MAPPING Dr.dr. Imran,Sp.

S (K)

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

MINA Usman, Lk, Kejang E 1. Obs. Seizure + 28/10/21 IV Citicolone 500mg/12 jam ACC pindah
1 58 thn M Hemiparesis dextra Hb : 13,6 PO Phenetoin 3x100mg ruangan
V ec stroke iskemik Ht : 40 IV Diazepam 1 amp K/P Drip phenetoin
Dpjp : dr. IM 2. Septis ec severe Trom : 316 Drip phenitoin lanjut 1.5 lanjutkan +;
cc/jam phenetoin
K7B1 Raber : pneumonia Leu : 24,3
3x100mg
Pulmo GDS : 332
Ur/cr : 45/1,30
Tanggal Na/k/cl :
mulai rawat 141/4,80/110
29/10/2021
 MAPPING Dr.dr. Imran,Sp.S (K)

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

Mina 2 Nurasiah Penurunan E Penurunan kesadaran + 30/10/21 IV Citicoline 500mg/12 Konsul Rehab
Abd Gani, Lk, kesadaran M hemiparese dextra ec Hb : 13,6 jam medik
62 thn V stroke iskemik tipe Ht : 39 Drip paracetamol 1g/8 jam
K1B2 emboli Trom : 417 IV Omeprazole 40mg/12
Dpjp : dr. IM Leu : 10,3 jam
Hipertensi emergency GDS : 99 PO Amlodipine 1x10mg
Tanggal Ur/cr : 28/0,60 PO Xarelto 1x10 mg STOP
mulai rawat Na/k/cl :
30/10/2021 139/3,60/103
 MAPPING Dr.dr. Imran,Sp.S (K)

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

MINA Marlini Penurunan E LBP dengan reffered 30/10/21 Gabapentin 2x300mg Fisioterapi
2 jamalaon, kesadaran M pain ec susp. Foraminal Hb : 11,7 Iv mecobalamin 500mg/12 RUQIYAH UST
Pr,43 thn V stenosis Ht : 33 jam
K4B2 Trom : 126 Iv omeprazole 40mg/12
Dpjp : dr. IM Leu : 4,2 jam
GDS : 99 Meloxicam 2x15mg
Tanggal Ur/cr : 17/0,20 PO Betahistin 3x6mg
mulai rawat Na/k/cl :
30/10/2021 145/3,90/118

SUBJEKTIF
 MAPPING Dr.dr. Imran,Sp.S (K)

NO KAMAR IDENTITAS Keluhan GCS TD DIAGNOSIS LABORATORIUM TERAPI PLANING

MINA Annisa binti Penurunan E3 145/ 1. Penurunan 29/10/21 Iv citicoline 500mg/12 jam
2 A. Ali, LK, 53 kesadaran M5 88 kesadaran Hb : 15,4 Iv Ceftriaxone 1 g/12 jam Konsul Rehab medik
thn V4 ( Gradually ) ec Ht : 50.8 Iv Omeprazole 40mg/12
K4B4 susp. Metabolik Trom : 438 jam
Dpjp : dr. IM enchephalopaty Leu : 30,4 Iv furosemid 20mh/24 jam
2. Hemiparesis GDS : 336 PO ramipril 1x 1,25
Raber : dextra + Paresis Ur/cr :31/1,3 PO Atorvastatin 1x20mg
Pulmo N.VII dextra + Na/k/cl : PO Clopidogrel 1x75 STOP
IPD HOM paresis N.VII Vit c 2x500
dextra central ec Ostriol2x0,25
Tanggal susp stroke Zink 1x20mg
mulai rawat 3. CAD PO xarelto 1x10 mg
29/10/2021 4. Pneumonia

SUBJEKTIF
 MAPPING Dr.dr. Imran,Sp.S (K)

NO KAMAR IDENTITAS Keluhan GCS TD DIAGNOSIS LABORATORIUM TERAPI PLANING

MINA Juariah, Pr, Kelemahan E 1. Hemiparese 28/10/21 PO Clopidogrel 1x75mg Fisioterapi

2 42thn anggota M dextra + Parese Hb : 15,0 STOP
gerak V N.VII,XII dextra Ht : 41 Po Amlodipine 1x10mg
K1B2 Dpjp : dr. IM kanan sentral ec Trom : 377 IV Mecobalamine 500mg/
Raber : stroke iskemik Leu : 13,6 12 jam
IPD,Pulmo 2. Hipertensy GDS : 475 IV Omeprazole 40mg/
emergency Ur/cr :59/1,30 12jam
Tanggal 3. DM Tipe 2 Na/k/cl : SC Lancus 0-0-0-10iu
mulai rawat 139/4,70/103 PO Xarelto 1x10mg
29/10/2021

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

ZAM Masturidi, Kelemahan E 1. Hemiparese dextra 29/10/21 IV Citicoline 500mg/12 Fisioterapi

ZAM 4 LK, 53 thn anggota M + Paresis N.VII,XII Hb : 16,1 jam
gerak V dextra sentral ec Ht : 47 Drip Paracetamol 1 g/ 8
K9 Dpjp : dr. IM kanan stroke reccurent Trom : 419 jam
2. Hipertensi stage 2 Leu : 8,7 IV Mecobalamin
Tanggal GDS : 118 500mg/12 jam
mulai rawat Ur/cr : 28/1,10 PO Amlodipine 1x10mg
29/10/2021 Na/k/cl : SC Diviti 2,5cc/24jam
145/3,90/109 IV Omeprazole 40mg/
12jam
PO Dexketoprofen 2x1 tab

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

Rauda T. Jauhar, Lk, Penurunan E - Subdural Hygroma 28/10/21 Saran : IV Citicoline Konsul psikiatri
h5 54 thn Kesadaran M bifrontal +Cephal Hb : 11,5 1000mg/8 jam
V hematom a/r Ht : 32 Drip Paracetamol 1g/8 jam
K2B1 temporoparietal Trom : 194 IV Pantopazole 40mg/
Dpjp : B. dexta Leu : 8,1 12jam
Saraf GDS : 94 IV Ceftriaxone 1gr/12 jam
Raber : dr. Ur/cr :30/0,80
IM Na/k/cl :
143/3,70/112
Tanggal
mulai rawat
29/10/2021

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

HCUS Meutia, Pr, Nyeri E 1. Penurunan 29/10/21 IV Citicoline 500mg/12

18 thn kepala M kesadaran + Hb : 12,0 jam
Bed 5 V chephalgia kronik Ht : 34 Drip Paracetamol 1 gr/8
Dpjp : dr. IM progresif + Trom : 218 jam
Hemiparese dextra Leu : 8,5 IV Omeprazole 40mg/12
Tanggal + Afasia ec dd SOL GDS : 106 jam
mulai rawat Intracranial Ur/cr : 24/0,40 IV Dexamethasone 5mg/8
29/10/2021 Na/k/cl : jam
135/4,20/100

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

ICU 2 Nurmawati, Penurunan E 1. Penurunan 29/10/21 IV Citicoline 500mg/12 Rencana VP Shunt

Pr, 47 thn kesadaran M kesadaran + Hb : 14,5 jam emergency
V Hemiparesw Ht : 42 IV Omeprazole
B4 Dpjp : dr. IM sinistra ec stroke Trom : 482 40mg/12jam
Raber : 2. Hipertensi stage II Leu : 16,4 PO Amlodipine 1x10mg
bedah saraf 3. PSMBA GDS : 134 Drip Paracetamol 1g/8 jam
Ur/cr : 64/1,10 Drip Perdipine titrasi dose
Tanggal Na/k/cl :
mulai rawat 148/3,60/106
29/10/2021

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

ICU 1 M. Nasir, LK, Penurunan E Penurunan kesadaran 30/10/21 Iv citicoline 500mg/12jam craniotomy evakuasi
26 thn kesadaran M ec EDH Hb : Drip paracetamol 1 g/8 edh
B3 V Ht : jam
Post op craniotomy Trom : Iv omeprazole 40mg/12
POD 1 Leu : jam
Dpjp : dr. IM GDS : drip manitol loading dose
Ur/cr : 250cc selanjut nya 125
Tanggal Na/k/cl : cc/6jam
mulai rawat
30/10/2021

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
 MAPPING Dr.dr. Imran,Sp.S (K)

Aqsa 1 Dahniar, Lk, Gangguan E 1. Gangguan 28/10/21 IV Citicoline 500mg/12 Lepas rawat
58thn Kesadran M kesadaran Hb : 8,6 jam
V ec – stroke Ht : 23
K8B2 Dpjp : IPD - Metabolik Trom : 196
Raber dr. IM enchephalopaty Leu : 79
GDS : 85
Tanggal 2. CKD stage V on Ur/cr :46/7,68
mulai rawat HD reguler Na/k/cl :
29/10/2021 130/3,70/95
MAPPING Dr.dr. Imran,Sp.S (K)