MAPPING AQSA 1 (Zamzam)

(Minggu, 10 Oktober 2021)

Tabulasi DPJP

No Nama DPJP Kamar Jumlah

1. dr. T. Mamfaluti SpPD Zamzam 1. K08. Zamzam 1K11. 2

2. dr. M. Riswan, Sp.PD KHOM Zamzam 1 K17 1

3. dr. Vera Abdullah, Sp.PD KPSi Mina 2 K7B3, Zamzam 1 K06 2

4. dr. Hendra Zufry Sp.PD KEMD Zamzam 1 K20 1

5. dr. Azhari Gani Sp.PD KKV Zamzam 3 Kamar 8 1

Zamzam 1 K06 Zamzam 1 Kamar 2 Zamzam 1 K08 Zamzam 1 K17

DPJP dr. Vera Abdullah,
Sp.PD KPsi
Cow dr. Rizqi Aulia
Ruangan : dr. K. Hendra
Nama : Tjut Maneh
CM : 103 59 84
TL : 7/4/1952 (69 th)
TM : 8/10/21
Ass/
1.Lower urinary tract
infection ec dd 1. Cystitis 2.
Uretritis
2. Gastropati diabetik
3. DM tipe 2 dgn obesitas
grade 2 Unwell controlled
4. Pain ec post ORIF a/r
Humerus dextra
5. Inanisi due to pain
6. Instabilitas dan Jatuh
7. Imobilisasi
8. Obesitas gr 2
9. Hipokalemia sedang
10. Hipoalbuminemia
sedang
11. Diabetik neuropati
Th/
Mobilisasi pasif
IVFD RL 20 tpm
Drip Levofloxacin 500
mg/24 jam (8/10)
IV Pantoprazole / 12 jam
Sucralfat syr 3xcI
Curcuma 3x1
Paracetamol 2x1000 mg
KSR 3x600 mg
Domperidone 3x10mg
Gabapentin 1x100mg
Lab 09/10/2021
PT/aPTT : 1,19/1.2
Anti HCV : Negatif
HBsAg : Non reaktif
SGOT/SGPT :59/13
Albumin : 2,5
Na/K/Cl : 139/4.4/108
Ca : 7.8
Urinalisa 08/10/2021
Warna Kuning keruh,
Leukosit (+), Darah (+),
Leukosit 25-50 LPB, Bakteri
(+)
Lab 7/10/2021
Hb/L/T : 13,5/16,3/218
Diftel : 0/0/0/87/10/3
Albumin : 3,0
Ur/Cr : 11/1,1
Na/K/Cl : 140,2,8/104
GDS : 271
Ca : 8,2
DPJP: dr. M. Riswan, SpPD- DPJP : dr. T.Mamfaluti,
KHOM Sp.PD
COW : dr. Saddam
(Divisi HOM) Ruangan : dr. Aidil
Nama: M Ridha Galis Nama: Adam Naja
CM: 1-23 77 82 CM: 126-98-50
TL: 08/05/1992 (29) TL: 03/04/2001
TM: 08/10/2021 TM: 03-10-2021
Raber GH
Ass Ass/
1. Anemia sedang HM ec 1. PSMBB (perbaikan ) ec
Malignancy dd 1) uremic bleeding 2)
2. Ca Nasofaring pro hemoroid
kemoterapi siklus V 2. CKD stage 5 dengan
Th/ uremic sindrom ec dd 1)
Bedrest PNC 2) HN
Diet MB 1700 kkal/hari 3. CHF NYHA ec dd 1)
IVFD NaCl 0,9% 20 tpm HHD2) sindrom kardiorenal
Omeprazole 2x1 4.Anemiasedang
Xarelto 1x10 mg normokrom normositer ec
Mecobalamin 3x500 mg dd 1) penyakit kronik 2)
perdarahan
Lab 08/10/2021 5.Hipoalbuminemia sedang
Hb/L/T : 9,3/ 3/112 ec dd 1) low intake 2) renal
MCV/MCH/MCHC: loss
90/34/37 6. Hiperkalemia ringan
Diftel : 0/0/0/58/34/8 Th/
Anc : 1740 Bedrest semifowler
O2 2-4 liter/menit
IVFD Nacl 0,9 % 10 tpm
IV Ceftriaxone 2 gr/24j
Drip Pantoprazole (2 vial +
Nacl 0,9%) kec : 5 cc/j
IV Ondansetron 4mg/8jam
Drip Furosemid 1cc/jam
Transamin amp / 8jam
Lenal ace 2x169mg
Asam folat 2x0.4 mg
Flumucil 3x200mg
Herbesser 1x200mg
Bisoprolol 1 x 5 mg
Klonidin 3 x 0,15 mg
Valsartan 1 x 160 mg
Kalitake 3x1 sach
Sucralfat Syr 3 x CII
8/10/21
Hb/L/T : 8,6/9,7/135
Mcv/Mch : 79/29
Diftel : 0/0/0/91/4/5
Ur/Cr : 132/11,60
Albumin ; 3,10
7/10/21
Hb/L/T : 6,8/ 9,8/148
MCV/MCH : 79/28
Diftel : 2/0/0/85/8/5
Ddimer : 2810
Pt/apt : 0,99 / 1,0
Na/K/Cl : 130/5,70/99
Calsium : 7,7
Ur/Cr : 189/14,90
SGPT / SGOT : 195/96
Lab 05/10/21
Hb/L/T : 1,9/7,5/113
MCV/MCH : 79/29
Diftel : 2/0/0/70/17/11
PT/APTT : 1,35/ 0,9
Ddimer : > 4000
Albumin : 2,40
Kalsium: 7,6
Ur/Cr : 165/12,90
Na/K/Cl: 133/6,20/108
DPJP : dr. M. Riswan,
SpPD-KHOM
COW : dr. Rizqi
Ruangan : dr. Marcellinus
Nama : Tini binti Satiman
CM : 1-28-44-49
TM : 03/10/2021
TL : 08-08-1969
Ass/
1. Kolitis
2. Tumor kolon descenden
susp malignancy
3. MDS
4. Hipertensi stg I
5. Gastritis erosif
6. Esofagitis gr A
7. Hipoalbuminemia (Alb 2,5)
8. Hipokalemia ringan (K: 3,2)
Th/
- Diet MII 1700 kkal/hari
- IVFD NaCl 0,9% 20 tpm
- IV Lansoprazole 30 mg/12j
- IV Ondansetron 4 mg/8 jam
- Synbio 3 x 1 tab
- Valsartan 1 x 80 mg
- Sandimun 2 x 100 mg
- Attapulgite 1 tab/BAB cair
- KSR 1 x 600 mg
- Dompridone 3x10mg
- Sucralfat syr 3x10ml
- Salofalk 2x250mg (8/10/21)
- Anti hemoroid supp 2x1
P/
- CT Scan Abdomen kontras-
nonkontras hari Kamis
14/10/2021
Kolonoskopi 8/9/2021 :
- Kolitis
- Tumor kolon descenden susp
malignansi
Lab 03/10/2021
Hb/L/T : 9,6/7,0/422
MCV/MCH/MCHC: 72/24/33
Diftel : 6/1/1/60/21/11
PT/aPTT : 1,01/1,02
Anti HCV : Negatif
HBsAg : Non reaktif
Albumin : 2,5
Na/K/Cl : 145/3,2/115
Ca : 7,9
Ur/Cr : 16/0,7
GDS : 108
 Zamzam 1K11 Zamzam 1 K20 Mina 2 K7B3 Zamzam 3 kamar 8

DPJP: dr. T. Mamfaluti, Dpjp : dr. Hendra Zufry DPJP: dr. Vera Abdullah, DPJP: dr. Azhari Gani, Sp
Sp.PD SpPD KEMD Sp.PD KPSi pD- KGH
Cow : dr. Rizqi Aulia
COW: dr. Saddam Emir Oetama
COW: dr. Rizqi Aulia COW: Saddam
Ruangan: dr. Aidil Ruang : dr. Bayu Oetama Ruangan: Murdia
Ruangan: dr. Fathir Raber : GEH
Nama: Rusmiati Nama : Salimah abdul Nama : Sakirawati Nama: Husnul Maab
CM: 1060848 hamid TTL : 13/07/1979 CM: 1287534
Tl : 29-9-1959
TL: 12/01/1968 Cm :0687867
NCM : 1054888 TL: 23-6-1969 (52)
TM: 04/10/2021 Tm : 9/10/2021 TM : 04/10/2021 TM: 06/10/2021
Ass/ Ass/ Ass/ Ass :
1. Dysphagia ec dd: 1.Hiponatremia 1. Pneumonia Lobaris (HAP) 1. Diare Akut dengan
hipoosmolar hipovolemik
- malignancy proses 2. Hipokalemia sedang
2. Bisitopenia ec dd: dehirasi ringan sedang
- akalasia 3. Geriatri problem - malignansi proses 2. DD 1) Gout arthritis
2.Pansitopenia ec dd 4. post tiroidectomi - ITP 3. High risk thrombosis
malignancy 5. Adeno Ca kolorectal - Paraneoplastik syndrome 4. Hemoroid Eksterna
3. AKI stage I 6. DM tipe 2 - MDS
4. Tumor konjungtivs kiri 3. Ca mamae post Th/
(non keratinizing squamous Th/
mastektomi putus Bedrest
cell carcinoma ) Bedrest kemoterapi 2 siklus O2 2-4 lpm
Diet DM sonde 6x200 4. Elevated liver enzyme IVFD RL 20 tpm
Th/ IVFD nACL 0,9% 20 tpm 5. Neutropenia (Perbaikan) IV Ceftriaxone 2g/24 jam
Bed rest IV Lansoprazole 30mg /24 (7/10)
jam
Diet sonde cair 6x200cc Th/ IV Lansoprazole 30mg/12
Levotiroksin 1x100 mcg
IVFD NaCl 3% 15tpm Domperidone 3x10 Bed rest jam
IV lansoprazole 30mg/12j Glurenorm 1x 30 mg Diet lunak 1700kkal/hari IV Transamin 1 amp/8 jam
Nystatin drop 4x2cc Metformin 2x500 mg IV Levofloxacin 500mg/24jam IV Vit K 1 amp/12 jam
Curcuma 3x1 Curcuma 3x1 IV Pantoprazole 40mg/24jam Attapulgite 2 tab per kali
Domperidone 3x10 mg IV Ondansetrone 4mg/8jam BAB cair
Nifedipin 1x 10mg Lab 09/10/2021 Curcuma 3x1 tab Synbio 1x1
Valsartan 1x160 mg Hb/l/t : 10,1/2.4/376 Paracetamol 500mg+N- Sucralfat syr 3xCI
Mcv/mch/mchc : 84/29/35 acetilsistein 200mg 3x1 Curcuma 3x1
Diftel : 0/0/0/82/13/5 Codein 3x10mg Recolfar 2x1
Alb 2,8
Lab 7/10/21 Cetirizine 2x10mg Zink 1x1
Calc : 6,9
Hb/L/ T : 11/2,2/12 Na/K/Cl : 127/2,5/78 Vastral 3x1
Mcv/Mch : 77/28 Lab 09/10/2021
Diftel : 1/1/0/ 62/20/16 Hb/l/t: 9.1/7.6/49 Lab 8/10/21
Na/K/Cl : 127/3,40/ 101 Mcv/mch/mchc: 86/28/33 PT/APTT : 0,85/1,06
Calsium : 7,6 Diftel: 0/0/0/11/30/59 Fibrinogen : 510
Albumin : 2,80 D dimer : 1480
Ur/Cr : 70/ 1,40 Lab 08/10/2021
PT/aPTT : 0.9/1.2 Lab 07/10/2021
Lab 6/10/21 HbsAg : Negatif Hb/L/T : 13,1/10,6/220
Hb/L/T : 9,9/2,0/23 Anti HCV : Negatif Diftell : 0/0/2/81/8/9
Mcv/Mch : 74/28 CRP Kualitatif : +
Diftel : 0/0/0/64/20/16 Lab 06/10/2021 Albumin : 3,66
MDT : NN, Anisokolosis, Hb/l/t: 10.2/7.6/49 As urat : 7
Dimorfiv cell Mcv/mch : 86/28 Ur/Cr : 28/1,16
Na/K/Cl : 113/ 4,00/ 90 Diftel: 0/0/0/22/30/48 Na/K/Cl : 142/3,9/111
Calsium : 5,9
Lab 04/10/2021 Lab 06/10/21
Urinalisa Hb/l/t: 11,6/3,9/30 Hb/Ht/L/T : 13/43/17/243
Lekosit : (+) Mcv/mch/mchc: 84/28/33 Diftel : 0/0/0/89/6/7
Protein : Positif (+2) Diftel: 0/0/1/8/35/56 GDS : 162
Darah: (+) Pt/aptt: 1,0/0,99 Na/K/Cl : 141/3,6/107
Leukosit : 100 – 150 Hcv/hbsag : -/-
Eritrosit : 25-50 Bil T/D/I: 1,61/0,7/0,91
Bakteri : (+) Sgot/sgpt: 96/297
Albumin: 3,6
Lab 05/10/2021 Ca: 7,9
Hb/l/lT: 9,2/2,2/43 Gds: 92
Mcv/mch/mchc: 73/28/39 Na/k/cl: 144/3,2/104
Diftel: 0/0/0/57/26/17 ANC : 351
Albumin: 2,2
GDS: 92
Ur/cr: 98/2,1
Na/k/cl: 107/4,6/86