Hiponatremia hipoosmolar
iskemik 6. Gangguan penyesuaian hipovolemik
4. Pneumonia DD/infeksi paru 5. Disfagia ec dd NPC, metastase
spesifik Th/ proses
5. HHD - bedrest 6. Nasofaringitis
6. Ulkus decubitus grade 1 -Diet sonde ginjal 6x200 cc total 7. Paralisis plika vocalis sinistra
7. Retinopati diabetic 1700kkal/hari + protein 70 gr/hari + dengan stomatitis
8. DM tipe 2 dgn critical ill karbohidrat 300 g/hari,+ lemak 57 Th/
9. CKD stg V ec PNC gr/hari - Bedrest
- Mobilisasai, Mika Miki/2 jam - O2 2-4L/i
Th/ - NGT - Diet sonde 6x200cc via oral
-Bedrest - IV citicolin 500 mg/12 jam - IV ceftriaxone 1gr/12jam
-O2 NK 2-4L/i - HD senin-kamis - IV OMZ 40mg/12jam
-Diet sonde 6x200 cc - Balance cairan seimbang - Flumucyl syr 3xC1
-Insulin drip 0,5cc/jam target 140-180 - IVFD dex 5% 1 fls/hari 5gtt/i - Pradaxa 75 mg/12 jam
mg/dl - Lenal Ace 2x169 mg - Clinimix 1 fls/24 jam
- IV Moxifloxacin 400 mg/24 jam - Asam folat 2x400 mcg - Nystatin drop 3x2 tts
- lenal ace 2x169mg - Lactulac 15 cc/8 jam
- asam folat 2x400mcg - IV Ca Glukonas 1 am/8jam Lab 10/4/19
- kalitake sach 3x1 - Haloperidol 2x0,5 mg Urinalisa
- IV Ca glukonas 1amp/8jam - lactulosa 3x30 mg protein (+1)
- Cendo vitrolenta 4gtt1 - Metoclopramide 1 amp/8 jam bilirubin (+)
- CPG 1x75mg leu 6-8
- Atorvastatin 1x40mg Lab 07/04/19 Epi 3-5
-SC apidra 3-3-3 iu Hb/L/T: 8,7/6,6/225
MCV/MCH: 66/22 Lab 8/4/19
Lab 03/04/2019 Diftell: 6/1/0/62/23/8 Hb/L/T : 6,9/12,3/769
Ca : 9,5 Ca : 7,6 MCV/MCH : 79/29
Na/K/Cl : 134/6,1/100 Ur/Cr : 118/9,41 GDS : 170
Na/K/Cl : 134/4,1/91 Ur/Cr : 35/0,60
Urinalisa : protein (+2), darah (+) Na/K/Cl : 120/4,5/90
Leukosit 8-10, eritrosit 10-15, epitel Lab 04/04/2019
10-20. Alb : 3,3
Ca : 10,2
Lab 01/04/19 Ur/Cr : 187/10,2
Hb/L/T: 8,7/20,0/215 Na/K/Cl : 129/4,6/9,1
MCV/MCH: 87/29
Diftell: 0/0/0/85/5/10 Lab 31/3/2019
Ca : 9,4 Ca: 9,7
Ur/Cr : 331/12,77 Na/K/Cl : 132/4/91
Na/K/Cl : 132/6,8/103
Lab30/3/2019
Hb/Ht/E/L/T : 8,8/27/3,9/9,8/132
MCV/MCH/MCHC : 69/23/33
Ca : 8,8
Na/K/Cl : 134/4/99

Lab 27/03/19
Hb/L/T: 9,1/9,5/273

Lab 24/3/2019
Hb/Ht/E/L/Tr: 7,3/21/3,2/20,5/130
MCV/MCH/MCHC: 65/23/35
 ISO 1 ISO 2 ISO 3 ISO 4
DR : DR : dr. Wahyu
COW : COW : dr. Dedi
DPJP BEDAH ORTHOPEDI
DPJP BEDAH DIGESTIVE DM : DM :
Raber EMD
Raber : Raber : Kardio
DPJP : DPJP: dr. M. Diah, SP.PD
Nama : Nama : Zulkifli Abbas
TTL : TTL : 22/05/1951
Alamat : Alamat : Lhoksemawe
CM : CM : 1185862
Hari Rawatan : Hari Rawatan : 12

A/ A/
1. Gangren diabetic ar pedis (S)
Th/ 2. CHF FC NYHA II-III ec. HHD
3. DM tipe II normoweight
4. HHD
5. Geriatri problem
- inanisi
- instabilitas dan jatuh
- Infeksi
- imobilisasi
- impairment of vision
6. AV block derajat I
7. pneumonia CAP

Th/
- Bedrest,
- Diet sonde 6x200 cc/hari
- threeway
- IV Ceftriaxone 2 gr/ 24 jam
- IV mecobalamin 500mg/12jam
- Atorvastatin 1x20 mg
- Clindamycin 3x300mg
- Lactulac syr 3xC1
-Gabapentin 1x100mg
-Rawat luka/24jam

Lab 06/04/19
Hb/L/T: 10,4/11,9/454
MCV/MCH: 86/28
Diftell: 2/0/1/76/13/8
Alb: 3,05
Ur/Cr: 69/1,05
Na/K/Cl: 142/5,9/99

Lab 01/4/2019
Hb/Ht/E/L/Tr: 8,8/26/3,1/10,6/335
Alb: 3,31
GDS: 163
Ur/Cr: 113/1,04
Na/K/Cl: 146/4,9/109
 ISO 5 ISO 6 ISO 7 ISO 8
DR : dr. Riza DR : dr. Wahyu
COW : dr. Indra COW : dr. Dedy
DPJP NEUROLOGI
DPJP DEPT KARDIOLOGI DM : DM :
Raber : GH Raber : PTI
DPJP: dr. Fauzi Yusuf, Sp.PD DPJP: dr. Azzaki, Sp.PD
Nama: Ivo Rista Nama : Surya Mukti Lestia
TTL: 10-09-1975 TTL : 14-08-1992(26 tahun)
Alamat: Bener Meriah Alamat : Aceh Singkil
CM: 0998972 CM : 1127034
Hari Rawatan: 20 Hari Rawatan: 15

A/ A/
1.Penurunan kesadaran ec dd 1.SIDA stadium IV
- Recurrent stroke 2.Anemia berat hipokrom mikrositer
2. PSMBA ec dd (perbaikan) ec DD
-Stress ulcer - defisiensi Fe
-Ulcus gaster - Peny.Kronik
-Induced heparin 3. Trombosis ec dd
3. CKD stage 5 on HD Reguler -DIC
4. Hipoalbuminemia -Viral Infection
5. Trombositopenia 4. candidiasis oral
6. Recurrent stroke 5. Prurigo Nodular
7. ulkus decubitus grade II 6. Peningkatan enzim transaminase ec
8. hiponatremia hipervolemik dd :
9. Hipokalsemia -Infeksi virus
-Drug Indused
Th/ 7. PSMBA ec DD/
-Bedrest, kasur decubitus - gastritis erosive
-Mobilisasi, mika miki /2 jam - ulcus gaster
-Diet Ginjal 1700 kkal/hari - ulkus duodenum
-O2 2-8 L/menit Simple mask 8. epistaksis anterior
-IVFD nacl 3% 10 tpm 9. Pneumonia DD/ infeksi paru
-Herbesser CD 1x200mg spesifik
-Amikasin 250mg/72jam post HD
-IV Furosemid 20 mg/ 8 jam Th/
-Drip albuminar 100 cc/hari -bedrest
-Trf PRC s/d HB >9gr/dl (ON HD) -Diet MII 1700 kal/hari
-HD free heparin (senin, rabu, jumat) - IVFD aminofluid 1 fls/hari
-IV .Omeprazole 40 mg/12 jam
-HCT 2x25 mg Lab 9/4/2019
-KSR tab 2x1 Bil. Tot/direct : 1,19/0,71
-Metronidazole 500 mg/8jam SGOT/SGPT : 126/125
-Ca.Glukonas 1 amp/8 jam
-Valsartan 1x16 mg Lab 7/4/2019
-Nystatin drop 4x 2 gtt Biltot/dir/indir: 1,19/126/125
-asam folat 40 mg/12 jam
-Citicolin 2x50 mg Lab 7/4/2019
Hb/Ht/E/L/T : 6,7/19/2,6/4,0/37
Lab 11/04/19 AGDA : MCV/MCH : 74/26
PH/PCO2/PCO2 : 7,482/34,10/254 PT/APTT : 1,03/1,45
HCO3/tot.CO2/BE : 25,7/26,8/3
Sat O2 : 98,1 Lab 6/4/2019
SGOT/SGPT : 600/150
Lab 10/04/19 Bilirubin tot/dir/indir : 1,06/0,58/0,48
Hb/l/T: 7,4/16,2/46
MCV/MCH/MCHC : 82/29/35 Lab 3/4/2019
Diftell: 0/0/1/89/6/4 Hb/Ht/E/L/T : 6,3/18/2,6/2,6/64
Alb / Ca: 2,18/ 7 MCV/MCH : 70/24
Ur/Cr : 46/1,99 SGOT/SGPT : 600/155
Na/K/Cl : 126/3/89 PT/APTT : 17,2/68,8

Lab 07/04/19
Hb/l/T: 8,3/17,2/51
MCV/MCH: 82/29
Diftell: 0/1/0/91/4/4
Alb: 2,2, Ca: 7,5
Ur/Cr: 59/1,74
Na/K/Cl: 127/3,1/88

Lab 05/04/2019
Hb/Ht/E/L/T : 8,2/23/2,9/18,9/36
MCV/MCH/MCHC : 81/29/3
Diftel : 0/1/0/89/6/4
PT/ APTT : 12,1/44,8 , Alb : 2,33
Ur/Cr : 77/2,26
Na/K/Cl : 117/2,9/8
 ISO 9 ISO 10 ISO 11 ISO 12
DR : dr. Riza DR : dr. Reyza
DR : dr. Wahyu DR :
COW : dr. T Fahril COW : dr. Febri
COW : dr. dedy COW :
DM : DM :
DM : DM :
Raber: HOM Raber :
Raber : Raber :
DPJP : dr. M. Riswan,Sp.PD KHOM DPJP: dr. Chacha M, Sp.PD
DPJP: dr. M Diah , Sp.PD DPJP:
Nama : Khatijah Nama :Farqadah Mala Nama : Nama : Dicki Juliandri
TTL : 31-12-1938 (80 th) TTL : 09/03/1972 (47 th) TTL : TTL : 21/07/1995 (23th)
Alamat : Ulee kareng Alamat :Banda Aceh Alamat : Alamat : Aceh Barat daya
CM : 1-07-63-22 CM :1205501 CM : CM : 1205981
Hari rawatan: 3 Hari Rawatan : 8 Hari Rawatan : Hari Rawatan: 2

A/ A/ A/ A/
1. Anemia sedang normokrom 1. Bisitopenia ec DD/ 1. PSMBA ec dd
normositter ec dd - multiple myeloma 1) Stress ulcer
- perdarahan - leukemia akut Th/ 2) Gastritis erosive
- Penyakit Kronik - MDS 2. Anemia ringan ec dd
2. Hipoalbumin sedang 2. Fr compresi VT8,VT10 dan VL3 1) Perdarahan
3. Diare akut ec DD : 3. cancer pain 2) Penyakit kronis
- Infeksi virus 4. hypokalemia sedang 3. Efusi pleura sinistra ec dd
- Infeksi Bakteri 5. Trombositopenia 1) Infeksis spesifik
- Infeksi Parasit 2) Malignancy
Th/ 4. Asites ec dd
Th/ - Bedrest 1) Infeksi spesifik
-Bedrest - diet MII 1700 kkal/hr 2) malignancy
-Diet MB 1700 kkal/hari + protein 80 - Threeway
gr/kgBB - MST 2x 15 mg Th/
-IVFD NaCl 0,9% 20 tpm - tracetat 2x1 - Bedrest
-Cefixime 2x100 mg - KCL 25 meq daam NaCl 0,9 % 500 - O2 2-4L/i
-Loperamid 1 tab tiap kali mencret cc 15 tpm - Diet MB 1700 kkal/hari
maksimal 8 tablet - IV. Ca Glukonas 1 amp/8 jam - IV ceftriaxone 2gr/24 jam
- Iv furosemide 40 mg/24 jam
Lab 10-4-2019 Lab 10/4/19
Hb/L/T: 8,4/9,7/314 Hb/Ht/E/L/T : 10,2/29/3,7/6,5/21 Lab 10/4/19
MCV/MCH : 81/28 MCV/MCH : 80/28 Hb/Ht/E/L/T : 9,9/30/4,0/6,4/424
Diftel: 2/1/0/63/27/7 Diftel : 2/1/0/55/24/18 MCV/MCH : 74/25
Retikulosit : 4,3 Ca : 7,1 Diftel : 2/1/0/71/15/11
MDT : Na/K/Cl : 138/2,6/110 Alb : 2,98
Kesimpulan : anemia normokrom GDS : 87
normositter Lab 07/04/19 Ur/Cr: 13/0,59
Hb/L/T:7,5/5,1/30 Na/4,8/94
Diftell: 2/2/047/34/15

Lab 5/4/2019
Hb/L/T :9,1/6,5/45
Diftel : 1/0/0/60/25/14
MCV/MCH:80/29
GDS: 97
Ur/Cr: 46/1,08
Na/K/Cl: 140/3,5/98